Original Contribution

Hidden in Plain Sight

Valerie Amato, NREMT

03/22/2019

For many people the term human trafficking conjures up dramatic images of kidnapped girls transported across borders and held against their will. While some trafficking victims are subjected to these horrors, their situations are often far more complicated and much less noticeable, and may be happening right in your backyard.

According to the website of the Polaris Project, an organization working to abolish human trafficking globally, “most human traffickers use psychological means such as tricking, defrauding, manipulating, or threatening victims into providing commercial sex or exploitative labor.”

The trafficking victim may have been the anxious 14-year-old female you saw at the hotel with severe pelvic pain and a poorly healed broken wrist, or the 16-year-old male with multiple contusions incongruous with his story about soccer injuries. It may have even been the malnourished 48-year-old male laborer who doesn’t speak English or have a valid ID, and who appears to be living in the very house he’s helping construct. Victims are often hidden in plain sight, unable or unwilling to seek help out of fear of abuse and retaliation from their traffickers.

Your Patients, Their Victims

Most people don’t realize how endemic human trafficking is in America. First responders “often come in direct contact with victims during the course of our day-to-day operations,” says Richard W. Patrick, director of the National Fire Programs Division of the United States Fire Administration (USFA). “We have an advantage to pay attention to things that don't seem right and have a great opportunity to save lives [by reporting] without even realizing we actually made a difference.”

Patrick works on the Department of Homeland Security’s Blue Campaign, an initiative that began in 2010 to combat human trafficking by collaborating with law enforcement and government entities such as Immigration and Customs Enforcement (ICE) and U.S. Customs and Border Protection. During its infancy Patrick worked at the DHS Office of Health Affairs, where he led the department’s first responder integration in special hazard areas for EMS and fire services. The Blue Campaign works to educate first responders on human trafficking, specifically fire and EMS personnel, considering their constant interaction with patients.

“Virtually every community in the nation likely has some form of trafficking associated with it. This is modern slavery,” says Patrick. “By noticing indicators of human trafficking when they enter homes or businesses, properly trained EMS and fire personnel play a very important role in saving victims’ lives by simply reporting their suspicions to ICE or local law enforcement. If you see something, you need to say something. Some would say it’s cliché, but we cannot allow it to be cliché.”

The Polaris Project’s National Human Trafficking Hotline has received nearly 34,700 reports of sex trafficking and 7,800 reports of labor trafficking in the United States since 2007. And in 2017 the National Center for Missing & Exploited Children estimated 1 in 7 reports on endangered runaways probably involved victims of sex trafficking. Considering these statistics, the odds of a first responder encountering a victim of trafficking are unfortunately likely.

In partnership with the DHS, the USFA’s education outreach efforts have reached thousands of first responders to date, providing “tangible, digestible information…for every level from senior management to the boots on the street,” Patrick says. One particularly handy resource for responders is 3.5-by-2-inch indicator cards that list common signs of trafficking and how to report suspected cases of it.

Agencies can order these cards in packs of 50 in a variety of languages from the Blue Campaign’s materials page so they can be discreetly handed to patients who may be victims of trafficking (like inserting it into a shoe during an assessment).

Below are some of the indicators on the cards to look out for:

Has the victim been harmed or deprived of food, water, sleep, medical care, or other life necessities?
Does the victim have freedom of movement?
Was the victim forced to perform sexual acts? (If a minor is involved in commercial sex, this is automatically considered trafficking.)
Can the victim freely contact friends or family? (If someone else is speaking for the patient instead of allowing them to speak for themselves, this is a red flag.)
Is the victim in possession of identification and travel documents? If not, who has control of the documents?

Even if you get to speak to the patient alone and they are indeed being trafficked, they may not admit it or ask for help. Traffickers are master manipulators who convince their victims they cannot survive without them—so much so that they’re sometimes allowed to roam freely without the traffickers worrying they will say anything to anyone. This is especially the case when traffickers have threatened to harm the victim or their family if they dare speak up. Some traffickers carry out violence against victims’ families to convince them of their control over their lives.

While on scene of a suspected trafficking case, “The recommendation is to provide care as usual and report later, like you would in a child abuse case,” says Patrick. “Treat the patient, transport if applicable—keep in mind that a lot of trafficked people aren't allowed healthcare." Look for indicators like old scars or wounds that weren't treated appropriately, mutilations, and infections.

Trafficking rings may hire rogue medical care providers, who are really just criminals with negligible medical knowledge, to treat the victims, adds Patrick—real medical professionals are only called when victims’ wounds are beyond their abilities to treat.

“In the Blue Campaign, they go by what’s called the three Ps,’” says Patrick. “It stands for prevent, which encompasses effective outreach and education; protect, which involves a healthcare component and immigration relief; and prosecute, which is a successful law enforcement investigation. It’s a victim-centered approach to law enforcement investigations.”

“There are things that need to be built out more for our first responder community, like reporting mechanisms,” says Patrick. “It's important for EMS and fire to collaborate with our law enforcement colleagues in having situational awareness.”

Once responders are trained on identifying signs of trafficking, determine on a local level how the reporting process should go. While the ICE hotline is important, whom else should you contact locally for a suspected trafficking case? Consider the resources available for a victim should they come forward, such as local shelters.

Trauma-Informed Care

Mike Lynn, a firefighter-EMT with the Alexandria (Va.) Fire Department, educates first responders and the public on identifying human trafficking victims for the Northern Virginia Human Trafficking Task Force. When he began working with the group and learned how pervasive trafficking is, he was sure he had come across victims without realizing it and recognized the need for a training program. Research turned up few results for training specific to fire and EMS personnel, so he sought experts and developed a program based on information from the Polaris Project. (Within a few weeks of a similar program delivered to first responders in Fairfax County, Va., a paramedic identified a victim they were able to help).

