Human trafficking: Identification and evaluation in the health care setting

INTRODUCTION — Human trafficking, also referred to as modern slavery, is a crime that affects nearly every country in the world, regardless of level of economic development. As awareness of human trafficking has evolved, victims have been identified and assisted in leaving exploitative situations within a variety of industries including agriculture, manufacturing, hospitality, health care, domestic service, and commercial sex work. The illegal nature of human trafficking makes it particularly difficult to identify and therefore aid victims. Health care providers have a unique opportunity to assist trafficked persons, as medical visits may be one of the few times they are in contact with individuals in a position to help.

This topic will review the identification, evaluation, and management of persons suspected of being trafficked. Topics specific to sexual abuse and intimate partner violence are presented separately.

●(See "Evaluation of sexual abuse in children and adolescents".)

●(See "Management and sequelae of sexual abuse in children and adolescents".)

●(See "Intimate partner violence: Diagnosis and screening".)

●(See "Intimate partner violence: Intervention and patient management".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION — In 2000, the United Nations Convention Against Transnational Organized Crime (the Palermo Convention) defined human trafficking as "the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude, or the removal of organs" [1]. The crime of human trafficking can be divided into three components, "the act, the means, and the purpose" [2], though evidence of malevolent means may not be required in some countries to satisfy the legal definition of human trafficking when children under the age of 18 are concerned.

Human trafficking does not require the movement of persons [3]; many victims are trafficked in their own homes, communities, or in cities within their countries of origin [4]. Additionally, human trafficking is different from migrant smuggling. While smuggling can evolve into the crime of human trafficking during transit or on arrival at the destination, migrant smuggling is a crime whereby persons gain illegal entry into a country with the assistance of individuals (smugglers) they contracted to help them navigate the journey [5,6].

EPIDEMIOLOGY — Reliable figures on the incidence and prevalence of human trafficking are difficult to obtain because of the illegal, and therefore clandestine, nature of this problem; the range and severity of trafficking activities; and the variation in the definitions used [7]. Up from 40 million in 2016, the United Nations International Labor Organization (ILO) estimated that approximately 50 million individuals were living in modern slavery in 2021, with 28 million individuals trapped in forced labor and another 22 million in forced marriage [8,9].

The broad scope of the problem is further highlighted by the following statistics:

●The ILO estimated that, of the 27.6 million persons trapped in forced labor, 17.3 million (63 percent) were enslaved in private sector industries, 3.9 million (14 percent) in state-imposed forced labor, and 6.3 million (23 percent) in forced commercial sexual exploitation. Women and girls account for 10.9 million (43 percent) of those in forced labor. Children comprise more than 3.3 million (12 percent), with over half of these children exploited for forced commercial sex [9].

●Of the 22 million people in forced marriage in 2021, 75 percent of forced marriages occurred in low- and low- to middle-income countries. While men and boys comprise 32 percent of those forced into marriage, 14.9 million (68 percent) are women and girls. Of the 22 million trapped in forced marriage, approximately 9 million (41 percent) were children under the age of 18 years at the time of marriage [9].

●In 2016, the United States Department of Labor identified 139 goods from 75 countries produced by "child labor or forced labor" [10,11].

●In 2022, the United States National Center for Missing and Exploited Children estimated that one in six children reported missing to the center were likely forced into sex trafficking [12,13].

●In 2015, the United States National Human Trafficking Resource Center published that human trafficking had been reported in all 50 states and the District of Columbia [14].

RISK FACTORS — Risk factors are elements that drive or entice the individual toward trafficking [2]. Risk factors can be identified at all four levels of the socioecological model: the individual, the individual's relationships, the community, and society at large. Of note, poverty increases the risk of trafficking at all four levels. Additional risk factors for being trafficked include young age (12- to 16-year-old girls are at greatest risk), increased psychiatric complexity, racial/ethnic minority status, rural location, lack of education, disability, inadequate family support and protection, and migration, including labor migration and migration due to mass displacements as a result of political unrest, armed conflict, and natural disasters [15,16]. Marginalized individuals are also at increased risk and include lesbian, gay, bisexual, transgender, queer, or questioning persons; runaway or "throwaway" youth; migrant workers; and indigenous people [8,17]. Multiple studies suggest that a history of childhood abuse is a risk factor for later sexual exploitation. In a survey study of nearly 200 female survivors of sex trafficking, approximately 60 percent reported physical and/or sexual abuse prior to being trafficked [18].

However, while there are risk factors for trafficking, trafficking is not limited to any one group of individuals. Victims can be of any age, gender, group, or status. In the United States, trafficked individuals come from all socioeconomic levels and include both citizens and noncitizens and documented and undocumented individuals [3].

