It was a balmy fall morning, the end of summer hanging on to the humid Texas air. One of those days that seems to move in slow motion. Except inside the emergency room at Houston Methodist Hospital. Its first COVID-19 wave crested a few months ago, and the frenetic, painful chaos of that life-changing spring settled back into a pace that was still busy, far from relaxed, but a little more familiar for now. Before noon, a young man came in, clutching the middle of his body. There was a pain in his abdomen, he said. The staff palpated and listened and charted but couldn’t find anything wrong. He was told he could go home.
The room went quiet for a moment, the air still. He paused, then revealed he was suicidal. Since he couldn’t be discharged if his life was in danger, he was moved to another bed, in the psychiatric unit, where nurse Melissa Graham was in the middle of her shift.
Graham scrolled through his chart. She wanted to see if he had any previous mental-health visits, maybe a history of depression. He didn’t, but she noticed that he’d come to several Houston-area ERs in the previous few months, each time receiving treatment for STDs and drug abuse. That he had been in so frequently in such a short time, for those two specific issues, gave Graham pause. She sat back in her chair as something clicked in her mind. A few months earlier, her hospital began using a protocol that helped nurses and doctors identify trafficking victims — a process spearheaded by Graham — and she thought this man might be one of them.
Her instincts were right. She told him she noticed his medical history. “Is someone making you do things you don’t want to do?” she asked. He didn’t look up at her but said “Yes,” explaining that a man was forcing him to have sex with others, using drugs to make him be compliant. He didn’t have to say the exact words for her to know, she says, that he was being trafficked. Graham asked if he was looking to get out of this situation. Again, he kept his eyes on the floor and said “Yes.” So she picked up the phone and called Rescue America, an organization that supports sexually exploited people, one of the resources suggested by the hospital’s protocol. The group was able to find him an open bed at a shelter about three hours away and arranged for a driver to take him from the hospital to the bus station; he would be there to pick the young man up in an hour.
Graham walked over to the break room to get him a sandwich, snacks, and juice for the trip. She told him the plan: He would be driven to the bus station in downtown Houston and take the next bus heading south. At his stop, about three hours away, he would call the number she’d written down and someone would come pick him up and bring him to the shelter. She encouraged him to keep his cell phone off so he wouldn’t be tracked.
When they walked outside, it was late afternoon, and the sun was starting to dip, casting long shadows over the empty ambulance bay. The driver was waiting in front of a pickup truck. Graham checked his ID before letting the young man get on. As he was about to step in, he turned to Graham, his eyes meeting hers for the first time, and embraced her tightly. A slow trickle of tears quietly rolled down her cheeks. “I felt like a mom, like here’s my kid who is hopefully able to now find a better life,” she said. The man wasn’t the first trafficked person who Graham helped, and he wouldn’t be her last. Since Houston Methodist Hospital rolled out its trafficking policy in 2020, the emergency-room staff has been identifying about nine people per month.
Human trafficking — the use of force, fraud, or coercion to obtain labor or commercial sex — has historically remained in the purview of law enforcement. But as more hospitals and medical offices across the U.S. roll out protocols like Graham’s, nurses, doctors, and other health-care staff are stepping in, becoming key players in the fight against trafficking. In Boston, Brigham and Women’s Hospital has had a protocol since 2015 and is working to branch out the ER’s anti-trafficking work to other areas of the hospital including inpatient facilities and affiliated outpatient primary-care and OB/GYN offices. Many states including New Jersey, Florida, and Texas have made it mandatory for certain health-care professionals to receive education and training on how to recognize and respond to trafficking.
According to a report from the U.S. National Human Trafficking Hotline, health-care workers are the third most common group of people that victims interact with after friends and family and law enforcement. Anti-trafficking manuals like the one used to train the staff at Houston Methodist are typically piloted in ERs because that’s where most trafficked patients go when they need medical care. And they’re slowly becoming a staple of medical training — just as you might expect providers in the ER to know how to attend to a heart attack or concussion, many now consider trafficking resources to be just as crucial to a hospital’s scope of care.