“Looking back on my career, I have probably run into [trafficking victims], where I thought it was a cut-and-dry prostitution or substance abuse case and now looking at it, there were red flags or something felt weird, but I couldn’t put it on anything. It really happens a lot,” says Lynn. “If you’re not familiar with the signs, it is very, very easy to hide in plain sight.”

While any of the indicators by themselves don't necessarily point to trafficking, if coupled with other red flags, they're worth investigating. A key point Lynn makes is the importance of responders approaching their departments about developing a protocol for recognizing and reporting trafficking cases. A core component of Lynn’s department’s protocol involves scene control. “Controlling the scene in a way that does not provoke any hostility from people on site” is crucial to developing a good rapport with victims, who may actually be protective of their traffickers, essentially developing Stockholm syndrome.

Having law enforcement on scene to help enforce that order allows EMS providers to spend time with victims. “We’re still sort of the ‘good guys,’ and the police can be the ‘bad guys’ taking people out of the room so we can start interviewing the victim by way of trauma-informed care so we’re not creating hostility,” says Lynn.

While some victims take advantage of being separated from traffickers to ask for help, “the majority of them tend not to self-identify as victims” due to the trauma they’ve endured, which is a common facet of their coping mechanisms, he says. “The use of force, fraud, and coercion is how a lot of traffickers control their victims, and a lot of it’s through fear of physical violence.”

Trauma-informed care is being aware of the patient’s past trauma and understanding its adverse effects on their behavior when treating them. The expectation is that every victim will jump at the opportunity for help, but the reality is most are so emotionally and psychologically tied to their traffickers that they feel safer with them than without.

“The executive function of the brain sometimes goes a bit offline because they're in survival mode,” Lynn says. “They'll have to feel some measure of safety, rapport, and trust with whomever they’re talking to before they’ll give any information, even if it’s in their best interest, because they’re just trying to survive and we’re an unknown factor. They know at least they can survive the other world.”

With this in mind, EMS providers shouldn’t try to persuade victims—trusting their answers, true or not, shows them they can trust you too. If you get to transport the patient to the hospital, “Let them have a significant amount of control about what happens with them. That goes back to your trauma-informed care, but the continuity of information going to the ER is a big part of it too,” says Lynn. And of course, having law enforcement involved from the beginning helps get the ball rolling on investigating the criminal aspect of the incident.

Typically what a trafficker will do is find somebody with some kind of vulnerability, perhaps financial or emotional, and leverage that against them. Young people who have had some kind of abuse at home can be susceptible. Other vulnerable populations include homeless youth (particularly LGBT), people with mental disabilities, and undocumented foreign nationals.

“Not only do victims fear the trafficker, but whatever situation they were in to begin with probably still exists and it’s now been exacerbated by the trauma, so it’s very difficult for them to return to what we would consider a normal life,” Lynn says.

Getting Help

Taking into account that some victims have no outside support network and struggle with substance abuse or psychological issues, their recovery and ability to start a new, healthy life will require appropriate resources your agency can acquire for them.

“Traffickers have already demonstrated that their value of other human beings is not where the rest of society’s is. That violence can occur against us, but it can also occur against the victim if a trafficker feels any kind of threat, so involving law enforcement right away is a good idea,” says Lynn. “But I call the hotline, too. Nobody knows how big the problem is because nobody has good statistics on it yet.”

Valerie Amato, NREMT, is assistant editor at EMS World. Reach her at vamato@emsworld.com.

Sidebar: Potential Sex Trafficking Indicators In Patients

Hypervigilance, paranoia, fear, anxiety, depression, submission, nervousness
Inconsistencies in story; story does not match injuries
Evidence of violence/physical abuse
Addiction/substance abuse; long-term antibiotic use
Disorientation about time or location
Tattoos or branding (may indicate “ownership”)
From the foster care system, homeless, runaway
Environment: e.g., hotel with doors to the outside, multiple females in a room, security designed to keep people in (locks on outsides of interior doors)
Pregnancy resulting from rape/being prostituted (reproductive coercion is a central element of sex trafficking—more than one-fourth of women report forced abortions)
Pelvic pain; vaginal or rectal trauma
STDs, urinary tract trauma/infections/mutilations from bad procedures
Chronic untreated health problems, including cardio, respiratory, gastrointestinal
Weak eyes or eye problems from working in dimly lit areas
Dental, jaw, and neck problems
Chronic back pain

Sidebar: Education That Can Save a Life

Human trafficking wasn’t always on the Williamson County EMS radar. In 2016 Commander John Gonzales and I attended the National Association of EMS Physicians conference in San Diego. The important yet typical fare of NAEMSP is mostly clinical research. Neither of us expected the powerful story brought to us by Rebecca Bender, a human trafficking survivor and education advocate. As her desperate story played out before the audience, John and I realized we’d missed some real lifesaving opportunities as field medics. We could both reference patients who were almost surely being trafficked. As educators we promised ourselves we would bring the message home. It took us a few years and a new building with adequate meeting space to get human trafficking education on our agenda. We found many willing participants, each with an important mission and most with a personal story to tell. If you’ve got the space, you will be amazed at the number of organizations willing to provide your staff with valuable education at the right price (free). Organizations eager to share their knowledge are best found by starting within the public safety community. Cast your net wider using an internet search, but beware, not all of these groups are equal, legit, or capable of providing education. Do your homework!

Look for a five-part CE series on human trafficking from WCEMS on EMSWorld.

–Dan Cohen, LP, Captain, Clinical Practice, Williamson County EMS

Sidebar: Where To Get Help

If you suspect a case of human trafficking, please report it to any of the following organizations: