Identifying Sex Trafficking in the ED

From movies to music to clothing lines, the widespread promotion of the glorified “pimp and Ho” culture has unwittingly created an unacceptable tolerance and ignorance to the reality of the sex slave industry in the United States. Unfortunately, the misperceptions about prostitution are pervasive even among healthcare workers, who are missing valuable opportunities to recognize and offer aid to victims of sex trafficking.

Misidentification of trafficking victims in the ED often stems from misperceptions of the sex trade itself

From movies to music to clothing lines, the widespread promotion of the glorified “pimp and Ho” culture has unwittingly created an unacceptable tolerance and ignorance to the reality of the sex slave industry in the United States. Unfortunately, the misperceptions about prostitution are pervasive even among healthcare workers, who are missing valuable opportunities to recognize and offer aid to victims of sex trafficking. This article, pulled from first-hand experience working with victims of sex trafficking in California and Hawaii, is intended to debunk common myths and provide healthcare workers with a few key tools in combatting this heinous – yet all-too-common – crime.

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Slavery is a dark mark on America’s history, yet it is hardly a bygone concept. Human slavery – now termed human trafficking – exists internationally and domestically. The buying and selling of human lives, specifically women and children for the purpose of sexual exploitation, is a growing epidemic in this country. It is estimated that there are around 27 million people caught in slavery worldwide. Between 600,000–800,000 are trafficked internationally, with as many as 17,500 trafficked into the U.S yearly (DHHS, 2006). Nearly three out of every four victims are women and half are children. The US not only faces an influx of international victims but also has its own homegrown problem of interstate sex trafficking of minors. Although a comprehensive research to document the number of children engaged in prostitution in the US is lacking, an estimated 300,000 American youths are currently at risk for becoming victims of commercial exploitation (Rodriguez & Hill, 2011). The consequences and damage that is left in the wake of its destructive path has left thousands of women and children with devastating physical, emotional, spiritual, and psychological health consequences. Due to the hidden nature of this crime, the victims of sex trafficking and the circumstances they are forced to live within, are often invisible to society, even though they are in plain sight.

Emergency medicine providers play a unique role in the fight against human trafficking because most of these victims lack access to health care and end up in the ED seeking care. Sadly, while emergency care providers are trained to recognize the signs and symptoms of many diseases and forms of abuse, the unique symptoms of human trafficking are often misunderstood and overlooked. There are few studies documenting the exact number of victims flying under the radar in our emergency rooms; however, given the statistics and prevalence of this crime, we can infer that victims are receiving some sort of health care and likely these are ER visits. Every victim of trafficking we have worked with was in the emergency room at some point while in captivity and these encounters did not result in identification and rescue. From our experience working in California and Hawaii, victim referrals to service providers by and large are not coming from HCPs.

Hidden in Plain Sight
Health Care Professionals (HCPs) can play a critical role by aiding to properly identify victims of trafficking while they are still in bondage. A Family Violence Prevention Fund Study, found that 28% of victims of trafficking have actually sought health care during their captivity. However, during their encounter with a HCP, the “signs and symptoms” of duress and abuse were missed. Another study examined the overall experience of emergency room personnel (San Francisco, Los Angeles, and Atlanta) in regards to trafficking victims. The study found that although 29% thought it was a problem in their emergency department population, only 13% felt confident that they could identify a victim of trafficking and less than 3% had ever had any training on recognizing victims (Chisolm, 2007). The findings from this study indicate a gap in the HCP knowledge about the existence of HT in today’s society, as well as the proper identification, and assistance victims of HT require.

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There is an apparent need for HCPs to be trained on the issue of human trafficking and identifying victims. One of the major obstacles to proper identification of sex trafficking victims is simply misinformation and ill-conceived societal biases that exist within the mind of members of society, even HCP. Sex trafficking victims often present as prostitutes or sex workers. The need to dispel common misbeliefs about “prostitutes and prostitution” is foundational to the proper training of HCPs.

Human Trafficking Defined
According to the U.S. State Department, the Trafficking Victims Protection Act of 2000, (TVPA, 2000- the first comprehensive federal law to combat human trafficking and help victims) Defines human trafficking as:

The recruitment, harboring, transportation, provision, or obtaining of a person for one of three purposes:

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1. Labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery.
2. A commercial sex act through the use of force, fraud, or coercion.
3. Any commercial sex act, if the person is under 18 years of age, regardless of whether any form of coercion is involved.