In 2016, one study found that only 30 hospitals in the U.S. had anti-trafficking protocols in place. That same year, HEAL Trafficking — a network of medical professionals and survivors working to combat trafficking by improving the health-care response — was the first organization to create a tool kit providers could download and refer to when developing a trafficking protocol at their hospital or clinic. “We found that lack of having a plan was really harming trafficking survivors, and not having good resources in place can retraumatize the patient or, in some cases, result in them getting arrested or deported inadvertently,” says Hanni Stoklosa, a co-founder of HEAL and an emergency-department physician at Brigham and Women’s Hospital. “When you have a plan in place, you can say ‘I can offer you X, Y, Z’ instead of ‘Oh, let me make a bunch of phone calls and try to figure this out on the fly.’ In that time, you might lose the person.” As of 2021, HEAL’s guide has been downloaded by nearly 3,000 users from 35 countries. In 2018, Henry Ford Hospital in Detroit implemented a trafficking-screening tool created by ER nurse Danielle Bastien; like many, it started in the emergency room and was later rolled out hospital-wide. Based on the requests and correspondence she’s received, she estimates that at least 50 hospitals in the U.S. and abroad use her protocol. It’s now integrated into EPIC, a software company that holds 54 percent of Americans’ electronic medical records so any hospital or clinic that uses EPIC can screen for trafficking.
There isn’t a universal trafficking protocol that all hospitals follow; each one usually designs its own, borrowing from existing policies or looking to resources like HEAL. But they do typically follow a similar format: clues to look for, questions to ask, and how to offer help. The first signs can reveal themselves in small details that providers can observe. Trafficked patients often don’t have an ID or can’t provide a home address or the time or date. They may have tattoos that designate them as “property” such as bar codes, money symbols, or phrases like “Daddy’s girl.” They may come in with someone who does all the talking for them or who absolutely refuses to leave their side. Hovering is not just about physical supervision; it’s an attempt to control the narrative so the servitude can remain tucked away, a secret gasping for air beneath the surface.
Medical records and health complaints might offer more information. Patients who come in frequently for sexual-health-related issues or substance abuse are generally considered at higher risk for trafficking. People who are being sex trafficked frequently have UTIs or complications from STDs. Heat stroke, pesticide poisoning, or overuse injuries on the hands and back can point to labor trafficking. Victims may have broken bones or have overdosed or need to be stitched up after a fight with their trafficker. They come in for signs of mental-health trauma like hallucinations or suicidal thoughts, psychic bruises that mirror the invisibility of their lives.
Of course, these conditions aren’t specific to trafficking. Observations and symptoms aren’t meant to confirm trafficking; they’re reasons to dig a little deeper. What can reveal trafficking a little more explicitly are a patient’s circumstances of work, safety, and personal freedom. So in private, providers may ask, Are you able to come and go freely? Does someone control your money or your documents? Have you received anything in exchange for sex (drugs, money, gifts)? Have you ever been afraid to leave a work situation because someone has threatened you or your family? “If anybody is making anybody do something for financial gain, for emotional or physical safety, to maintain a lifestyle or habit, that’s trafficking,” says Andrea MacDonald, an emergency-department nurse at Brigham.
In these conversations, health-care workers are discouraged from using the word trafficking outright or without at least describing what it is a little more generally. “I think for all patients that I’ve dealt with who have been trafficked … that word may not even be in their verbiage,” says MacDonald. “Or they may not think that what they are doing is trafficking — it’s getting by; it’s making do. So you could miss someone because they’re going to say, ‘No, that’s not me,’ if you use that word.”
If the patient’s responses suggest trafficking is happening, the next step is to offer resources. What’s proposed depends on the hospital’s protocol but also, importantly, on what the trafficked person is looking for. At the very basic level, that might be more information about trafficking. Stoklosa has pamphlets in 20 languages that detail what sex and labor trafficking are; she gives them to interested patients to read in the exam room if she’s able to get them alone. Many providers share the number of the National Human Trafficking Hotline, which victims can call at a safe time or even during the visit to get connected to safe houses and other resources. More often than not, patients are first trying to feel out what’s available to them and who they can turn to. “These people really have been manipulated — mentally, physically, every way possible,” says Graham. “And they just don’t trust people. So they have to test you out, make sure you’re not going to abuse them as well.”
Sometimes people want an out. In that case, nurses and doctors will work with local shelters, community organizations, or law enforcement to help get the person to safety. (These are resources the hospital will have vetted to make sure that they are available and that they handle trafficking without punishing or traumatizing the patient.) Graham’s hospital network turns to Rescue America for logistical help; the organization will call local shelters to see what’s available, find a bed, and arrange for a ride to pick the patient up from the hospital. The National Human Trafficking Hotline will give patients phone numbers for resources, but callers are responsible for arranging their next steps. Stoklosa’s hospital has a page-long list of resources that nurses and doctors can reference including safe spaces (specific to minors, women, and transgender individuals), a legal clinic, and appropriate law enforcement. All these resources “are a way to signal to patients that this is a safe place; this is a place that cares about folks that are in these situations, and they know what they are doing,” says Stoklosa. “It helps build trust.”