The National Human Trafficking Resource Center utilizes the AMP model (Action, Means, and Purpose) to outline the various mechanisms traffickers utilize to coerce and manipulate others [19].

HEALTH IMPACT

General — For people who are trafficked, the experiences of recruitment, travel, detention and exploitation, and reintegration can negatively impact health and well-being and often have cumulative effects (figure 1) [7]. At every stage, women, men, and children can encounter abuse (psychological, physical, and/or sexual abuse); mandatory or coerced use of substances; social constraints; emotional manipulation; and economic exploitation, inescapable debts, and legal challenges (table 1) [20,21]. The long-lasting mental and physical health consequences of trafficking can make engaging and retaining survivors in the health-care system a challenge, which further adds to their marginalization [22].

Mental — As a result of trafficking, survivors carry a significant burden of mental health symptoms that can include depression, posttraumatic stress disorder, anxiety disorders, suicidal ideation, and somatic conditions [23-25]. In addition, victims may be forced to use drugs and alcohol as a form of control, or victims may use these substances as a means of coping [20]. Once an addiction is established, the trafficker may use access to the drug as a means of reward, punishment, and even re-trafficking.

Sex trafficking — The majority of available studies tend to focus on female survivors of sex trafficking. Representative findings from such studies include that the vast majority of women report physical and/or sexual abuse and subsequent physical and mental health issues [18,26]. Nearly half of survivors have reported attempted suicide [26]. Rates of human immunodeficiency virus (HIV) infection vary by global region and have been reported as high as between 30 and 60 percent [27,28]. Reproductive health issues include multiple sexually transmitted infections, pregnancies, miscarriages, and pregnancy terminations (a portion of which are forced) [26].

The true extent of the health impact of sex trafficking cannot be fully appreciated, however, as these cases are likely underreported [3]. Additionally, while the focus has been on females, data indicate that males, boys, and persons of nonbinary genders are also trafficked for commercial sex, though the extent to which this occurs is unknown and likely underappreciated.

Labor trafficking — Persons trafficked for nonsexual labor are vulnerable to industry-specific environmental and occupational risks and exposures that negatively impact health. Risks can include unsafe ventilation and sanitation, extended hours, repetitive-motion activities, limited or no training in use of heavy or high-risk equipment, hazards (chemical, electrical), lack of protective equipment, extremes of temperature, and infectious contaminants [29]. Subsequent health outcomes include exhaustion, dehydration, heat stroke or stress, hypothermia, frostbite, accidental injuries, repetitive-motion syndromes, respiratory problems and infection (eg, tuberculosis), and skin infections [20,24,29,30].

Drug trafficking — Trafficking of drugs and humans often overlaps. Drug trafficking, including body packing and body stuffing, are presented separately. (See "Internal concealment of drugs of abuse (body packing)" and "Acute ingestion of illicit drugs (body stuffing)".)

IDENTIFICATION

Barriers to disclosure — A major challenge for health care providers is the difficulty in identifying victims. Victims rarely self-identify because of multiple factors including fear of the trafficker, distrust of authorities, feelings of shame and hopelessness, trauma bonds (ie, Stockholm syndrome), and threats [25,31,32]. Threats used by traffickers can include acts of retribution against children or other family members, deportation, or criminal prosecution, in addition to psychological and physical harm. Further, some victims may not fully understand the nature of their situation and may not realize they are being trafficked because they receive housing, food, or clothing [33]. Similarly, when human trafficking is carried out under the guise of romance, trafficked persons may believe they are simply involved in a troubled romantic relationship and fail to recognize their exploitation.

In addition to being potentially dangerous, disclosure can also be emotionally difficult and is an act demonstrating significant courage [2]. One interview study of 17 survivors of childhood trafficking reported that patients do want clinicians to ask about trafficking, clinicians should emphasize confidentiality and privacy, and that, when done with appropriate privacy, being asked about trafficking is not retraumatizing [32]. Some victims may make multiple visits to a health care setting before deciding if they can safely reveal their situation. Lastly, discussing trafficking may be easier for the individual when the provider is of the same sex, ethnicity, or age range.

Warning signs — Red flags, indicators, and warning signs that a patient may be a victim of trafficking are described in the tables (table 2 and table 3). Providers should proceed with a more comprehensive assessment for potential trafficking when red flags emerge in the presentation, history, or physical examination. Health care providers are uniquely poised to identify human trafficking victims because they often present to emergency departments, reproductive health units, and family planning clinics [26,34]. In a retrospective survey of 173 survivors of trafficking in the United States, 68 percent were seen by a health care provider while trafficked, with 56 percent seeing emergency or urgent care providers [35].

