Defining Human Trafficking
Human trafficking is an under-recognized health and social injustice affecting patients presenting to emergency departments across Canada.1 It is defined by the United Nations as the “recruitment, transportation, transfer, harbouring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose including forced labour or sexual exploitation”.2 Human trafficking is sometimes referred to as modern day slavery or human exploitation.
The three components of human trafficking:
- Act (what is done): Recruitment, transportation, harbouring2
Ex. Recruitment of individual to work in the sex trade
- Means (how it is done): Coercion, deception, abduction, fraud, force2
Ex. Individual is recruited through means of threats and deception into sex trade work1
- Purpose (why it is done): Sexual exploitation, forced labour, removal of organs2
Ex. Individual is recruited through means of threats and deception to work in the sex trade for financial benefit of the trafficker[bg_faq_start]
Sex Trade vs Sexual Exploitation
Not all sex trade work is sexual exploitation. Individuals may choose to work in the sex trade and our role should be to ensure that our medical care supports them to work as safely as possible. Sex trade work is only human trafficking when it involves the components of: act, means, and purpose.2[bg_faq_end][bg_faq_start]
Human Smuggling vs Human Trafficking
Human smuggling is defined as the exchange of goods or services for the illegal migration of individuals across an international border.2,3 Human trafficking may involve human smuggling, however it does not have to include migration across a border.2,3 In fact, the majority of cases in Canada are domestic.3,4 In cases managed from 2008 to 2015 by the Action Coalition on Human Trafficking Alberta, only forty-four percent of trafficked individuals had crossed an international border.3 Statistics Canada reported only one third of incidents involving international travel from 2009 to 2016.5[bg_faq_end][bg_faq_start]
Human Trafficking in Canada
There are different forms of human trafficking with the most common in Canada being sexual exploitation and labour trafficking.3,4 An example of sexual exploitation was outlined above using the act, means, and purpose definition.
Labour trafficking may present as following:
- Act: recruiting an individual from another country to work on a farm in Canada
- Means: using deception regarding the labour expectations and coercion by generating the expectation of owing the employer for assisting in transport to Canada
- Purpose: forced labour with inadequate or no payment, often unsafe working conditions
Again, a labour trafficking case does not have to involve crossing an international border. In reviewing cases managed by the Action Coalition on Human Trafficking Alberta, over forty percent involved labour trafficking.3
In Canada, The Criminal Code contains six specific human trafficking offences, including trafficking in adults, child trafficking, materially benefitting from human trafficking and withholding or destroying identity documents to facilitate this crime. The Immigration and Refugee Protection Act also includes a human trafficking-specific offence. These offences have penalties as high as life imprisonment in certain circumstances.6 In the past decade (2009-2019), there have been over 1,700 incidents of human trafficking reported by Canadian police services.5[bg_faq_end][bg_faq_start]
Human Trafficking is Under-Reported
Although there has been an annual increase in human trafficking cases reported in Canada, it is unclear if there is a true increase in the number of incidents or if it is the result of increased awareness and reporting.3,4Regardless, human trafficking continues to be highly underreported due to a variety of factors including:1,3,4
- Unaware of being trafficked, either due to lack of awareness of human rights and labour protections or due to lack of insight/acceptance of the situation
- Relationship with the trafficker
- Threats made by traffickers
- Distrust towards police
- Language barriers
- Nature of the exploitative work that may prevent a trafficked person from wanting to report due to humiliation, illegal activities, etc.
- Cases involving multiple offences in which human trafficking may not be reported as the most serious violation
- Lack of resources to escape the situation ex. Access to shelter, access to financial resources, etc.
Human trafficking does not discriminate to age, gender, or ethnicity.1,3Individuals at increased risk of trafficking include those with social or economic disadvantages, history of trauma, and mental health conditions.1,3 Immigrants and refugees, Indigenous peoples, and LGBTQ+ individuals are also at increased risk of being trafficked.1,3 Again despite these populations being at increased risk, anyone can be trafficked.