Anti-trafficking efforts are especially important, advocates say, as we begin addressing the consequences of the pandemic. According to a June 2021 report from the State Department, the loss of jobs, health care, and housing has put more people at risk for trafficking. Some estimates suggest that labor trafficking alone increased by 70 percent during the pandemic. This can make it even more urgent for ERs and clinics to have the right tools in place, especially because “we don’t really have ways to identify and help people that are as robust as the resources developed by health-care workers,” says Stoklosa.
It both makes sense that the emergency room is an ideal place to look for and address trafficking and is a surprise that it’s possible at all. According to a survey by Polaris, 68 percent of trafficking victims went to an emergency room during their exploitation, making it the most common type of health-care facility visited by this group, followed by reproductive health and primary-care appointments. “In the ER, victims can get urgent care for their injuries, but it also gives them the chance to be a little more unnoticed or anonymous given how busy things can get,” says Bastien. That invisibility can be a blessing and a hurdle. On the one hand, it’s a win for traffickers who want to keep things under wraps by taking advantage of the at-times-frenetic environment in order to keep their victim as just another patient, another file in the system. But anonymity can also be a security of sorts, a refuge for patients who are too afraid or ashamed to come forward, and a way to test the waters.
Sometimes the blur of it all can even inspire disclosure. “This sounds counterintuitive,” MacDonald says, “but I think sometimes people in that setting are saying, ‘I’m going to tell this person something I would never tell another person because I know I’m not going to see them again.’”
The ER’s pace can be fast and disorienting, but nurses and doctors say that even in the chaos, it’s possible to connect and foster trust. It’s not necessarily the “right” questions that thaw wariness (though using appropriate and informed language certainly helps) but the perceived attention, respect, and thoughtfulness that victims receive during a visit that opens them up. “It’s not about creating the perfect checklist for providers to run through,” says Stoklosa. “People can figure out that they’re being checklisted, and that sort of shuts them down” because they can sense the clinician is just trying to get through a task. Instead it’s the small, basic, yet often overlooked communication skills that help peel away the layers of shame and fear: eye contact, genuine interest, a nonjudgmental tone.
Almost a decade ago, Susy found herself sitting in the waiting room of a hospital in the Bronx. She was afraid and restless. For years, her traffickers had threatened that if she ran away, the police would put her in jail or deport her; so the security guards patrolling the hospital hallways made her anxious, and a tightness clenched her stomach. When she was called into the exam room, she expected more of the same: brevity, fear, come and go, in and out. She stared at her lap and flicked her fingers nervously. But when the nurse started speaking to her, she felt the unease come down to a simmer.
“When we started talking, his body language just showed me you can trust this person,” Susy says. “He was smiling; he took his time.” So she started explaining. She came from Kenya for what she thought was a nanny job working for a higher-up at the U.N. The job turned into indentured servitude as Susy became not just a nanny but a cook and a cleaner, logging 16-hour days seven days a week without pay. She was able to miraculously escape when the woman went abroad on a vacation. Susy moved out but soon found herself in another exploitative situation, again clocking in long days doing domestic work, this time for another Kenyan woman in the Bronx. She told the nurse how one day, this woman took her to pick up a rental car, where a man noticed how she was berating and shouting at Susy. He pulled Susy aside; she took a risk and told him about what was going on, and he ended up driving her to a social-service clinic a few months later. That’s how she found herself sitting in front of this nurse, telling him her story.
She remembers the nurse saying that her work conditions were abusive and that he’d connect her with Safe Horizon; through the organization, which works with victims of violence, Susy was able to get to a shelter and then find more permanent housing and work that paid her fairly. Today, she’s a nanny and a home aide in New Jersey. “I always pray for him. He saved my life,” she says. “Without him, I might have been dead a long time ago.”
Even with a plan in place, the doctors and nurses I spoke with acknowledged that these visits can be tough. Patients may have been coached to deny anything is wrong or be too ashamed or afraid to admit it. “They’ve been criminalized for so long that they don’t believe they’re victims, that this is a life they’ve chosen, even if they’ve been forced into it,” says Bastien. Sometimes, especially with labor trafficking, people who are being trafficked might not even recognize they are being exploited. A migrant laborer brought to the U.S. to work in agriculture may believe they have to work without pay because they are repaying a debt to the person who gave them a job, says Stoloksa. “They may just feel like they are surviving.” And the data speaks to the difficulty of getting it right: A 2016 study that surveyed 173 trafficked persons found that 67.6 percent of labor- and sex-trafficking survivors who saw a health-care professional while they were trafficked were not identified as victim during their visit.
