Diagnosis: Human Trafficking

Diagnosis: Human Trafficking

By Mary Adams, AWC The Hague

Violence against women is major health problem and a violation of women’s human rights. When the United Nations announced the 2030 Sustainable Development Goals agenda, in SDG 5 (Gender Equality) they included target 5.2: Eliminate all forms of violence against women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation. Studies have indicated approximately 87% of trafficking victims visit a health care facility during their captivity. A health practitioner writing for Physicians Weekly commented, “What is truly frightening is that approximately10% of physicians in the United States recognize a human trafficking victim and less than 3% of emergency room doctors receive any training in recognizing them.”[1]

This raises an interesting question: Could adequate training provide a rare opportunity for health care providers to identify and report trafficking victims? There is a global awakening that the answer is YES, but identifying trafficking victims is very difficult. Victims of human trafficking have no “classic” presentation. Many women do not identify themselves as human trafficking victims because their traffickers are with them at the health care facility, shame, fear of harm to their families if they tell or even worse, or Stockholm Syndrome when victims form positive feelings about traffickers.  

The health sector in the United States has a firm commitment to ending violence against women by identifying potential trafficking victims through greater awareness programs. The Human Trafficking Legal Center contends that healthcare providers have an important, proactive role to play in combating human trafficking. This is a documented case from the Human Trafficking Legal Center of what is happening every day at medical centers across America.

In Ohio, a young woman with cognitive disabilities was held in domestic servitude and forced labor for two years. She suffered severe physical and sexual abuse at the hands of her traffickers. The traffickers repeatedly injured the victim to secure painkillers and prescriptions for additional pharmaceuticals. The defendants smashed the victim’s hand with a rock, beat her back with a wooden fence post, and kicked her in the hip with a steel-toed boot. After each injury, the traffickers took the victim to an emergency room or another medical facility. Their goal in each case was to procure opioids for their own use. They succeeded. In each instance, the traffickers accompanied the victim as she received medical care. At no point did healthcare providers identify the woman as a victim of trafficking. She escaped only after the police arrested her for stealing a candy bar at a store. In all, the victim had at least three contacts with medical personnel.[2]

As health care professional awareness rises and clinicians recognize their role as first responders to human trafficking victims, they are thrust into a unique position at the intersection of health and law.[3] Legal requirements regarding mandatory hospital reporting of human trafficking are in place but differ from state to state. With proper training, health care providers can play a significant part in identifying and caring for trafficking victims. Personnel can also document injuries, testify as expert witnesses, and provide affidavits for submission in legal cases. But in order to be able to identify trafficking cases, health care providers must be familiar with red flags and trafficking indicators.[4]

In 2008, Massachusetts General Hospital launched an initiative to frame human trafficking as a public health issue and advance anti-trafficking efforts in research, education, policy and clinical care. The following example further explains the difficulties medical professionals face in identifying potential victims when dealing with patients with language barriers and a fear of authority (including healthcare workers).  The following incident is from an actual hospital case report.[5]

Police transported a 36-year-old Spanish-speaking female to Massachusetts General Hospital for intimate partner violence. She reported that she had been living with her boyfriend for two months and in recent weeks she “constantly made mistakes” and was “punished for them.” Her vital signs were normal. Examination revealed several bruises in various stages of healing around her eyes and ears, her left shoulder, and her upper left thigh. There was no evidence of fractures.

At this hospital, the staff suspected that something else was going on that the patient did not want to discuss. This seems like a dominating and violent relationship if an adult woman is being “punished.” If English was not her native tongue, could she tell the full story about what happened to her? The hospital took additional steps and conducted another interview in Spanish.

Through a medical interpreter, a more detailed history revealed that her plight had been more complicated than was initially reported. Several months prior, she had been living in her home in Colombia, and was “befriended” by a woman who claimed that she was visiting the country temporarily. This new “friend” electronically introduced her to a man living in Massachusetts. After a brief period of email exchanges, our patient traveled to Massachusetts to meet her new online romance. She claimed to have been swept off her feet and said, “everything seemed perfect.” However, within days, she found herself trapped and feeling helpless. He took away her passport and forbid her to leave his home. The romance was quickly replaced by endless work with physical and sexual abuse. After a few weeks, the woman that our patient had met in Colombia arrived at the home and took her place as the man’s true spouse. On the day that she was transported to MGH, she had escaped the home and run to a neighbor for help.

Traffickers use force, fraud or coercion to lure their victims and force them into labor or commercial sexual exploitation. This woman was definitely a victim of both physical and mental violence as well as being trafficked. Once the woman was identified as a human trafficking victim, the hospital was able to respond in a team approach to contact the appropriate resources for housing, food, medical care and legal services. In this way, medical providers have a unique opportunity to provide potential trafficking victims with information and options.

“Every nurse takes vitals. Some collect evidence.”

Researchers have discovered that changes in the way that healthcare workers interact with possible victims can make a big difference. Studies have shown that trafficking victims are more likely to talk to medical staff than police.[6] A 2017 study at Allegheny Health Network in southwestern Pennsylvania found advanced training helped identify trafficking victims. This study, published in the Journal of Emergency Nursing, noted 38 patients were identified as possible human-trafficking victims at the hospital during the five-month pilot program. After further examination, one of the patients was confirmed as a victim of trafficking.