In the 2016 Statistics Canada report, the majority of trafficked persons identified as female (97%).5 In reported cases from 2018, three quarters of trafficked persons were under 25 years old. The previous 2016 report specified that nearly one third of trafficked persons were less than 18 years old and six percent of the perpetrators were minors.5[bg_faq_end][bg_faq_start]
Human Trafficking Presentations in Health Care
Emergency health care providers are in a unique position to help trafficked individuals as the Emergency Department (ED) is often the only site of care accessed by trafficked persons.1,7 In 2015, the AMA Journal of Ethics published that over eighty percent of participants come into contact with a health care provider while under the control of their trafficker.7 It is our responsibility as health care workers, particularly in the ED, to be able to recognize patients who may be trafficked so that we can provide care and resources.
You may not think of human trafficking as an emergency medicine diagnosis, however in terms of providing life saving treatment, it is no different than diagnosing a DVT. A DVT is not initially an emergency, but when missed it can lead to devastating health consequences including death if it leads to a PE. An initial human trafficking presentation may not be life threatening, but similar to a DVT, recognition and providing appropriate treatment is ultimately life saving.[bg_faq_end]
It is important to remember that our job as physicians is to determine if someone is at risk of being trafficked and then to facilitate connections to an interdisciplinary team and resources. It is not our responsibility to determine if someone meets the legal definition of trafficking and use only this as a measure of whether or not treatment and interventions are required.[bg_faq_start]
Step 1: Identification of Red Flags
The following list highlights some of the more common red flags, however it is not an exhaustive list.1 Many of the red flags overlap with other forms of abuse, neglect, and violence.
- Delay in seeking medical care
- Lack of identification documents or documents in possession by person accompanying patient
- Person accompanying patient answers questions or insists on being interpreter
- Accompanying person refuses to leave patient alone with health care providers
- Patient is anxious, needing to contact their partner or leave the ED quickly
- Discrepancy between history and clinical presentation
- Tattoos or other marks that may signify ownership by trafficker
- Loss of sense of time, ex. Reports symptoms started only a couple weeks ago in the fall and then finds out it is now spring
- Lack of knowledge of surroundings/location
- Minor spending time with older partner
Step 2: Preparing to screen
- Recognize your own abilities and comfort in screening. If you are not comfortable, identify someone who may be able to take on this role such as a social worker or a nurse with special training in trauma-informed care.1 Note: As an ED provider, it is important to reflect on your own compassion fatigue and risk for vicarious trauma. Be aware of your own supports.
- Screen in the language that the patient feels most comfortable, using a hospital based interpreter or language line when available.1 Always assume that the accompanying person could be a trafficker or reporting back to a trafficker and therefore should not be used to provide translation.8
- Know your referral services and what you have available to offer the patient before beginning to screen 1,8. This is particularly important during the pandemic when many resources and shelters are often at maximum capacity.
If you are unaware of human trafficking resources in your location, please refer to the Canadian Human Trafficking Hotline at https://www.canadianhumantraffickinghotline.ca or call 1-833-900-1010. You can search by location and specify the type of resource your patient requires. For example: shelter, legal services, counselling, etc. Additionally someone on the health care team can speak directly to an assistant on the 24/7 helpline for further guidance. This phone number can also be provided to the patient for 24/7 access to help and counselling.
- Let your team know that you are going to screen the patient to ensure safety of the team and that any visitors do not interrupt the screening. This may include alerting security depending on your site and your concern for possible safety threats.1,8
- Ask the accompanying person to leave prior to screening. This includes any person accompanying the patient: parent, friend, family, etc.
As previously mentioned, assume that any accompanying person could be a trafficker or could be reporting to the trafficker. There are cases in which a family member is the trafficker.8 It is important to speak with our patients one on one.
You may consider starting this request by saying:
Thank you for providing so much help during today’s visit. For the next part of the visit, I always speak to my patients alone. May I show you where you can wait while I talk to your family member/partner/friend?
If they seem hesitant, you can further explain that it is important for the privacy of the patient and may consider timing your screening around when you are doing a physical exam as an additional reason for why you would request the accompanying person to leave.8 If the accompanying person feels threatened, it may be safer to let them stay in order to reduce risk to the patient and maintain an opportunity to provide medical treatment without putting them at increased risk of harm after the visit. In this case, if your hospital has a policy on patients going for diagnostic tests alone, this may be a key time to approach a patient and provide resources.8[bg_faq_end][bg_faq_start]
Step 3: The PEARR Tool and Screening
The PEARR Tool is an approach that was designed by Dignity Health and HEAL Trafficking to provide trauma-informed care to patients who are at high risk of abuse, neglect, or violence.9
Trauma-informed care puts a focus on educating patients about violence with the goal of normalizing the conversation in order to support patients in sharing their own experiences. This tool emphasizes that the “goal of encounter is not for patient to disclose victimization, but for providers to treat, educate, and empower the patient.” 8,9
As discussed, it is important to speak to your patient in a safe private environment. It is also important to have a discussion with your patients regarding confidentiality and certain situations that would mandate reporting. 8,9
One of the key approaches of trauma-informed care is education. It is particularly important to recognize that individuals may not recognize that they are being trafficked or in danger.8
There are many reasons why someone may not recognize that they are in a situation of abuse, neglect, or violence.8 It is not limited to only cases of human trafficking. Individuals may not have an awareness of their human rights or their current situation may be improved from conditions they were living in previously.8 Trafficked persons may have a fear of being arrested or deported due to crimes they have had to commit while being trafficked, and/or due to threats made by the trafficker.8 There is a process called ‘grooming’ in which a trafficker may develop the trust of a trafficked person by giving them attention, gifts, and other forms of adoration.3,8 They then use this relationship to manipulate the trafficked individual into exploitative situations in which the trafficked person may or may not be aware of the benefit to the trafficker.3,8
The following examples may help in starting the conversation:
- I would like to ask you some personal questions about your safety that can help me care for you better, is it ok that I ask you a few questions now?1
- It is my practice to ask all my patients about violence because we know that violence is unfortunately common in our society. Is it safe for me to ask you a few questions?1
- Many people I see are dealing with abuse in their lives. Some are too afraid and uncomfortable to bring it up themselves, so I have started asking all my patients about their experiences. Is it ok if I ask you some questions about your safety?1
Ask if there is anyone you can call for the patient or anything that you can do for them right now to make them feel safe and more comfortable.8 Do not ask questions out of personal interest.1,8,9 This is now the time to ask your screening questions, which we will include in the next section. If you do not have access to the provided screening questions, you can simplify your question to something such as: Do you feel like anyone is hurting your health, safety, or well-being?
Given the nature of our short encounters with patients in the ED and challenges building rapport, if you are having difficulty engaging with the patient you might use the following: I noticed [ ], you mentioned [ ] and I’m concerned for your health and safety. You don’t have to share the details with me, but I’d like to connect you with resources if you’re in need of assistance. Would you be ok if I connect you to [ ]?
If a patient does not feel that they need assistance, respect their autonomy . If you have concerns, you can still offer resources that they can choose to use a later time1,8. The goal of our visit is not disclosure or rescue, but rather to create a safe space and empower the patient8,9.
Please remember that similar to intimate partner violence, consent is required prior to reporting a crime unless you believe that the patient’s life is in immediate danger1. If the patient is less than 16 years old, Children’s Aid Society (or your regional equivalent) should be contacted regardless of patient consent1. Patients 16-18 years old must provide consent for you to contact your local Children’s Aid Society.