Specific warning signs can often include late presentation, discrepancy between the verbal history and clinical findings, and signs an individual is being controlled (eg, not being able to carry one's own identification or not being allowed to answer questions) [2,36-40].

Warning signs specific to sex trafficking victims of any age or gender include reports of multiple sexual partners and/or recurrent or untreated sexually transmitted infections [2]. In addition, sex trafficked women and girls often have multiple pregnancies, miscarriages, or pregnancy terminations. Cases of sex trafficking may often appear, on the surface, to be instances of intimate partner violence (IPV).

Approach to assessment — We take a stepwise approach to the evaluation and treatment of patients with warning signs of human trafficking (algorithm 1). The goal of the clinical visit is not to obtain a disclosure or carry out a rescue but rather to provide medical care and create a climate that allows "every patient to feel safe, secure, cared for, validated, and empowered to disclose, if he or she so chooses" [2]. Before beginning any conversation with a patient, the clinician should assess the potential safety risks that may result from asking the patient sensitive questions and ensure privacy for the patient. Interactions with potential trafficked patients should be honest and nonjudgmental [33]. Transparency about the limits of confidentiality is recommended for mandated reporters to avoid fracturing the patient-provider relationship.

There is no consensus on the optimal content, length, or format of screening questions for identifying victims of human trafficking [41]. Similar to interviewing victims of IPV, clinicians should not begin by asking outright if individuals have been beaten or retained against their will. Rather, the clinician should start with indirect questions that touch upon aspects of the patient's life, job, and general sense of safety. Suggested screening questions for adults and minors are listed in the tables (table 4 and table 5 and table 6). For more advanced training, the United States National Human Trafficking Training and Technical Assistance Center (NHTTAC) has additional resources, and providers who undergo such training can incorporate a longer screening evaluation.

Facilitate disclosure — Victims of trafficking do not often reveal their situation in clinical settings [2]. Patients are more likely to disclose their experience of violence when the following are addressed [39,42,43]:

●Privacy – Questioning is done in private. Others present should be asked to leave for the interview and examination. Resistance to leave may be important diagnostic information. To potentially improve privacy, one study reported successful use of an electronic tablet to administer a validated six-item screening tool as a means of identifying at-risk minors [44].

●Interpreter – Providers should engage the services of an in-person or telephonic professional interpreter when indicated. Accompanying persons should never function as the sole means of communication when language barriers exist since they may be responsible for or involved in the patient's exploitation. Providers can utilize different strategies to screen patients, including stating that it is routine practice to have accompanying individuals leave for a portion of the exam.

●Open-ended questions – Providers use open-ended questions and demonstrate active listening using answers to previous questions to determine subsequent questions. Eye contact, body language, and expression of concern are just as important as the sensitivity employed when posing the actual questions.

●Conversational approach – One or only a few questions are posed, and a conversational approach is maintained.

●Pediatric interviewing skills – For children, a person who is skilled at interviewing underage trafficking or abuse victims (eg, social service provider) is present.

●Provider preparation – Providers demonstrate an understanding of the described circumstances, experience with similar situations, and confidence in their knowledge of how to assist.

●Confidentiality and limits – Providers assure confidentiality while informing patients about the limits of confidentiality when the situation invokes state mandatory reporting laws (eg, persons in grave danger, minors under the age of 18, or persons with disabilities). (See "Intimate partner violence: Intervention and patient management", section on 'Mandatory reporting' and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

The decision to disclose trafficking can be mentally challenging, emotionally draining, and potentially physically unsafe for the victim [2]. If the victim does not feel prepared to disclose during the immediate clinical visit, disclosure may occur at a future visit. Therefore, each contact is a step on a potential pathway to safety for at-risk patients. Similar to patients for whom IPV is suspected but not acknowledged, clinicians should ask suspected victims of trafficking about their situation at every visit and respect their decisions to forego disclosure or decline additional services. For victims of IPV, some data suggest that patients are more likely to disclose information after they have been asked repeatedly in the health care setting about experiences of violence because the inquiries become normalized [45,46]. Thus, the clinician may want to schedule follow-up visits for any medical indication in order to bring the individual back into the health care setting and potentially access resources.

Confidentiality — Confidentiality is critical for victims of abuse, including human trafficking [39]. Trafficked individuals and their families can be at risk if the victim tries to escape or to initiate reporting. Clinicians are advised to limit the number of staff who interact with the victim and ensure that all involved, including interpreters and advocates, understand that confidentiality is critically important for patient safety. (See "Confidentiality in adolescent health care" and "Consent in adolescent health care".)