The study inspired Duquesne University (Pittsburgh, PA) to develop new training in forensic nursing especially in the role as advocate for patients. “Assessing and identifying human trafficking cases is essential to rescuing victims from a life of desperation and brutality. Seeking legitimate medical care may occur only in cases of severe need, however sensitive and culturally sensitive questioning may break the silence and afford the victim the opportunity for rescue,” said Barbara Moynihan, Ph.D., an Advanced Practice Registered Nurse (APRN) who is lauded as one of the first nurses to identify the role of forensic nurses in human trafficking. “As health care providers we have a responsibility to provide comprehensive, holistic, and culturally-sensitive care in a safe setting.”[7]

It is interesting to note that although a variety of health professional organizations have released statements regarding education on human trafficking—including the American College of Obstetrics and Gynecologists, the American Medical Association Medical Student Section, the Christian Medical and Dental Associations, and the American Academy of Pediatrics—there is still no standardized, “formal, evidence-based curricula” for medical professionals.[8]

Evidence is data.

In June 2018, the American Health Association’s (AHA) Hospitals Against Violence initiative released the first ICD-10CM codes for classifying human trafficking in 2018 in partnership with Massachusetts General Hospital’s Human Trafficking Initiative and Freedom clinic and Catholic Health Initiatives.[9]  The International Classification of Diseases, Tenth Revision, Clinical Modification  (ICD-10CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. Starting in October, healthcare providers can use these new diagnosis codes in their records that differentiate trafficking from other types of abuse. This will help track the number of victims and provide appropriate treatment.

In addition to the diagnostic codes, the entire healthcare sector is collaborating to conduct trainings and provide onsite materials. Training is given not only to doctors and nurses but also to registration and reception staff, social workers and security guards. What are the red flags that hospital staff need to learn to link the violence with trafficking? Examples of red flags include:

  • · Clinical presentation and oral history do not match
  • · Oral history is scripted, memorized or mechanical
  • · Someone with the patient exerts an unusual amount of control over the visit
  • · Patient appears fearful, anxious, depressed, submissive, hyper-vigilant or paranoid
  • · Patient is not in possession of her identity documents

Literature on the health care needs of trafficking victims, tools for identifying trafficked persons, and the role of physicians in fighting trafficking continues to grow. AHA, the National Human Trafficking Resource Center and the World Health Organization as well as other organizations publish fact sheets and provide training and e-learning. Literature includes a comprehensive list of other trafficking indicators such as mental health and social / developmental.

This excerpt from an online NPR article[10] provides a glimpse into future care where everyone involved in at a medical facility is responsible for trusting a gut feeling that something isn’t right when meeting patients.

The woman arrived at the emergency department at Huntington Hospital on New York's Long Island after she was hit by her boyfriend during an argument. Her situation raised concerns among the medical staff, which had recently been trained to be on the lookout for signs of sex trafficking.

An undocumented immigrant from El Salvador, she worked at a local cantina frequented by immigrants. Her job was to get patrons drinks and to dance with them, but many workers in those jobs are expected to offer sex, too. Her boyfriend didn't want her to work there, and that led to the fight, one doctor recalled. 

As part of the intake process, the emergency staff asked the 36-year-old woman a series of questions about whether she'd ever had sex for money, or whether she had to give someone else part of what she earns, among other things. The screening questions were part of a new program at Northwell Health, a 23-hospital system in the New York metro area that includes Huntington Hospital, to train staff and provide them with tools to identify and support victims of human trafficking.

Violence against women is now proven to be closely linked to human trafficking. The health care sector is joining the ranks of first responders in a cohesive way that links learning to practice, law to medicine, and patients to community. By taking a greater role in identifying victims, the health care professions are ending violence against women. For victims, surviving violence from traffickers does not end at the hospital – it is the beginning of a long journey back to mental, physical and spiritual health.  It is no coincidence that four of the six letters in health are ‘heal.’ – Ed Northstrum


[1] Girgis, Linda MD, "How are you treating human trafficking victims in your practice?", Physician’s Weekly, May 9, 2018.

[2] Bessell, S, Baldwin SB, Vandenberg ME, Stoklosa H. "Human Trafficking and Health Care Providers: Lessons Learned from Federal Criminal Indictments and Civil Trafficking Cases." Human Trafficking Legal Center and HEAL Trafficking; 2017.

[3] Clydette Powell, Michelle Asbill, Samantha Brew & Hanni Stoklosa (2018) "Human Trafficking and HIPAA: What the Health Care Professional Needs to Know", Journal of Human Trafficking, 4:2, 105-113, DOI: 10.1080/23322705.2017.1285613

[4] Hanni Stoklosa, Grace Aimee, Nicole Littenberg, Medical Education on Human Trafficking, 17 AMA J. ETHICS 914, 914-921 (2015); Clydette Powell, Kirsten Dickins, Hanni Stoklosa, Training US Health Care Professionals on Human Trafficking: Where Do We Go from Here?, MED EDUC. ONLINE, Jan. 2017.

[5] Patel RB, Ahn R, Burke TF. "Human Trafficking in the Emergency Department". Western Journal of Emergency Medicine. 2010;11(5):402-404.

[6] Bespalova N., Morgan J., Coverdale J. “A pathway to freedom: An evaluation of screening tools for the identification of trafficking victims,” Academic Psychiatry. 2014:1–5.  [PubMed]

[7] Duquesne University School of Nursing Blog,

[8] Grace A.M., Ahn R., Macias Konstantopoulos W. “Integrating curricula on human trafficking into medical education and residency training,” JAMA Pediatrics. 2014;168(9):793–794.  [PubMed]

[9] ICD-1—"CM Coding for Human trafficking Fact Sheet", American Hospital Association, September 2018

[10] Andrews, Michelle, "Hospitals Gear Up for New Diagnosis: Human Trafficking", Health News from NPR, July 24, 2018.

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