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INDICATORS OF LABOR TRAFFICKING Patients will often appear malnourished or extremely dehydrated. Most will have poor dental hygiene, untreated skin infections, or serious injuries from exposure to harmful chemicals. Some patients will have ophthalmologic complaints due to lack of protective eye equipment. They may claim to work in “mom-and-pop” businesses, farms, factories, construction, or oil/gas extraction. Victims may carry high debt, live in crowded sleeping quarters, and sleep only in shifts. DOCUMENTATION IN THE CHART According to the Assistant State Attorney of the Anti-Trafficking Unit, physicians should document the following in order be proactive: State who the patient is with, e.g. “Male who seems to be answering all the questions for patient, very defensive about leaving patient alone in the room with the doctor.” Document if the patient appears intoxicated, fearful, or disheveled. Include tattoos, bruising, and clothing in the documentation, as well as the scene on EMS arrival. It is appropriate to document statements by the patient or others around her/him RESPONDING TO VICTIMS OF HUMAN TRAFFICKING Institutions are encouraged to implement a human trafficking protocol in the emergency department. The National Human Trafficking Resource Center has examples of algorithms that may be used, as well as specific resources for patients. The first step is to carefully separate the victim from the trafficker. A reasonable example is to ask the patient to provide a urine sample. Next, attend to the medical, psychological, and basic (clothing, food, etc.) needs of the patient. Sit at eye level and perform a safety check by asking “Is it safe for you to talk to me right now?” Next, determine if the patient is working or has a means of income. Ask questions pertaining to their work environment. Examples include “What are your work hours? Can you come and go as you please? Do you owe money to your employer or anyone else? Do you feel safe? Where do you eat and sleep? Is anyone hurting you or threatening you? Did someone tell you what to say today?”Questions helpful when assessing for sex trafficking: Do you feel safe at home? At school? With your boyfriend or spouse? With your peers? Is anyone hurting you, threatening you, or pressuring you to do anything you don’t want to do? Is anyone hurting or threatening your family, children, or friends? Is anyone forcing you to have sex with others or to perform sex acts for money, food, clothes, drugs, or a place to sleep? Has anyone ever taken a photo of you that made you feel uncomfortable? Was it posted on a website for classified ads? OFFER RESCUE Educate the patient on their rights and resources available to them. Offer assistance, but if the patient declines then respect their decision. Call the Human Trafficking Hotline at 888-3737-888 to report a possible case. Offer to place the human trafficking phone number in the patient’s shoe. It may also be provided in the follow up instructions disguised as the primary care physician office number to follow-up with. Alternatively, the patient may memorize the number. Tell the patient that, if their “no” turns into a “yes” at any time, they can always return to the ER. If the patient needs an excuse to come back, place a follow up appointment in their discharge instructions. The goal should not be “rescuing” or gaining disclosure from the patient. The goal is to create a safe, non-judgmental space to educate the patient on their rights, options, and offer assistance. PROTOCOL ATAVENTURA HOSPITAL At Aventura Hospital, we developed a human trafficking protocol with three screening tools. The first screening method is based on indicators or “red flags” of trafficking. The second screening method is a question at triage that asks “Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened, or made to feel physical pain for working slowly or for trying to leave?” The third screening method is also referred to as the “urine cup method.” Posters with educational material about human trafficking are placed in the restrooms and if patients believe they may be a potential survivor of human trafficking, they are asked to place a blue sticker on the bottom of their urine cup. CONCLUSION Human trafficking is an egregious criminal act and human rights violation. A majority of survivors of human trafficking access medical services at some point during their captivity. Providers everywhere, in particular those in primary care, reproductive health, mental health, and pediatrics, must be cognizant of the indicators of human trafficking, barriers to disclosure, and how to provide trauma-informed care. Emergency medicine providers are in a unique position to be a fundamental part of the solution to this global epidemic. This article was originally published in the July 2019 edition of The Pulse. Globally countries are detecting and reporting more victims, and are convicting more traffickers. This can be the result of increased capacity to identify victims and/or an increased number of trafficked victims Countries have reported increased numbers of detected trafficking victims over the last few years. While the number of reporting countries did not significantly increase, the total number of victims per country did. The trend for the average number of detected and reported victims per country had previously fluctuated during the earlier years for which UNODC has collected this data, but it has been increasing steadily over the last few years. From a regional perspective, the increases in the numbers of detected victims have been more pronounced in the Americas and in Asia. These increases can be the result of enhanced national capacities to detect, record and report data on trafficking victims, or to a growth in the incidence of trafficking, that is, that more victims have been trafficked. Enhanced national capacity to detect victims could be achieved through strengthened institutional efforts to combat trafficking including legislative reforms, coordination among national actors, special law enforcement capacities and improved victim protection efforts, to mention some. In countries with a long-standing anti-trafficking framework, with no major recent legislative or programmatic initiatives, more detections may be more likely to reflect an increased number of trafficked victims. Trends in the total number of detected trafficking victims, average number of detected victims per country and number of reporting countries, by year, 2003-2016 Source: UNODC elaboration of national data. Trends in the number of people convicted of trafficking in persons since 2007, globally and by region, 2007-2016 Source: UNODC elaboration of national data. 196 168 192 215 203 163 181 150 170 179 216 198 238 254 50 100 150 200 250 300 5,000 10,000 15,000 20,000 25,000 30,000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Average number of detected victims per country reporting to UNODC Total number of detected victims reported to UNODC 39 Number of countries covered Percentage of world population 58 68 71 62 79 85 93 81 87 80 100 104 97 23 32 36 38 40 35 39 43 35 45 44 50 51 47 -10% 21% 30% 67% -50% 0% 50% 100% 150% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Europe and Central Asia South Asia, East Asia and the Pacific The Americas Africa and the Middle East Global GLOTiP_2018_BOOK.indb 7 17/12/2018 19:49:05 8 GLOBAL REPORT ON TRAFFICKING IN PERSONS 2018 Over the last ten years, the capacity of national authorities to track and assess patterns and flows of trafficking in persons has improved in many parts of the world. This is also due to a specific focus of the international community in developing standards for data collection. Capacity building in data collection has become one of the aspects of counter trafficking activities that the international community considers for evidence-based responses. More countries are now also able to collect and record data and report on trafficking in persons, the capacity to collect official statistics on trafficking in persons at the national level has improved. In 2009, only 26 countries had an institution which systematically collected and disseminated data on trafficking cases, while by 2018, the number had risen to 65. Still large areas of impunity While most countries have had comprehensive trafficking in persons legislation in place for some years, the number of convictions has only recently started to grow. Pronounced increasing trends in the numbers of convictions were