The Human Trafficking Prevalence-Diagnostic Disparity in the Emergency  Department – A Stark Call for Action

Sanjeev Sirpal and Suman Kakar

doi:https://doi.org/10.1057/whr000023

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Commentary

The Human Trafficking Prevalence-Diagnostic Disparity in the Emergency Department – A Stark Call for Action

Sanjeev Sirpal and Suman Kakar

Women's Health Research [2023; 4(1):26-30]

DOI: https://doi.org/10.1057/whr000023

Received: 19 January 2023, Accepted: 13 February 2023, Published: 18 February 2023

Human trafficking (HT) is a burgeoning problem of global proportion with a recent report showing that there are over 40.3 million victims worldwide with over 70% of victims being women and girls and 25% of victims being under the age of 8. HT is a $150 billion dollar industry, representing the second largest stream of income for organized crime. It has also been identified as a global public health problem. Existing research demonstrates that there is a significant need for the screening of possible human trafficking victims in an acute care environment such as the emergency department.

Several studies demonstrate that most victims may not have access to primary healthcare and their first contact may be emergency department. By some estimates, 28%–87% of HT victims have some contact with the health care system and approximately 60% of them will present to the emergency department (ED) at some point during their exploitation. However, only less than 5% of ED physicians feel confident in their ability to
identify a trafficked individual. The cited reasons for such prevalence-diagnostic disparity include the oft-nebulous presentation of HT victims, health professionals’ limited awareness of HT symptoms and a confusion of the role of the care provider towards HT patients in a high paced acute care environment.

The objective of this article is to briefly examine the literature on the need for improved diagnostic strategies for human trafficking in the emergency department as well as to explore possible avenues for future research into improving such prevalence-diagnostic gap.

Key words:

Human trafficking, morbidity and mortality, exploitation

*Corresponding Author:

Suman Kakar, Associate Professor, Department of Criminology and Criminal Justice, Florida International University, 11200 SW 8th Street, PCA-352 B, Miami, Florida 33199, United States, E-mail: kakars@fiu.edu

Human trafficking (HT) is a burgeoning problem of global proportion with a recent report showing that there are over 40.3 million victims worldwide with over 70% of victims being women and girls and 25% of victims being under the age of 8 [1] [2] [3]. HT is a $150 billion dollar industry, representing the second largest stream of income for organized crime [4] [5]. It has also been identified as a global public health problem [6]. Existing research demonstrates that there is a significant need for the screening of possible human trafficking victims in an acute care environment such as the emergency department.

Several studies [7] [5] [6] [8] demonstrate that most victims may not have access to primary healthcare and their first contact may be emergency department. By some estimates [9] [10], 28%–87% of HT victims have some contact with the health care system and approximately60% of them will present to the emergency department (ED) at some point during their exploitation. However, only less than 5% of ED physicians feel confident in their ability to identify a trafficked individual [11] [12]. The cited reasons for such prevalence-diagnostic disparity include the oft-nebulous presentation of HT victims, health professionals’ limited awareness of HT symptoms [13] [14] [10] and a confusion of the role of the care provider towards HT patients in a high paced acute care environment.

1. Burden of the Human Trafficking problem

According to the International Labour Organization, 25 million people are estimated to be affected by human trafficking on a global basis. Owing to methodological differences in estimates [15] and as a consequence of the nature of the offence – an oft-invisible yet ubiquitous crime – this number is likely an underestimate of the global burden of the human trafficking problem [16].

In Canada, the Canadian Centre to End Human Trafficking (CCEHT) reports self and community reported data [17]. In 2019, for 115 cases of human trafficking were reported involving 593 victims. The majority were related to sex trafficking, and females constituted 90% of the victims. Vulnerable patient populations as well as marginalized groups are disproportionately more susceptible to trafficking. The literature suggests that structural determinants including systemic racism, rigid immigration policies, increased demand for commercial sex, as well as vestiges of colonialism woven into the fabric of modern-day society [18] [1] [19] create systemic factors that potentiate the risks and probabilities of human trafficking and amplify individual factors that draw victims to HT (e.g., economic need).

There are notable health consequences of human trafficking that have been documented in the literature. HT survivors often have been subjected to various forms of abuse, dangerous living conditions, and health outcomes that directly result there from [20]. Inasmuch as traditional health consequences of HT have been reported in the literature, including both physical and mental health consequences, little attention has been paid to the ensemble of socioeconomic and legal sequelae endured by HT victims.

There is a paucity of rigorous public health evidence on the mobility and mortality of HT mostly owing to methodological challenges. Notwithstanding this, the literature suggests that HT and its consequences are closely tied with morbidity and mortality, life expectancy and quality of life, and injury rates. The burden of HT and its consequences has been estimated at 2.8 trillion U.S. dollars on a world-wide level [21].