It must be noted that while Justice Department found in its 2011 report that 80% of human trafficking cases involved prostitution, not all prostitution is sex trafficking. However, the TVPA, states that anyone under the age of 18 involved in commercial sex acts is a Sex trafficking victim, therefore every child prostitute is a victim.

5 Common Myths of Prostitution

Myth #1 – Prostitution is a glamorous life, a victimless crime and/or a safe life
The thriving sex industry in America can only exist as long as the culture and community at large allows. As a whole, the U.S is being shaped by a culture that glamorizes pimping and prostitution. This tolerance is embodied in multiple venues of daily life. The consumerist, hyper violent, and super-eroticized content of movies (Hustle & Flow), reality TV (Cathouse), video games (Grand Theft Auto), gangsta rap/music videos (Nelly’s “Tip Drill”) has normalized sexual harm. The song “It’s hard out there being a pimp” took top honors for best song at the 78th Academy Awards (Kotrla, 2010). Sadly, this sexually toxic era has even led to “pimpfantwear” for newborn boys and thongs for 5 year olds. These are only a few examples of the ways in which, as a culture, the pimps are “heroes”. This glamorization of prostitution has failed to acknowledge the degradation, the beatings and the demoralization that the vast majority of female prostitutes experience at the hands of the pimps and “johns” or customers. The “oldest profession” should really be thought of as the oldest form of slavery and is far from a victimless crime. Many victims of trafficking have faced numerous arrests, charges and jail time while the perpetrators and buyers go free.

The FBI states that the average life expectancy of a child once in prostitution is 7 years due to homicide and HIV/AIDS (Farley, 2008). The health problems seen in victims of trafficking are a result of several factors: malnutrition, sleep deprivation, extreme stress, and severe physical and mental abuse.
Some of the health problems suffered by victim
s of prostitution leave lasting scars and can be devastating and life threatening. In our experience working with victims of sex trafficking in Hawaii and California, we have seen girls suffer from severe PTSD and flashbacks that can be triggered at any moment during the day. Here’s the account of one victim who we’ll call “Survivor D”:

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“He told me he would cut me into pieces and send me back like that. Every single day I heard the threat, “I’ll kill you, bitch”. The flashbacks come in waves and can be triggered at any time. I feel as if sometimes I am losing my mind. I am constantly looking behind me, thinking he is going to be there. I live in fear.”

Myth #2- Women in the sex industry have made a willful empowered career choice.
The average age of entry into prostitution in the U.S. is 12 years old, thus many of the over-18-year-old-females seen working in prostitution started in their youth (NCMEC, 2009). All child prostitution is sex trafficking. About 80% of the victims of human trafficking are women and children who are being sold into sex slavery (DHHS, 2006). Often the women and children enter into prostitution due to false job opportunities. Victims of sex trafficking can be found working in massage parlors, brothels, strip clubs, escort services, modeling studios, pornography, internet classified ads, truck stops, and walking the streets as prostitutes. In a study done on prostitution, 89% of women stated they wanted off the track (Farley, 2008).

Domestic minor sex trafficking is the most hidden form of child abuse in the United States. The numbers of teens ending up in prostitution is growing by epidemic proportions. Currently, there are an estimated 100,000 American children and adolescents annually who are enticed into the U.S. sex industry (NCMEC, 2009). There are approximately 400,000-500,000 children currently being exploited in the U.S. Often the victims will present to the emergency room with a false I.D stating they over 18 when in fact they are minors. While force, fraud, and coercion are not necessary to prove sex trafficking of minors, they are the very reasons young girls remain compliant to their traffickers. In our work with victims, we have never had a victim say that she woke up one morning wanting to have sex with numerous men every day. Here’s the account of another victim, Survivor A:

“I was young. The abuse at home was unbearable. I wanted out so I ran. I ran unknowingly from one source of abuse into the arms of another abuser. I thought he loved me. No female wakes up one morning and thinks, I want to have sex with several men every day. Instead of looking at the female on the corner and asking what did she do to get there, ask yourself who taught her to stand on that corner and lie in the hotel bed waiting for the next client. My teenage years and early adulthood are scarred with abuse and trauma. All of us on the track started in this life as young girls.”