Conversations can feel frustrating, and some staff may be uncomfortable talking about exploitation, so they avoid it. Relatedly, one of the biggest hurdles with these trafficking protocols lies with health-care workers themselves; putting in these policies requires providers to edit their perceptions about what trafficking is, how it can present, and where it happens. When they first started educating their colleagues, every nurse and doctor I spoke with told me that people would come up to them and say something along the lines of “Trafficking doesn’t happen here.” “Some institutions still say, ‘Oh, trafficking seems like such a fringe issue. We’re not seeing it,’” says Katherine Chon, the director of the Office on Trafficking in Persons at the U.S. Department of Health and Human Services. “But what we’re saying is, if you’re doing any work on any form of violence — interpersonal violence, child maltreatment — you are likely also going to see this commercialized aspect of human trafficking.”
That’s not to say trafficking is everywhere — the existence of these protocols is not meant to suggest there might be truth to, say, conspiracy theories like those perpetuated by QAnon believers. It’s still a fairly rare type of crime. According to the latest Crime in the U.S. Report, the FBI logged 1,883 incidents of trafficking in the U.S. in 2019 compared with more than 1 million incidents of violent crime (including murder, rape, and aggravated assault) and nearly 5.1 million incidents of larceny and theft. (Still, many experts argue that trafficking, because of its covert nature, is seriously underreported.) And because it’s fairly uncommon, trafficking is still misunderstood, so the ways it presents can sometimes feel so ordinary compared to what some people might expect. Many trafficked people are allowed to move through the world in certain ways. They shop at grocery stores, get their nails done, pick up kids from school, and work at restaurants. And they certainly show up at hospitals and clinics. The goal with the protocols is to have a plan in place but also to educate providers and adjust some of the biases they may have, to underscore the fact that trafficking may be rare and unusual, but victims aren’t as far away as we think.
Even if patients are suspected or identified, they may not want resources or be ready to leave — something that can be hard for many health-care workers to accept. “I’m an emergency-medicine doctor; it’s in my DNA to rescue people,” says Stoklosa. The ER staff at Brigham identify somewhere between one to four possible victims a week, but Stoklosa says only about 10 percent of those patients are prepared to fully exit their situation. It’s worth noting that not every suspected case is confirmed, so yes, they could be wrong. There could be cases in which their instinct is off, they jumped to a conclusion too quickly, or they missed something. But they could also be right, and it’s that not knowing that stays with these health-care professionals long after their shifts.
“There’s a superhero complex in health care, where you think you’re going to save everyone’s life. Or bust a sex ring and blow the lid off trafficking,” says Bastien. “But it’s actually really hard. And you may think you’re not helping anyone.” Every health-care worker I spoke to has what they call their “heartbreak story,” a visit they replay over and over, retracing their steps to see what they could have said or done differently even if they can’t ever come up with an alternative.
To those who are unfamiliar with the nuances of trafficking, unaware of how much is at stake or how much victims are coerced or brainwashed, not taking the opportunity to leave can feel like a terrible mistake. If you had the option to end your oppression, why wouldn’t you? But for trafficking victims, there are so many complications and calculations to make. That’s why providers are learning to reframe what “help” is.
During one of our conversations, Stoklosa called me out when I asked her how many people go on to accept help. (I was referring to those who end up leaving their situation.) “I think of accepting help more broadly,” she told me. “Like when I’m providing them safety planning or giving them resources to read so they have a better plan — that’s help that they didn’t have previously.” For her and other providers I spoke with, these visits aren’t necessarily an escape hatch so much as they are a way to empower and educate patients. In fact, Stoklosa told me that words like rescue and save are avoided to retain a sense of victims’ agency.
Stoklosa’s work with survivors has led her to think of her role less as saving and more as planting seeds, a life-giving metaphor that several survivors brought up unprompted in my conversations with them. Kelli S., who was trafficked by her own family members before they sold her to another trafficker in her early teens, will always remember the ER nurse who made her realize that her life mattered even when her traffickers told her otherwise. Kelli was too scared to admit the exact details of what was happening during that visit — she was a teen, afraid of betraying her family and of what would happen if she said something. But she remembers the nurse saying she was a mom, and for some reason, that intimate personal detail narrowed the gap between them. Kelli ended up telling her she didn’t like her situation at home and wished it could be different.
“She told me that this wasn’t okay for anyone to treat me this way, and I deserved care and safety,” Kelli says. A few years later, Kelli left her traffickers by checking herself into a psychiatric-care facility, and she says what the nurse told her that day always stayed with her. “I realized that people out of my situation cared about me, so I figured I needed to. That woman built the spark that my life mattered and I deserved more than harm, disrespect, and pain. That I could find a new normal,” Kelli says. “My journey has been hard and fraught with obstacles, but I finally believe what that nurse told me.”