Interpreters — Interpreters should not be accompanying persons (eg, friend or relative) or come from the patient's community [2]. Use of a professional interpreter avoids the interpreter being the trafficker, knowing either the victim or trafficker, compromising the patient's safety, and/or having a conflict of interest within a specific community. Information specific to confidentiality and consent for minors is presented separately.

Unique role of reproductive health care providers — In a study of nearly 100 women and girls who were trafficked for sex, 88 percent had at least one visit with a health care provider, of which nearly one-half were at Planned Parenthood or a women's health clinic [26]. Victims of sex trafficking can present for care related to sexually transmitted infections, pregnancy, miscarriage, and pregnancy termination [4].

In addition, pregnancy and parenthood can have a significant impact on the physical, mental, and emotional well-being of trafficked women and girls [47]. For those whose pregnancy resulted from rape or sexual exploitation, the pregnancy itself can be traumatic, and the child may become a constant reminder of past trauma. The rape or trafficking experience can complicate the survivor's relationship with the child; feelings of both love and resentment can intensify the psychological distress of both. Trafficked parents are vulnerable to further exploitation, as traffickers often threaten a victim's child to maintain control over them. The children themselves may also be trafficked or exploited [48].

EVALUATION AND MANAGEMENT

Provider preparedness — For optimal care of the trafficking victim, the clinician needs to be prepared with appropriate and up-to-date referral information and able to offer interdisciplinary care in a sensitive, confidential manner [24]. Health care providers have cited lack of training and awareness as the greatest barriers in identifying victims of trafficking [49]. In an effort to expand access to education, multiple organizations have created free webinars to aid health care providers in creating a response to human trafficking.

●Futures Without Violence

●National Health Collaborative on Violence and Abuse

●National Human Trafficking Hotline (NHTH) awareness materials

●Office on Trafficking in Persons – National Human Trafficking Training and Technical Assistance Center

The NHTH has published a framework to help providers identify victims, assess their safety, and connect them with resources [50]. Once acute medical issues have been addressed, social workers and case managers can aid the victim in safety planning and obtaining housing, financial aid, and legal assistance. In the United States, the Trafficking Victims Protection Authorization Act of 2000 and the Reauthorization Act of 2013 (Title XII of the Violence Against Women Reauthorization Act of 2013) authorized an interagency government task force to combat human trafficking both domestically and abroad and to provide coordinated services for victims, including a trafficking victim protection visa [51]. The Countering Human Trafficking Act of 2021 codified and expanded the Department of Homeland Security's Center for Countering Human Trafficking, appropriating $14 million USD and at least 45 employees to continue this essential work [51].

Safety issues — When working with victims of abuse or trafficking, the safety of patients, staff, and clinicians is critical [52]. Traffickers can be involved in organized crime, local gangs, or other crime networks. Care providers, clinics, and institutions are advised to establish a relationship with the local police force, obtain a security audit, develop an emergency notification system, and periodically have emergency drills or review plans. Other safety measures include restricting after-hours access; installing lighting, security cameras, panic buzzers, and deadbolts or electronic locks; restricting access to all doors except the main entrance; and preprogramming emergency access phone numbers (eg, 911 in the United States) in all telephones.

Trauma-informed care

●Definition and purpose – Trauma-informed care (TIC), also known as trauma-sensitive or trauma-aware care, is a "strengths-based framework that incorporates acknowledgment of the prevalence and impact of traumatic events into clinical practice, placing an emphasis on instilling in the patient a sense of safety, agency, and reclamation of control and autonomy over one's life and decisions" [2]. The basic goals are to avoid reinjury; emphasize survivor strengths and resilience; aid empowerment, healing, and recovery; and promote the development of survivorship skills [2,53,54]. A 16-minute online video is available from the NHTH to educate providers on trauma-informed human trafficking screenings.

●How to apply – TIC can be applied to all patients as it involves modification of a health care provider's practice style to reflect a basic understanding of how trauma impacts the life of that individual [55,56]. Approaches to reducing retraumatization include examining patients only after obtaining their permission, having them remain clothed and in a comfortable place until the examination is performed, ensuring a sense of predictability by informing patients of what they should expect, and offering aids to allow individuals to observe procedures (eg, a handheld mirror). Providers should ask patients what their expectations are regarding the visit and how the provider can potentially make them more comfortable during the encounter, even if that means leaving the door slightly ajar. Some authors suggest identifying a "signal" patients can utilize to indicate if they are feeling distressed during the visit [57]. As an entire practice assimilates a trauma-informed approach, including layout, policies, and procedures, the clinic may meet trauma-competent criteria.

●Critical role of trust – Most victims of trafficking have extreme fear of the traffickers, deportation, being placed back into an abusive home of origin or foster home, and legal involvement (eg, facing criminal charges for prostitution or selling drugs) [58]. Gaining the trust of trafficked patients is a key initial event. Sample messages to convey are presented in the table (table 7).

Medical evaluation

All victims — The NHTH has published a framework that outlines the evaluation of trafficking victims [50]. Trafficking victims may not seek medical evaluation until they have no other options. The initial assessment should screen for acute medical needs and conditions typically found in trafficked persons (table 8) [33].

●Physical examination – In addition to performing a physical examination related to the presenting complaint, clinicians who suspect trafficking should perform a complete physical examination to detect other potential indicators of abuse, including human trafficking. Physical examination findings that are suggestive of trafficking include [2,33,36,59]:

•Unexplained injuries or injuries in various stages of healing

•Burns and scarring

•Branding or tattoos, including symbols, numbers, or bar codes that indicate which individuals "belong" to which trafficker

•Strangulation injuries

•Dental and oral injuries

•Traumatic head injuries

•Genital trauma

•Implanted radiofrequency identification chips

•Occupational injuries not linked clearly to legitimate employment

●Assess for substance use – Victims of trafficking can experience forced drug use or drug-facilitated sexual assault [33]. Patients with altered mental status, symptoms of amnesia, or a history or symptoms of substance use within five days of presentation are screened for substance use/exposure, including a urine toxicology test and specific tests for gamma hydroxybutyrate, flunitrazepam (Rohypnol) or other benzodiazepines, ketamine, or other sedative drugs [33,60]. (See "Testing for drugs of abuse (DOAs)".)

●Screen for delayed growth – Trafficked children and adolescents are at particular risk for physical, mental, and psychological repercussions. Whether exploited for sex or labor, these young survivors are screened for delayed physical and cognitive milestones, impaired social skills, stunted growth, and long-term effects of untreated common childhood diseases [2]. (See "Management and sequelae of sexual abuse in children and adolescents".)

Victims of sexual abuse and exploitation

●Forensic evidence – After urgent medical and safety needs are met, sex-trafficked and sexually abused labor-trafficked persons should be offered a forensic medical evaluation [60]. Examinations of survivors of sexual assault, after appropriate consent has been obtained, should be conducted by an experienced clinician in a manner that does not add to the survivor's trauma [61]. Sexual assault nurse examiners, also known as forensic nurse examiners, are registered nurses specifically educated in the examination of individuals who have experienced sexual assault or abuse and in the collection and management of medical forensic evidence [62]. The time limit for evidence collection varies by jurisdiction and by patient age but typically ranges from 72 to 120 hours. If the patient declines a forensic medical evaluation, the clinician can provide information about the time window for future collection of forensic evidence and prophylactic treatment for sexually transmitted infections (STIs) and pregnancy. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Forensic evaluation'.)

●STIs – For adolescent and adult victims of sexual assault, the United States Centers for Disease Control and Prevention recommend empiric antibiotic prophylaxis because victims may not be able to return for a follow-up visit, thus making treatment based upon test results problematic [61]. Patients are also evaluated for risk of HIV acquisition and need for pre-exposure prophylaxis (PrEP). Recommended presumptive treatment includes antibiotics for chlamydia, gonorrhea, and trichomoniasis; postexposure vaccination for hepatitis B; and human papillomavirus vaccination for survivors ages 9 to 46 years [63]. Testing for HIV, hepatitis B and C, syphilis, and pregnancy should be performed in this high-risk population. Assuming appropriate results, follow-up, cervical cytology, and HPV screening should also be considered.

•(See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Overview'.)

•(See "HIV pre-exposure prophylaxis".)

Testing for STIs in prepubertal children (ie, sexual maturity rating of ≤2) is presented separately (picture 1 and picture 2). (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing'.)

●Pregnancy and contraception – As with the setting of sexual assault, pregnancy testing and emergency contraception should be offered to reproductive-age victims of trafficking if they are seen within five days of the incident [60]. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Preventing pregnancy' and "Emergency contraception".)

In addition, clinicians should discuss long-term, concealable contraception, such as that provided by intrauterine devices (IUDs) or etonogestrel implants. These methods have failure rates of less than 1 percent (figure 2). However, IUD strings and the implant are both potentially palpable, which places the user at risk of discovery. To reduce the risk, the clinician can cut the IUD strings to the level of the cervix, so they reside within the endocervical canal [64]. The patient should be counseled that this approach may complicate eventual IUD removal. For the IUD, the risk of STI transmission and resultant pelvic inflammatory disease must be balanced against the desire to avoid pregnancy. Information on contraceptive selection in general, as well as IUDs and the progestin implants, is available separately.

•(See "Contraception: Counseling and selection".)

•(See "Intrauterine contraception: Background and device types".)

•(See "Intrauterine contraception: Candidates and device selection".)

•(See "Contraception: Etonogestrel implant".)

●Repeat testing – As with victims of acute sexual assault, sex trafficking victims and labor trafficking victims experiencing sexual violence should be reevaluated one to two weeks after the initial assessment to the extent possible [61]. During this subsequent visit, providers offer repeat testing for pregnancy and/or STIs as well as reassess suspected or confirmed genital injuries [33,61]. A follow-up examination at one to two months is performed to assess for development of anogenital warts, especially among sexual assault survivors who received a diagnosis of other STIs [61]. For survivors whose initial test results were negative but infection in the assailant cannot be ruled out, repeat serologic testing can be performed for syphilis (repeated at four to six weeks and three months) and HIV (repeated at six weeks and at three and six months using methods to identify acute HIV infection). (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Follow-up care'.)

Ongoing care — Follow-up care is individualized to the patient's circumstances. If the patient is not able to leave the trafficking situation, efforts are made to ensure the patient understands available resources. The clinician can aid the patient in memorizing contact information, such as the National Human Trafficking Hotline (NHTH; 1-888-373-7888) or the text HELP or INFO to BeFree (233733). Physical materials should not be given out without first considering along with the patient the possibility that discovery of this information may place the patient at risk for retaliation from the trafficker. Providers can discuss specific safety plans including the development of a safe contact system [65]. Polaris provides specific tips to assist patients who aren't yet able to leave regarding safe online searching, the use of social media, and the prevalence of online harassment [66]. (See 'Resources' below.)

In the interim, providers can work with local agencies to identify potential sources of legal assistance, transportation, vocational training, employment, childcare, and housing for when the patient is able to leave. If and when the patient leaves the trafficking situation, providers should remain mindful of the potential for revictimization due to the patient's ongoing fear, shame, and many sources of vulnerability, such as substance use [67].

TIPS FOR DOCUMENTATION

●General – The patient's medical history is documented in writing [2]. Written documentation should be recorded in an unbiased manner and include the language used directly by the patient. Wording that could be used against the patient is avoided (eg, "prostitute," "drug dealer," or "patient claims" or "alleges"). Rather, the clinician documents the activities the individual was required to perform and types of force and/or coercion used.

●Photography – Prior to taking any photographs, the planned images are discussed with the patient and consent is obtained and documented [2]. The clinical situation and local policy guides if and when repeat photographs are taken [60]. Photographs are taken of the part of the body that was involved in the assault. In addition, photos can be taken of the normal anatomic counterpoint to provide a comparison (eg, photos of the same area of bruised and unbruised arms). One group of experts advises documenting in the medical record the name of the photographer and that "the photos are both accurate and unaltered" [2]. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Physical examination'.)

●Minors – A minor is someone under the legal age of adulthood, which varies based on the jurisdiction and the activity involved. (See "Consent in adolescent health care", section on 'Minor status'.)

When caring for sex trafficked minors (suspected or disclosed), the following approaches are advised [33]:

•Fully document the statements by the child/adolescent and use quotes when possible. In addition, document the actions taken to protect the individuals and the resources activated on their behalf (eg, social service consult, law enforcement contact).

•When discussing the possibility of trafficking with law enforcement or child protection agencies, bring up the concern for trafficking early in the conversation. Identifying a trafficking suspicion can potentially activate protocols and improve the response to victims and survivors. As with adults, language that could divert attention from the trafficking issue (eg, prostitute, pimp, or drug dealer) is avoided.

•Avoid medical jargon in both written and verbal communications so that nonmedical personnel can easily understand the issues. Protected health information is not discussed.

•Both medical and mental health follow-up is arranged when possible. Providers educated in trauma-informed care are preferred. (See 'Trauma-informed care' above.)

MANDATORY REPORTING — Clinicians in many countries are required to report all cases of suspected or known child abuse, sexual or otherwise [68-70]. The designated agency to which abuse should be reported varies by region; clinicians should be aware of the local laws. The procedure for reporting is presented in detail separately. (See "Child abuse: Social and medicolegal issues".)