Myth #3- All prostitutes come from low socioeconomic backgrounds
Sex trafficking knows no geographic boundaries. It affects every socioeconomic level, ethnicity, and age group. The perpetrators of human trafficking can be organized in informal networks of street pimps and families, or highly organized international crime networks. (Laczko & Gozdiak, 2005). Health care providers must understand some of the many risk factors that place girls at high risk for ending up in trafficking situations – there’s no one predictor will predict a life of prostitution. Runaway youth are at one of the highest risks for ending up in trafficking. Approximately 450,000 teen runaways each year. 1 out of 3 teens on the street will be lured into prostitution within 48 hours of leaving home. Having a history of violence and abuse increases (28x) the likelihood of entering into prostitution (National Center for Missing and Exploited Children, 2009). See table for more risk factors.

In California and Hawaii, we have worked with girls from every socioeconomic/ethnic background. Girls with solid families and broken homes. Sex slavery knows no boundaries.

“My biological mother was a nurse, my father worked in banking,” said one underage survivor. “They would be considered white, middle class and successful. When I was 6 years old, the sexual abuse started. I began being pimped out by my parents in my own home and in my own bedroom. Many of the ‘respected’ persons in our community were my clients.”

Myth #4 Prostitutes can choose to leave their situation.
The approach pimps use when recruiting a victim can be very sophisticated. There are even books written on the methods pimps use to lure girls into prostitution. Girls are recruited in arcades, malls, bus stops, entertainment parties, “school skip parties”, tourist attractions, on-line, and in a myriad other ways. The pimp capitalizes on two key human emotions, hope and fear. Hope for a new, better life and fear of abandonment. They often seduce a new recruit with the lure of wealth, luxury, fancy clothes and usually they present themselves as the “man of her dreams,” a caring boyfriend, here to rescue her from all her problems.

Once she is emotionally attached to him, he will move her from city to city forcing her to stand on the street corner or wait in the hotel room for the next “client.” He keeps her alone, desperate, and alienated and thus controls her entire being. There are repeated physical and psychological abuses, gang rapes, and beatings to keep her into submission (Shared Hope International, 2009). If she attempts to leave, there are severe repercussions and with the severity of the violence she has seen and experienced she is fearful for her life. Sadly, many women and children fall for this con-game every year. The idea that a prostitute can “walk away” is false. She likely has run away from a life of abuse and run into the arms of another abuser. She did not knowingly choose this life of abuse but she has been conned and truly believes her pimp loves her and she will do anything for him. The victim develops a trauma bond and often suffers from Stockholm Syndrome. What’s worse, victims have been taught to fear authority figures and those in uniform (I.e. law enforcement, health care personnel, firemen).

“If he was even suspicious that I was trying to leave, the beatings would increase, the threats would intensify, and I truly was without anywhere to go,” one survivor related. “No one would believe me. I believed no one saw me anyway. I was invisible to the rest of society. I thought he really loved me afterall he was the only one who could take care of me. When I finally left, no one told me the stalkings, threats would be this bad.”

If any doubt remains about the psychological ability for a prostitute to simple walk away from a life on the street, read an excerpt from the book The Pimp Game: “You’ll start to dress her, think for her, own her. If you and your victim are sexually active, slow it down. After sex, take her shopping for one item. Hair and/or nails is fine. She’ll develop a feeling of accomplishment. The shopping after a month will be replaced with cash. The love making turns into raw sex. She’ll start to crave the intimacy and be willing to get back into your good graces. After you have broken her spirit, she has no sense of self value. Now pimp, put a price tag on the item you have manufactured.”

Myth #5- The prostitute keeps the money
To understanding the heinous practice of sex trafficking we have to follow the money. At its core, human trafficking is about financial profit. Within the confines of every continent, there is an ever-increasing inexhaustible demand for commercial sex. The trafficker is motivated by greed and money and the consumer is driven by sexual desires. Anywhere that there is a thrivi
ng sex industry, exploiters must meet the demand for “human bodies” that will be used as sexual commodities. There is an ample supply of women and children who are vulnerable to trafficking due to their living in situations of poverty, abuse and family instability. Trafficking is a capitalistic business generating $32 billion annually (Hodge, 2008). It is the second largest source of profit for organized crime, surpassing even the dealing of illegal arms (U.S. Department of State, 2008). Trafficking of human beings is lucrative because, unlike drugs which are sold and consumed quickly, human beings can be sold multiple times for repeated profit. On an average night a victim of sex trafficking can be sold to 10-15 buyers. The traffickers typically set a quota for their “girls” around $1,000 a night (Shared Hope International, 2009). The pimp confiscates every penny she makes.
 

“I stood on the street corner, had the date ‘daddy’ would meet me around the corner and the bundle would be handed over,” said Survivor C. “He took everything and [only]when I was ‘good’ – as he deemed – was I allowed to buy something even as simple as a meal”

The issue of sex trafficking is multifaceted and complex. This article barely scratches the surface. It is not easy to reprogram our minds to see things in a new light. However healthcare providers must abandon any erroneous myths and/or common stereotypes associated with prostitution and recognize the dire need presenting to the ED. The problem often seems overwhelming and almost paralyzing, but there is hope and there are several ways that HCPs can play an active part in combating, rescuing and restoring this vulnerable population. The approach to working with this population is unique. Understanding the background, scope, etiology and epidemiology of the problem is the first critical step.

Common Health Problems Seen in Victims of Human Trafficking–

• Anxiety
• Chronic pain
• Contusion, traumatic alopecia
• Repeated closed head injuries, chronic headaches
• Fractures
• Pelvic pain, pelvic scaring, toxic shock
• Oral health problems
• STD’s
• PTSD, SI, flashbacks
• Complications from unsafe abortions
• GI problems
• Substance Addiction

(Zimmerman, 2003)

Risk Factors for Becoming a Victim of Human Trafficking–

• Abuse and Neglect
• Homelessness
• Low self esteem
• Limited education
• Family dysfunction
• Young girls in foster care
• Social isolation/disruption
• Rebellion
• Truancy
• Drug use
• Delinquency
• Searching for love and self-value

References

• Barrows, J & Finger, R. (2008). Human Trafficking and the health care professional. Southern Medical Journal. 101(5) 521-524.
• Department of Health and Human Services [DHHS].(2006). Look beneath the surface: Role of health care providers in identifying and helping victims of human trafficking. Retrieved from http://www.acf.hhs.gov/trafficking/Chisolm-strike M, Richardson L. Assessment of emergency department provider knowledge about human trafficking victims in the ED. Acad Emerg Med 2007;14 (suppl1):134.
• Farley, M. (2008). Human Trafficking and Prostitution. Retrieved April 5, 2012 from     http://www.prostitutionresearch.com/c-prostitution-facts.html
• Family Violence Prevention Fund, World childhood foundation. Turning pain into power: trafficking survivors’ perspectives on early intervention strategies. San Francisco Ca, 2005. www.endabuse.org/programs/immigrant/files/paintopower.pdf
• Hodge, D. (2008). Sexual trafficking in the United States: a domestic problem with transnational Dimensions. Social Work. 53(2), 143-152.
• Kotrla, K. (2010). Domestic Minor sex trafficking in the United States. Social Work. 55(2) 181-187
• Laczko, F & Gozdziak, E. (2005). Data and Research on Human Trafficking: A Global Survey. International Migration. 43. International Organization for Migration.
• National Center for Missing and Exploited Children. (2009). Missing children statistics. Retrieved on June 14, 2009 from www.missingkids.org
• Rodriguez & Hill. (2011). Human sex trafficking. FBI Enforcement Bulletin. From www.fbi.gov/stats-services/publications/law-enforcement-bulletin/march_2011/human_sex_trafficking
• Shared Hope International (2009). Human trafficking- Demand. Retrieved from www.sharedhope.org/learn/index.asp
• U.S. Congress (2000). Victims of Trafficking and Violence Protection Act of 2000. Public Law 106–386
• U.S. Department of State (2008). 2008 trafficking in persons report. Washington, DC: Author.
• Zimmerman, C. & Watts, C. (2003). WHO ethical and safety recommendations for interviewing Trafficked women. WHO: Geneva: Switzerland.
• Zimmerman, C., Yun, K., Watts, C., Shvab, I., Trappolin, L., Treppete, M., Bimbi, F., Jiraporn, S., Beci, L., Albrecht, M., Bindel, J., and Regan, L. (2003). The health risks and consequences of trafficking in women and adolescents- Findings from a European study. London School of Hygiene & Tropical Medicine and the Daphne     Program of the European Commission: London

Jessica Munoz, RN, BSN, MSN, APRN-RX, FNP-BC is a practicing emergency nurse practitioner in Hawaii. She has spent the past 5 years working with victims of sex trafficking. She is currently the volunteer director for the Courage House Hawaii ™ project whose goal is to build a long-term residential home for underage victims of sex trafficking in Hawaii.