Human Trafficking in Healthcare: Learn to See the Unseen

I work as a rapid response nurse at a large academic hospital system. After 20 years at this hospital and 34 years in nursing, I thought I had seen it all – until one day when I was called to a rapid response alert on a peripartum unit.

The bedside nurse was concerned that her patient, who I’ll call Mrs. J, was experiencing a myocardial infarction (MI). Mrs. J was admitted to the emergency department the night before with demand ischemia on her 12-lead ekg due to cocaine use. She now complained of mild mid-sternal chest pain and shortness of breath, and was thrashing around, screaming and crying in her bed. Like all other potential MI cases, we ruled out injury with a 12-lead (it showed normal sinus tachycardia), drew some troponins and called for a cardiology consult.

Clinically, the patient appeared stable. The nurse informed me that the patient was having a bad day because she had received some disturbing information about her health that morning, so this looked like an anxiety attack to my nursing eye. My nursing gut, however, told me that something else was wrong and I needed to take another look at the situation in front of me.

The Invisible Patient

Mrs. J’s hair was disheveled and matted. She had herpes blisters on her lips and chin. Bruises covered her body, and the fingerprint bruises on her thighs were consistent with a grab mark pattern – the kind of fingerprint bruises that are sometimes associated with rape victims. A poison ivy rash affected Mrs. J’s arms, legs and trunk, and her skin had old blood, dirt and scabs. A tattoo across her lower abdomen read “Property of Daniel.”

When I looked at her chart, I found that Mrs. J had been admitted with pyelonephritis, dehydration, starvation and acute kidney injury. She tested positive for polysubstances on her drug screen. In addition, Mrs. J tested positive for many sexually transmitted infections and hepatitis C, and was unaware she had contracted these infections until the morning of our encounter. Her initial HIV test results had come back positive, although the repeat test produced a negative result. What most concerned me was that she was 24 weeks pregnant with no prenatal care – Mrs. J had no idea she was pregnant.

I was heartbroken and believed she was being trafficked, or at least severely abused. I thought back to the month before, when I attended human trafficking education classes through a program called She Has a Name. Two of my friends and co-workers had recently become involved with human trafficking victim identification and outreach to combat this growing issue, and encouraged me to attend one of their classes. When one of my friends started a nonprofit organization called Local Outreach Volunteers (LOV) to help the unhoused and trafficked people in our city, I continued my education about this underserved population. I joined a team of social workers, nurses, ministers, lawyers, police officers and community leaders in an outreach program aimed at helping prostitutes get off the street and receive help.

As a result of my education and LOV involvement, I assessed that something was not right with Mrs. J. Deeply concerned for her well-being, I decided to trust my gut and intervene.

Helping Mrs. J Make Choices

I waited in the hallway for everyone to leave Mrs. J’s room and went in to talk with her. My training had taught me that when talking with victims of human trafficking, it is important to be kind and respectful, and offer them choices. The power of choice helps them regain their right to self-determination, which is so tragically denied by their abusers.

I asked her if we could spend a little time talking, because I wanted her to feel comfortable and not think I was being nosy. She told me that her day had really sucked and asked me to come back the next day. I agreed that tomorrow was fine but asked Mrs. J what I could do to make her more comfortable at that moment. She said she simply wanted to take a hot bath and get cleaned up. Who knows when she had last enjoyed a hot shower prior to admission.

I gathered her bath supplies and towels, and helped Mrs. J into the bath. She asked me to help wash her hair and then told me she wanted to soak for a while. I gave her some quiet time alone and found her obstetrics resident to discuss my trafficking concerns. He agreed with my assessment, so I called a social worker to share our suspicions. I also reached out to my co-worker who had founded the nonprofit organization LOV to mentor me through this situation.