In the United States, laws vary across states regarding the definition of suspected child abuse, personnel who are mandated to report, and the agency (or agencies) to which the report is made (eg, Child Protective Services, Department of Social Service, the local police department) [71,72]. However, in the United States, the Victims of Child Abuse Act of 1990 was expanded to include human trafficking at the federal level [73]. Information on statutes by state can be found at the Child Welfare Information Gateway State Statutes Search [70].

Clinicians should also be aware of the various events or circumstances, outside of child maltreatment, that are reportable under local laws.

If mandatory reporting laws apply, the clinician should approach the subject with care and sensitivity, offering support while expressing concern and explaining next steps. Because it is important to maintain a therapeutic rapport and protect trust and confidence, the clinician would have ideally discussed the limits of confidentiality with the patient when preparing to assess for human trafficking.

RESOURCES

National human trafficking hotline (NHTH) — The National Human Trafficking Hotline (NHTH) is accessible by telephone (1-888-373-7888), text messaging (text HELP or INFO to BeFree [233733]), and email ([email protected]) and is used by laypersons to report suspected or disclosed cases of trafficking; by persons experiencing trafficking and seeking help from authorities; and by clinicians in need of guidance on assessment steps, immediate care, and social and legal services in the local area [50,74]. The hotline helps clinicians determine if they have encountered victims of human trafficking; identifies local, state, and federal resources; and helps arrange local social services to aid victims [39]. When speaking with hotline operators or other NHTH personnel, clinicians should adhere to HIPAA regulations and avoid revealing the patient's identity or discussing other protected health information [75].

If patients disclose that they have been trafficked, the NHTH advises the following actions [50]:

●Provide the patient with the NHTH number (telephone 1-888-373-7888). If the patient feels it is dangerous to have something with the number written on it, the clinician can help the individual memorize the number (it may be easier to remember the telephone number as 888-3737-888). Avoid giving patients materials (eg, printed information or cards) that could place them at increased risk if detected.

●Activate the appropriate institutional response teams in situations of life-threatening emergencies. If a law enforcement agency is going to be contacted, the patient is included in the decision process whenever possible.

●Discuss safety planning, available resources, and potential services with the individual.

●Follow local mandatory reporting laws for legal minors, disabled persons, and other reportable events or circumstances. (See 'Mandatory reporting' above.)

●Accurately document the patient's injuries and treatment plan, and avoid insertion of personal judgments or interpretations. (See 'Tips for documentation' above.)

Patients

●National Human Trafficking Hotline – A free hotline (1-888-373-7888) supported by the United States Department of Health and Human Services that helps protect and serve victims of trafficking in the United States.

●Polaris – A nonprofit organization that operates the BeFree text line as well as provides support services. Text HELP or INFO to BeFree (233733).

Clinicians

●National Human Trafficking Hotline – A free national hotline supported by the United States Department of Health and Human Services to help clinicians determine if they have encountered victims of human trafficking, identify local resources available in their community to help victims, and help clinicians coordinate with local social service organizations to help protect and serve victims. Telephone number 1-888-373-7888.

●Polaris – A nonprofit organization dedicated to the global fight to eradicate modern slavery.

●Blue Campaign – The United States Department of Homeland Security-sponsored website dedicated to ending human trafficking provides information on identifying victims and training programs. Anonymous tips regarding possible victims can be reported through thistip form.

●Rescue and Restore Campaign – Supported by the Office on Trafficking in Persons of the United States Department of Health and Human Services (HHS) Office of the Administration of Children and Families. This site provides tips for identifying and helping victims of human trafficking, screening questions, lists of health problems seen in victims, and brochures and posters that can be printed for the office.

●Services Available to Victims of Human Trafficking – A resource guide for social service providers from the HHS, including information on types of federal benefits and services available to trafficking victims as well as information on how a foreign national trafficking victim can obtain a certification letter or eligibility letter from the HHS Office of Refugee Resettlement.

●Human Trafficking Guidebook – A 2014 joint publication by the Massachusetts General Hospital Human Trafficking Initiative and the Massachusetts Medical Society Committee on Violence Intervention and Prevention.

●Caring for Trafficked Persons: Guidance for Health Providers – A 2009 joint publication by the International Organization for Migration, the United Nations Global Initiative to Fight Human Trafficking, and the London School of Hygiene and Tropical Medicine.

●HEAL Trafficking – The HEAL (Health, Education, Advocacy, Linkage) network is a public health group that connects interdisciplinary health professionals in the fight to end human trafficking.

●SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Training – A training program for health care and social service providers sponsored by the Administration for Children and Families, United States Department of Health and Human Services.

●Anti-Slavery International – Anti-Slavery International, founded in 1839, is the world's oldest international human rights organization and works to eliminate all forms of slavery around the world.

