Labor and sex trafficking are the two major forms of human trafficking occurring in the United States. Although U.S. discourse on human trafficking is excessively focused on forced commercial sexual exploitation, this should not be interpreted to mean that sex trafficking is more prevalent than labor trafficking. Indeed, accurate prevalence estimates elude our epidemiological understanding of the problem in the United States, though global research suggests that labor trafficking is the more prevalent form.

Notwithstanding the frequently invoked image of women and girls trafficked for commercial sex by predatory males, the truth is that victims and perpetrators of this crime exist in all combinations. Indeed, labor- and sex-trafficked persons can be male, female, transgender, and gender-nonconforming children and adults, much like the traffickers who exploit them. Despite human traffickers being typically thought of as ruthless, unscrupulous adults, it is important to recognize contexts in which the youth themselves engage, either under duress or of their own accord, in the trafficking of other youth. Examples include peer recruitment out of schools and residential homes, homeless youth “street families” (formed out of convenience and necessity) internally exploiting labor and sex, and youth gang leaders trafficking weaker youth for labor related to criminal activities and commercial sex. Thus, to broaden our conceptualization of human trafficking and maximize detection, clinicians must refrain from relying only on the recognition of sex trafficking and male perpetrator–female victim combinations.

Although the crime of human trafficking doesn’t discriminate based on age, gender, race, ethnicity, and immigration status, traffickers strategically exploit specific personal, social, and economic vulnerabilities that may disproportionately place certain demographic groups at higher risk for labor trafficking, sex trafficking, or both. For example, youth who are abused, are homeless, or identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) are at greater risk for trafficking than their non-abused, non-homeless, and non-LGBTQ counterparts. Linguistically, educationally, economically, and otherwise systematically disadvantaged adults and minors, such as immigrants and racial/ethnic minorities, are likewise at elevated risk. Understanding risk factors can help clinicians recognize at-risk and potentially trafficked persons while avoiding victim (and perpetrator) profiling that is based solely on visual cues and can result in missed opportunities to assist.

Due to the inherently abusive and violent nature of these crimes, trafficked persons suffer a wide range of physical, reproductive, and mental health morbidity (see Table 1). Studies suggest that trafficked persons are accessing medical care during their exploitation and emergency departments serve as a primary health care access point. In one study of sex-trafficking survivors, nearly 88 percent of survivors surveyed reported accessing care at least once while trafficked, and 63 percent of them reported doing so in a hospital emergency department. Survivors present with the same injuries and illnesses as other emergency departments patients. However, delayed presentations (eg, walking on a fractured ankle for a week before seeking care) should raise concern for something amiss.

Table 1. Health Problems Associated with Human Trafficking

Adapted from Ann Intern Med. 2016;165(8):582-588.

For patients who are accompanied to the emergency department, potential red flags include accompanying persons who appear overbearing, attempt to answer all questions, insist on translating, and seem to want to control access to the patient. As accompanying persons can be traffickers or their associates, clinicians should be aware that these individuals can either pose as or be the patient’s parent, legal guardian, family member, family friend, spouse, romantic partner, roommate, friend, coworker, or manager/boss. To avoid missed opportunities, clinicians should always use professional language-interpretation services when needed and should always evaluate the patient in private at some point during the visit without seeking the patient’s permission to do so in the presence of the accompanying person and potentially placing the patient in a precarious position. Clinicians can accomplish this by simply stating it’s their policy to involve professional interpreters and/or evaluate the patient alone for a certain portion of the exam, or by resorting to less conspicuous, more creative ways to separate them or meet with the patient alone. Other potential indicators include patient responses that seem rehearsed or restricted, explanations that don’t match injury patterns, apparent and stated age discrepancies, patients who appear subordinate or fearful of an accompanying person, and patients who do not know their whereabouts (city) or their own address but are otherwise oriented and unaltered.

Trafficking survivors are threatened, coerced, and forced into submission and silence. Rarely will survivors volunteer any information or want to answer questions about their exploitation for fear of retribution, harm to loved ones (including children), deportation, or criminal charges. As with intimate partner violence, the person being trafficked is in the best position to determine the risk behind attempting an escape or seeking or receiving help. They possess firsthand knowledge of the threats made, the ease with which they or their loved ones can be harmed, and the degree of violence and lethality displayed by the trafficker. Trafficking survivors who believe their silence is protecting loved ones from harm may fear “losing control” of the situation by the involvement of immigration or police officers and the ensuing cascade of events. If, given the circumstances of the situation, the maximum response allowed by law is not definitive or forceful enough and cannot guarantee their protection, then victims may end up in potentially worse or even lethal situations. Clinicians should also be aware that victims may end up punished under the same anti-trafficking laws designed to protect them if they were forced or coerced to engage in recruitment or other trafficking activities.

Unless clinicians have good reason to believe that the patient’s life is in imminent danger, clinicians should always engage the patient in discussion, seek their consent before involving law enforcement, and avoid promising safety. In cases where involvement of outside authorities is mandated by law (ie, state mandatory reporting laws), clinicians should work closely with colleagues from other disciplines (eg, social work, child protection) to ensure the process is as transparent, predictable, and non-retraumatizing as possible.

In some situations, despite the abuse and violence, trafficked persons may not recognize their own exploitation and therefore may not identify with the victim narrative. This is most often the case in sex trafficking when the exploitation is achieved under the guise of romantic seduction rather than more overtly non-relational forms of victimization. In these cases, trafficking can have the appearance of intimate partner violence and may be initially understood as that alone by the exploited person. In addition to mandated reporting when applicable, clinicians should offer to consult social services for a lethality assessment, safety planning, and referral to resources. If a patient declines social work involvement, the clinician should be prepared to perform some of these tasks and recommend the patient returns to the emergency department when they’re ready to receive assistance or go to the nearest police station if the level of danger escalates.

One important resource for clinicians and patients is the 1-888-373-7888 National Human Trafficking Hotline. A patient can be offered a private space in the emergency department to call the hotline, and the clinician can offer to accompany them while making the call. If the patient asks the clinician to make the call on their behalf, the purpose of the call and how much personal information the patient wants revealed should be established first (eg, request for local resources versus assistance). The hotline number can also be provided to the patient for later use, or if a patient fears it being found in their possession, the clinician can help the patient memorize it by noting it may be more easily recalled as 888-3737-888. Patients can also text “HELP” or “INFO” to BeFree (233-733) to reach the hotline, but clinicians should remind patients that smartphones provided to them by the trafficker may be monitored. For greater effectiveness, emergency physicians should become familiar with the local anti-trafficking resources and partner with local law enforcement and other hospital disciplines (eg, addiction, child protection, forensic nurse examiners, social work, security, risk management, legal counsel) in developing a multidisciplinary protocol to facilitate and streamline a trauma-informed, victim-centered response.

Dr. Macias-Konstantopoulos is founding chair of the ACEP Trauma and Injury Prevention Section Human Trafficking Work Group. She is a physician in the department of emergency medicine at Massachusetts General Hospital and assistant professor of emergency medicine at Harvard Medical School, both in Boston.