Finally it is import to provide care in the following ways:
- Safety Plan: Ensure that you have addressed the presenting medical needs.1,8 Confirm contact information for the patient, which may include asking if they have any names that they use at work or in a shelter.8 Make a patient-centred plan and encourage returning to the ED should they have any safety concerns.1,8
- Interdisciplinary: Aside from medical needs, trafficked persons may also have needs for safety, housing, legal assistance, social services, and employment.1,8 A multidisciplinary approach is needed to provide the appropriate support.1,8 Team members may vary depending on your region, however with the patient’s consent, be sure to connect social work, forensic nursing, Victim Services, specialized clinics, and local community organizations.1
- Resources: Provide information for shelters, counselling, and most importantly the phone number or webpage for the Canadian Human Trafficking Hotline: 1-833-900-1010 https://www.canadianhumantraffickinghotline.ca
Remember the psychological coercion involved in trafficking often makes it difficult for a victim to disclose or exit their situation.1,8 Screening helps to introduce the conversation and implement motivational interviewing techniques.8 “Do not take patient’s decisions to stay in abusive situations or relationships as an indication that your efforts have failed; your supportive words and kind actions carry weight and may make a difference in the future.”8[bg_faq_end]
Clinical Decision Tools
In the following tools, if a patient answers yes to any of the questions, they should be connected to interdisciplinary care for further screening and connected to resources.[bg_faq_start]
Modified Vera Institute of Justice Screening Tool10
The Vera Institute of Justice screening tool was tested in the setting of victim services organizations in 5 different states with the screening interviews completed by social workers or attorneys. The interviewers received training from the Vera Institute of Justice prior to conducting the study. This shortened 5 question assessment tool was not published in the study, however is comprised of the questions with the highest sensitivity and the recommended tool used by the Canadian Alliance of Medical Students Against Human Trafficking in addition to other physicians across Canada. Its intended purpose is to be used as an initial screening assessment that may prompt further investigation.
- Are you allowed to take breaks where you work?
- Have you ever felt that you could not leave where you work?
- Does anyone at home or that you work with make you feel scared or unsafe?
- Does anyone where you work ever trick or pressure you into doing something that you did not want to do?
- Did anyone arrange your travel to Canada?
For the full Vera Insitute of Justice screening tool please see the following pdf, the 20 question tool is on page 25:
Labour Trafficking Self-Assessment Tool11
This tool was designed to be completed as a self-assessment and if answering yes to any of the questions, the client was referred to the National Human Trafficking Resource Centre in the US.
- Is someone holding your personal documents for you?
- Does someone else control the decisions you make about your life?
- Do you owe money to your boss, the person who hired you, or the person who helped you find the job?
- Are you receiving your pay?
- Are you afraid something bad will happen to you or someone else if you leave your work?
Pediatric Sex Trafficking Screening Tool12
This tool was tested in the pediatric EDs in the US. The study population included English speaking 13 to 17 year olds presenting with high risk complaints such as pelvic pain. If the patient answered yes to being sexually active, additional screening questions were asked pertaining to sexual history. Out of the patients that were identified as possible trafficked persons during the ED visit, forty-five percent would not have been identified without the use of the screening tool.
Initial Screening Questions (Dr. Kalitso and Dr. Greenbaum)
- Have you ever broken any bones, had any cuts that required stitches, or been knocked unconscious?
- Some kids have a hard time living at home and feel that they need to run away. Have you ever run away from home?
- Kids often use drugs or drink alcohol, and different kids use different drugs. Have you used drugs or alcohol in the past 12 months?
- Sometimes kids have been involved with the police. Maybe for running away, for breaking curfew, for shoplifting. There can be lots of different reasons. Have you ever had any problems with the police?
- Added question for transition into sexual history: Have you ever had sex of any type? (penis in vagina or penis/finger in “butt” or mouth on penis or mouth on vagina)
- How many sexual partners have you had?
- Have you ever had an STI, like herpes or gonorrhea or chlamydia or trichomonas?