●Coalition Against Trafficking in Women – Coalition Against Trafficking in Women (CATW) is a nongovernmental organization that works to end human trafficking and the commercial sexual exploitation of women and children worldwide. CATW is the world's first organization to fight human trafficking internationally.

SUMMARY AND RECOMMENDATIONS

●Free reporting resource – The United States National Human Trafficking Hotline provides a 24/7/365 hotline (telephone 1-888-373-7888) that can be used by clinicians or patients to report human trafficking (even if suspected but not disclosed), seek guidance, and access social and legal services. The hotline helps clinicians determine if they have encountered victims of human trafficking without requiring patient identification or other breach of patient confidentiality; identifies local, state, and federal resources; and helps arrange local social services to aid victims. Alternatively, Polaris operates a reporting text line. Text HELP or INFO to BeFree (233733). (See 'National human trafficking hotline (NHTH)' above.)

●Definition – Human trafficking is considered a modern form of slavery in which one person exerts control over another person for the purpose of exploitation. Human trafficking comprises sex and labor trafficking, forced criminality, and sale of human organs. Human trafficking does not require movement of the victim; many people are enslaved in their own communities or in cities within their country of origin. (See 'Definition' above.)

●Risk factors – Risk factors include elements that drive or entice the individual toward trafficking. Risk factors can be identified in the individual, the individual's relationships, the community, and society at large. Of note, poverty increases the risk of trafficking at all four levels. (See 'Risk factors' above.)

●Potential harms to trafficked individual – At every stage of the trafficking experience, adults and children can encounter abuse (psychological, physical, and/or sexual abuse); mandatory or coerced use of substances; social constraints; emotional manipulation; and economic exploitation, inescapable debts, and legal challenges (table 1). (See 'General' above.)

●Barriers to disclosure – A major challenge for health care providers is the difficulty in identifying victims. Victims rarely self-identify because of multiple factors including fear of the trafficker, distrust of authorities, feelings of shame and hopelessness, trauma bonds (ie, Stockholm syndrome), and threats. Providers should screen patients for potential trafficking when red flags emerge in the presentation, history, or physical examination (table 2 and table 4). (See 'Barriers to disclosure' above.)

●Warning signs – Specific warning signs can often include late presentation for care, discrepancy between the verbal history and clinical findings, and signs an individual is being controlled (eg, not being able to carry one's own identification or not being allowed to answer questions). Additional warning signs are listed in the table (table 3). Warning signs specific to sex trafficking include reports of multiple sexual partners, sexually transmitted infections, pregnancies, miscarriages, or pregnancy terminations. (See 'Warning signs' above.)

●Questions to help identify victims – There is no consensus regarding the optimal questions for identifying victims of human trafficking. The clinician should conduct a conversational assessment that starts with indirect questions that touch upon aspects of the patient's life, job, and general sense of safety. Suggested questions for adults and minors are listed in the table (table 4). (See 'Approach to assessment' above.)

●Medical evaluation – The initial evaluation of a suspected or confirmed trafficking victim includes assessing acute medical needs and screening for medical conditions common in trafficked persons (table 8). Victims of sex trafficking have additional needs including forensic examination and evidence collection, treatment of sexually transmitted infections, possible pre-exposure prophylaxis to prevent HIV acquisition, and provision of emergency contraception or pregnancy care. In addition, the options for highly effective and concealable contraception, such as the intrauterine device or etonogestrel implant, are discussed with the patient. (See 'Medical evaluation' above.)

•Provision of trauma-informed care – Clinicians working with victims should provide trauma-informed care, also known as trauma-sensitive or trauma-aware care. The basic goals are to avoid reinjury, emphasize survivor strengths and resilience, aid healing and recovery, and promote the development of survivorship skills. A 16-minute online video is available from the NHTH to educate providers on trauma-informed human trafficking screenings. (See 'Trauma-informed care' above.)

•Documentation – Written documentation should be recorded in an unbiased manner and include the language used directly by the patient. Wording that could be used against the patient is avoided (eg, prostitute or drug dealer). Prior to taking any photographs, the planned images are discussed with the patient and consent is obtained and documented. (See 'Tips for documentation' above.)

●Reporting requirements – Clinicians in many countries are required to report all cases of suspected or known child abuse, sexual or otherwise. However, laws vary across countries, states, and regions regarding the definition of suspected child abuse, personnel who are mandated to report, and the agency (or agencies) to which the report is made (eg, Child Protective Services, Department of Social Service, the local police department). In the United States, information on mandatory reporting statutes by state can be found at the Child Welfare Information Gateway State Statutes Search. (See 'Mandatory reporting' above.)