After Mrs. J got out of the bath, I asked her if she wanted a Wendy’s frosty or a popsicle for her sore throat before I left for the day. After delivering her frosty, I asked Mrs. J if she liked specialty coffee. I assured her I would be back in the morning to check on her and offered to bring her favorite drink with me. She started to cry and said, “I cannot believe how nice you have been to me. Thank you so much.”

The following morning my friend and I brought Mrs. J coffee and sat at her bedside to talk. To further develop a rapport and gain her trust, I started with easy questions. I asked her if she felt safe in her living conditions. As the conversation went on, my questions became more directed toward human trafficking.

I asked if she had been forced to do something she did not want to do for survival. Mrs. J shared that she had most recently been handcuffed to a couch in the basement of a motorcycle gang’s clubhouse. She had escaped and was running, naked and high, when the police arrested her and brought her to the hospital. She had no job, was estranged from her family and lost in a state where she had never been before. Unfortunately, human traffickers look for these types of conditions when approaching vulnerable young people who could be susceptible to coercion and sexual exploitation.

Mrs. J said she was ashamed and felt hopeless about how to get out of this mess. I told her about the Salvation Army’s two-year program to help people who are in similar circumstances. The program offers two years of assistance in the form of psychological counseling and drug and alcohol addiction recovery services. They would also assist in procuring housing and employment if she completed the program. Mrs. J agreed to enter the program and get sober, and was admitted for treatment two days later upon discharge from her hospital stay.

For confidentiality reasons, I don’t know if she stayed with the program. On average, most trafficking victims are offered assistance nine times before they accept help to leave their situation.

What Can You Do as a Nurse to Help Stop Human Trafficking?

About 80% of human trafficking victims are in a healthcare system at some point while they are being trafficked.

Potential indicators that your patient may be a victim of human trafficking include:

• Inability to speak to a healthcare provider or authority figure alone
• Signs of physical abuse
• Answers that appear to be scripted and rehearsed, submissive or fearful
• Anxiety to get back to the person who brought them to the hospital
• Not possessing identification documents
• Poor living conditions
• Tattoos of wealth symbols, crowns and/or tattoos that indicate possession (such as “Property of Jon”) on easy-to-see areas, such as the neck or face
• Drug and alcohol abuse
• Sexually transmitted diseases/sexually transmitted infections, pregnancies and/or frequent abortions
• Physical abuse and/or injuries, including facial or dental injuries
• Trauma and history of traumatic brain injury

If you think your patient is a victim:

• Try to develop a rapport while screening your patient (see suggested questions below). Kindness and listening without judgment go a long way. Human trafficking victims are not accustomed to people being kind to them or doing even little things for them without expecting something in return.
• Offer them choices. The power of choice helps them regain their right to self-determination, which is so tragically denied by their abusers. Although their decisions may be in contrast to yours, a trauma-informed approach when interacting helps give the patient a sense of personal choice, control and respect.
• Screen them alone. If you screen them in front of the person who is trafficking or abusing them, you will receive their scripted, “allowable” answers. Additionally, you don’t want to jeopardize the patient’s safety because the trafficker is watching. Keep in mind that the person trafficking your patient may be a “family member” or someone close to them.
• Trust your gut if you see something strange or think something could be off with your patient.
• Know your state-mandated reporting obligations, as well as informed consent policies regarding information sharing and confidentiality obligations.
• Reach out for help. Consult experts such as social workers, law enforcement, the National Human Trafficking Hotline (1-888-373-7888) and nonprofit organizations that specialize in helping human trafficking victims, such as the Coalition to Abolish Slavery and Trafficking (CAST).

Suggested questions to ask potential victims of human trafficking:

• Do you feel unsafe or threatened at home or at work?
• Have you been forced to do something that you did not want to do for survival?
• Can you tell me about your living conditions?
• Have you been hurt or threatened if you tried to leave your situation?
• Do you have your passport or other identification? If not, who has it?

In your nursing career, have you seen patients who fit this description? How will you change your practice to potentially save someone from human trafficking?

*All personal information was changed to protect the patient’s identity.