Human trafficking is an incredibly challenging problem to solve because it hides in the shadows. Not only are traffickers motivated to keep their activities under the radar of law enforcement, but often victims are, too. Is that young woman with the broken arm who was brought to your emergency department by a male “friend” a trafficking victim? What about the shy young man with the black eye and sexually transmitted infection? And if they are, what can you do about it?

Cynthia M. Deitle, JD

Cynthia M. Deitle, JD, spent two decades with the FBI’s civil rights program, which includes a program to combat human trafficking. Her experience ranged from working on individual trafficking cases to being chief of the civil rights unit, giving her a broad understanding of the trafficking problem in the United States and the bureau’s efforts to combat it. She recently sat down with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, to talk about some of the challenges she faced while trying to help trafficking victims, and what emergency department staff can use to try to help suspected victims. Here is Part 2 of that conversation; Part 1 appeared in the March issue.

KK: I heard you tell a story not long ago that really illustrated how victims are able to hide in communities, oftentimes intentionally, because they’re not ready to leave or feel like they can’t. Can you tell us about that?

CD: Sure. We love for victims to somehow get to an ER. Please understand I’m not happy they’re injured, but we’re grateful that now they’re in a place that is safe. Also, there are many people the victim has to talk to, and hopefully one of them can crack through and encourage her and persuade her to tell the truth about why she is there to begin with.

So what we see, especially when it comes to ERs, is most of the time she’s not going to walk in there by herself. She’s going to an ER because her pimp can’t use her because she’s pregnant, she has an ovarian cyst that is painful, she needs an appendectomy, she’s been beaten so badly that she’s no use to him, etc. For him to keep earning money from her, she has to get cured, she has to be healed. He needs her back on her feet, so he will take her to get medical attention.

He’s never going to let her go by herself, because then she’s out of his control. He will take her, and it will be apparent right from the ER waiting area that there’s something odd about these two people. It will be a boy and a girl, and there will be obvious signs of control over the girl from the boy. She’s not going up to the desk by herself. He’s standing with her, and she clearly is giving a story that doesn’t seem all that credible. “You fell down the stairs is why you’re here?” Perhaps she is afraid she is pregnant and has vaginal bleeding. “Is this your husband? Is this your boyfriend?” He’ll still be standing there and not looking very caring or loving. He’ll often look quite menacing. He just wants to get her in and get her out. He won’t have health insurance, and she won’t either. Chances are, he will want to pay cash.

I’ve spoken with other ER personnel before, and the best thing you can do is get her alone. He will want to go everywhere with her. He will say, “I’m her husband, I’m the father of the baby,” whatever it takes, and she will say, “I want him right here with me.” Get a female to talk to her, if possible, and keep her there as long as you can.

Now, I know you and I are both sensitive and very aware of HIPAA violations and HIPAA protection, and when that question comes up, I always tell medical personnel I respect HIPAA the same way you do. I don’t want to get in trouble with HIPAA, but there are things you can do to bring attention to this girl who is in your care and in your control, because as physicians you can help her in a variety of ways without violating HIPAA.

She needs law enforcement. Whomever can break away, call the local police department and say, “I’m not going to violate HIPAA, and I’m not going to talk about who I have in the ER, but there is a gentleman who is standing in the emergency department wearing jeans and a red baseball hat and you might want to talk to him.” He’s not your patient. You’re not violating HIPAA by calling the police department. Chances are, if you develop a relationship with law enforcement and it’s a familiar name who makes the call to a certain officer, the person on the other end of the phone will understand what you are conveying.

KK: Once we have the possible victim alone, should we be very direct or a bit more tangential with our questions?

CD: This will be one of those answers every lawyer and doctor hates: It depends. It depends on the person asking the questions. If you have one of your nurses in the ER who has been there for 20 years, and she is phenomenal at getting victims of domestic violence and human trafficking to talk to her due to a slow, methodical and caring approach, then you let her do it her way. Or you may have other people just come right out and say, “Honey, who is that guy in the waiting room, he’s not your husband. What is going on?” And that might work. It’s very personally driven, and it’s very situation specific. Go with your strength.

As an FBI agent, I’ve been in ERs and I know that intake questioning list can be fine-tuned to get at the trafficking situation. “So, are you safe in your home?” She will lie to you and say, “Yes.” If you just keep drilling into her domestic situation, you might be able to get at it. “So who lives in your home with you?” Well, right away, Kevin, that presumes she has a home. These domestic trafficking victims don’t have a home. They go from hotel to hotel to hotel. “Are you safe in your home? Where do you live? How long have you lived there? Do you rent?” Really try to delve into tripping her up in the answers and getting her to admit what’s going on. That’s really the key, along with asking her who else you should call. “Is there a grandmother, an aunt, a teacher? Is there somebody else I can call who can come down and be with you? You don’t have to stay with him.”

KK: That’s a great approach. Thank you very much for your time, Cynthia.