2. Identifying human trafficking

The US National Human Trafficking Hotline (NHTH) identified 22,326 survivors of human trafficking (HT) across the United States in 2019 [22]. Among these, the majority were sex trafficking victims. It is one of the most pervasive and the least visible crimes that have far reaching long-term effects. HT victims, in addition to varied other effects, suffer serious health effects [8]. They are at a disproportionately higher risk for health consequences compared to their non-HT counterparts [23] [24]. Some health manifestations of HT consequences include physical injuries, untreated chronic health conditions, substance abuse, and sexually transmitted infections along with a host of psychosocial manifestations – repetitive emotional and physical abuse, social marginalization, legal insecurity, and economic exploitation [23] [8].

ED health care personnel are uniquely poised to screen for possible HT, given that up to 88% of victims report seeking medical care during the period of their exploitation [11] [25] [26]. Notwithstanding the high consultation rates, HT detection is challenging given the reticence of victims to self-report abuse and the fact that care providers are rarely adequately equipped to detect signs of HT, given its inherent broad scope and complexity in presentation [12] [8]. Rapoza conducted a review of the existing research on HT (between 2010- 2020) [8]. They identified 41 primary research articles. Their results concluded that health providers reported to have had little to no training towards identification of HT [27] [28] [29] [8]. Therefore, few providers felt confident to identify victims.

Marcinkowski et al. performed a scoping review of sex trafficking and intervention in the emergency department [30]. They identified 23 articles that met the established inclusion criteria focusing on adult human sex trafficking identification, screening, interventions, or education in the ED. The authors demonstrated that most published research was descriptive and qualitative in nature, and that there is a paucity of validated screening tools for the identification of possible adult trafficked victims in the ED. Furthermore, educational and training interventions as well as dedicated screening tools may improve clinician confidence, victim identification, and referral of patients to appropriate resources.

3. Vulnerable patient populations

HT-vulnerable patient populations in the North American context include: “children in the child welfare and juvenile justice systems; runaway and homeless youth; children working in agriculture,manufacturing, and other industries,; American Indians and Alaska Natives; migrant laborers; foreign national domestic workers in diplomatic households; employees of businesses in ethnic communities; populations with limited English proficiency; persons with disabilities; rural populations; and lesbian, gay, bisexual, and transgender individuals.” [4]. Psychosocial factors predisposing individuals to HT include poverty; prior physical, sexual, and emotional abuse; substance abuse; and limited education [23].

Younger patients at risk of HT may include those with a history of multiple sexually transmitted infections, complex mental health history, substance abuse, and homelessness [31] [32].

The goal of an ED encounter with a possible HT victim is tripartite: 1) addressing health reason for consultation; 2) establish the ED as a safe haven; and 3) adequately refer the patient to appropriate resources and services for follow-up care. It is salient to note that the role of an ED visit is not necessarily disclosure. As such, known paradigms in care for child abuse and domestic violence can be adapted for implementation by clinicians in the ED context [33].

4. Avenues for future research towards curbing the prevalence – diagnostic gap in HT

There is decidedly a need to augment healthcare provider ability to recognize and respond to suspected human trafficking. Extant research demonstrates the increasing prevalence and burden of the human trafficking problem. Yet, healthcare providers are severely underperforming in their ability to adequately detect signs of human trafficking, and correspondingly intervene to refer patients to the appropriate resources. This aptly termed prevalence-diagnostic gap merits further attention and elaboration of specific approaches to curb such discordance.

Winks et al. assessed frontline medical professionals' knowledge of youth sex trafficking, adolescent development, and forensically informed interviewing to provide guidance for professional training [34]. The authors in that study surveyed 277 frontline medical professionals about their background, training, perceptions of likely youth sex trafficking scenarios, knowledge of adolescent development, sex trafficking, and forensically informed interviewing. The result of the survey revealed that there are significant knowledge gaps among frontline medical professionals in awareness of youth sex trafficking, appropriate interviewing techniques, and adolescent development. The authors suggested that appropriate and tailored training programs could address preconceived notions of typical victims, commonly presented victim characteristics, and allow for more effective and pertinent interview techniques to better meet the needs of HT victims.

Furthermore, McAmis et al. examined the self-reported knowledge levels of healthcare providers most likely to come in direct contact with victims of human trafficking [35]. The authors developed and distributed an online survey assessing self-reported knowledge of human trafficking. The survey respondents totalled more than 6000 and included physicians and allied health personnel. The authors concluded that HT-specific training was essential, and that universally appropriate curricula should be developed both for healthcare providers but also institutional staff.

Tiller and Reynolds developed a protocol to guide members of their local emergency department in order to identify at-risk patients through both screening questions and general observations [36]. Furthermore, their protocol centers around appropriate interviewing techniques with an emphasis on patient-centered and trauma-informed care.

The growing burden of the HT epidemic in North America and the prevalence of HT victim-patient consultations in the ED renders the Emergency department uniquely poised to screen possible HT and refer victims to appropriate patient resources. There is a stark need for the development of universally deployable protocols and concomitant ED personnel curricula to bridge the HT prevalence-diagnostic gap.

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PEER REVIEW

Not commissioned. Externally peer reviewed.

References