Recommended reading, videos, and podcasts
Human Trafficking: Help Don’t Hinder (Free online module, CME accredited for some programs). One hour module to help learn how to identify and respond to potential trafficked persons who present to the ED. https://www.fraserhealth.ca/health-topics-a-to-z/sexual-assault-and-violence/forensic-nursing-service/human-trafficking#.YAkEgS_b1QI
EM Quick Hits 20 Imaging Renal Colic, Human Trafficking, Atrial Fibrillation During COVID, Transvenous Pacemaker Placement, COVID Lung POCUS, COVID Derm, Virtual Simulation (Podcast) (segment 7:27-20:20 is on human trafficking) https://emergencymedicinecases.com/em-quick-hits-20-june-2020/
Detecting human trafficking: a life-saving diagnosis in the ED, BMJ Talk Medicine (Podcast)
This document was additionally reviewed by individuals who were previously trafficked. To protect their safety, their names have not been included in the authors list. We are extremely grateful for their feedback in preparing this document so that we can improve our care of trafficked persons.
Canadian Alliance of Medical Students Against Human Trafficking (https://www.camsaht.org): Special thanks to the co-founding presidents, Dr. Emma Herrington and Guido Guberman, who continue to contribute to the development of medical education resources and awareness initiatives for the improved health care of individuals experiencing or who have experienced trafficking.
Human Trafficking Health Alliance of Canada (https://hthealthalliancecanada.org/about/): This interdisciplinary network has been essential in developing medical education resources and programs that reflect the health needs of communities across Canada. It is a diverse team of health providers with representation from multiple health care and community organizations across Canada working directly with individuals who have been or are at risk of being trafficked.
Dr. Jordan Greenbaum kindly provided permission to include one of the screening tools she and her team have developed from their ongoing research in American pediatric EDs.
This post was edited by Drs. Evelyn Dell and Kate Hayman, who are both Assistant Professors at the University of Toronto. The post was copyedited by Jeremi Laski (@JeremiLaski).
- 1.Fraser Health. Human Trafficking-Help Don’t Hinder. https://learninghub.phsa.ca/Courses/6427/human-trafficking-help-dont-hinder
- 2.United Nations. Human Trafficking. Office on Drugs and Crime. https://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html
- 3.The Action Coalition on Human Trafficking Alberta. About Trafficking . https://www.actalberta.org/about-trafficking/
- 4.National Strategy to Combat Human Trafficking: 2019-2024. National Strategy to Combat Human Trafficking: 2019-2024. https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2020001/article/00006-eng.pdf?st=CP6ig_Z4
- 5.Cotter A. Trafficking in persons in Canada, 2018. Trafficking in persons in Canada, 2018. https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2020001/article/00006-eng.pdf?st=CP6ig_Z4
- 6.Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Beazley Institute for Health Law and Policy; 2014:61-91.
- 7.Stoklosa H, Grace A, Littenberg N. Medical Education on Human Trafficking. AMA Journal of Ethics. Published online October 1, 2015:914-921. doi:10.1001/journalofethics.2015.17.10.medu1-1510
- 8.HEAL Trafficking and Hope for Justice’s Protocol Toolkit. HEAL Trafficking. https://healtrafficking.org/2017/06/protocol-toolkit/
- 9.PEARR Tool: Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health. Published 2019. https://www.dignityhealth.org/-/media/cm/media/documents/PDFs/PEARRToolm15NoField2019.ashx?la=en&hash=F14648F8505CF79BAA9B62B87B6C584802673D3A
- 10.Screening for Human Trafficking. VERA Institute of Justice Guidelines for Administering the Trafficking Victim Identification Tool (TVIT). Published 2014. https://www.vera.org/downloads/publications/human-trafficking-identification-tool-and-user-guidelines.pdf
- 11.Labor Trafficking Self-Assessment Card. The Advocates for Human Rights. https://www.theadvocatesforhumanrights.org/labor_trafficking_self-assessment_card.html
- 12.Kaltiso SO, Greenbaum VJ, Agarwal M, et al. Evaluation of a Screening Tool for Child Sex Trafficking Among Patients With High‐Risk Chief Complaints in a Pediatric Emergency Department. Hwang U, ed. Acad Emerg Med. Published online October 31, 2018:1193-1203. doi:10.1111/acem.13497