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Sex Trafficking in the ED: Identification, Documentation, and Intervention

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  1. Case: ED CC: Abdominal pain, dysuria PMHx: None PSHx: None At a glance: 15y F, no past ED visits in EMR, accompanied by dad, appears withdrawn

  2. Case #1: SGAH ED • How deep do you need to go into investigating her mood? • What if dad refuses to leave room during the exam? • What if the man in the room isn’t the father?

  3. Sex Trafficking in the ED Patrick Finan, MD PGY-2 Georgetown Emergency Medicine

  4. Roadmap • Case • Who is at risk • What can we do • UC Davis Screening Tool • How do we document • Who to contact

  5. Who? In 2014, the Urban Institute studied the underground commercial sex economy in 8 U.S. cities and estimated that this illicit activity ranged from $39.9 million and $290 million in revenue According to the study, pimps in one city earned an average of $32,833 per week.

  6. Who?

  7. Who?

  8. Who?

  9. But how? • Financial instability: sustained unemployment, unpaid debts, and desperation • Chronic homelessness/lack of stable housing • Substance abuse • Complex relationships These are the people we should be screening.

  10. How are we finding them?

  11. UC Davis Screening Tool Who: Convenience sample of medically stable female ED patients (age range 18-40) How: 14-question survey + Physician Concern What: “yes” to any question = social work consultation “true positive”: admission for/documentation of sex trafficking

  12. UC Davis Screening Tool 143 patients enrolled 58% non-white (demographics of surrounding area 64% white, 23% Hispanic/Latino) Exclusion Criteria: <18yo Prisoners/those in custody Unable to read/understand English or Spanish

  13. UC Davis Screening Study • Out of 143 women, 46 patients screened positive for possible sex trafficking • 30 (21%) on the screening survey only • 7 (7%) on physician concern only • 9 on both 10 patients were confirmed victims, none on physician concern alone. Majority (80%) had visited the ED within the past 2 years while only 1 had been to a clinic within the hospitals health system

  14. UC Davis Screening Study • Sensitivity of screening study was better than physician concern (100% vs 40%) • Why are we missing these? • “were you/someone you worked with ever beaten, hit, yelled at, raped, threatened or made to feel physician pain for working slowly or for trying to leave”: 100% yes rate among the victims • Stand-alone question?

  15. Specifically, kids • Risk Factors • Children who are chronically missing or who frequently run away (especially 3+ missing incidents) • Children who have experienced childhood sexual abuse, sexual assault/rape • Experience with or exposure to substance abuse • Children who identify as LGBTQ (homelessness/stigmatization)

  16. Specifically, kids • Behavioral Indicators • significant change in behavior/sudden change in group of friends • avoids answering questions, looks to others or lets others speak for him or her • appears frightened, resistant, or belligerent to law enforcement  • lies about his or her age and identity • Reference traveling job opportunities

  17. Specifically, kids • Physical Indicators • multiple cell phone, large amounts of cash/CC, no ID • excessive travel to other locations, not from current location, lack knowledge of travel plans • appearance doesn’t match current situation

  18. How do we document? • History • medically relevant facts/supporting details -> avoids disputes in legal cases • Patients own words in quotation marks • PE • old scars, surgical incisions, birthmarks, lesions, tattoos, piercings (photographs? Drawings?) • Assessment/Plan • “not c/w history” • care with assessing age of bruising • “suspected human trafficking” – even if pt denies

  19. Who do we tell? Do we tell? • First and foremost: do no harm • the safety of the trafficked person, the ED staff, and other patients-> esp if trafficker is there • Provide necessary medical interventions for patients before addressing the possibility of/need for law enforcement involvement. • Consider Law Enforcement if: • state-specific mandated reporting scenarios • patient request • imminent danger to staff or the patient(s) • Suspected or confirmed? Call the NHTRC hotline (1-888-373-7888). They can help provide shelter, legal services, and law enforcement assistance • Information about human trafficking can also be displayed in the ED. (restrooms, small itemslike pens, matchboxes, and soap w/ resource numbers.

  20. Jot these down

  21. Questions?

  22. References • http://www.missingkids.com/theissues/trafficking • http://thesgem.com/2018/11/sgem237-screening-tool-for-child-sex-trafficking/ • https://omgfacts.com/this-horrifying-map-shows-sex-slavery-spots-across-the-us/ • https://www.acepnow.com/article/how-to-spot-and-help-human-trafficking-victims-in-the-emergency-department/ • https://www.emra.org/globalassets/emra/be-involved/events--activities/casecon/2018-posters/group-1/shacelles_bonner_final_poster.pdf • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468066/ • https://www.annemergmed.com/article/S0196-0644(16)30054-3/abstract • https://www.acepnow.com/article/the-complexities-of-recognizing-and-responding-to-trafficked-patients-in-the-ed/ • https://www.acepnow.com/bring-awareness-human-trafficking-medical-practice/ • http://polarisproject.org/sites/default/files/us-citizen-sex-trafficking.pdf

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