I see her every day, at the end of the exit ramp. Sitting on the ground, huddled over rain, snow or shine. No eye contact. Holding a sign that says HOMELESS, PLEASE HELP. People have given her blankets, umbrellas, bags of toiletry items, soft drinks….You can see them strewn in the grass. Every time I see her, I wonder how she physically gets to this spot. It is far (miles) from the homeless shelters and even farther from the “shanty town,” which is where many of the area homeless have crafted shelters from cardboard and wood, far away from the police patrol and public eyes. This situation in my mid-sized city is likely typical of most urban areas in America: Nearly every corner has someone panhandling with a sign. Some are aggressive and will knock on your window or wash your windshield and expect to get paid. Others are like the woman at the end of the ramp: absolutely still until someone rolls down a window and says something. It wasn’t until I went through human trafficking training that I realized that these panhandlers may actually be victims of human traffickers.

Human trafficking is a world-wide emergency. The evolution of the internet expanded the reach of traffickers and removed the victims from the public eye. According to The Polaris Project, there are more than 40 million victims of human trafficking globally, and the resulting industry generates more than $150 billion. There is no official estimate for the number of trafficking victims in the United States, but Polaris estimates it is in the hundreds of thousands.

The top 3 types of labor trafficking in 2017 were domestic work, agriculture and peddling/begging. I was really surprised during my human trafficking training to hear that panhandlers and sales teams are often composed of trafficking victims. I pictured the stereotypical trafficking victim to be a prostitute or a third-world child laborer. Sadly, I was misinformed. Human trafficking victims come from all ages and demographics, are found in many industries, and are present in every state in the nation.

As I thought about the woman at the end of the exit ramp, I wondered if she was a victim and what happened to her to get her into this situation. Victims of labor trafficking are often recruited by an offer of a job, typically well-paying. Other methods to entice victims into labor trafficking include false promises/fraud, smuggling, familial associations (often seen with agricultural work) and posing as a benefactor to a victim. Was one of these methods used to lure her into a life that consisted of begging on a highway exit?

So, why don’t the victims of labor trafficking simply walk away?

Human trafficking perpetrators are skilled in recruiting, manipulating and controlling their victims. They typically will initially groom the individuals who are vulnerable, who desire attention, money, drugs and/or security, by meeting these needs. They lure the victim into a sense of safety and dependency on the culprit. This period of grooming is often called “the honeymoon” as the perpetrator will provide lavish gifts or money, proclaim love or friendship and promise a better future. Once the target has been lulled into a feeling of security, the real purpose of the relationship is gradually introduced. The victim’s responses are diminished and any resistance is met with disapproval, threats of abandonment, violence or deportation. I can only parallel this “honeymoon” process to what Theon Greyjoy endured on Game of Thrones when he was imprisoned and tortured by Ramsay Bolton.

Why discuss this? Human trafficking is a major public health issue. Victims have an average of 9 healthcare provider encounters while in captivity. These visits represent missed opportunities to improve or perhaps save lives. Mandatory reporting laws vary from state to state; therefore, it is imperative that healthcare practitioners recognize red flags and include screening for every patient to recognize—and intervene via set protocols—when these victims are identified. As more information is published on best practices, clinicians must ensure these patients are recognized as a vulnerable population, thereby reducing risk from missed diagnoses. Healthcare professionals are in a unique position to identify and care for these patients. Education must be delivered to all providers, as these victims are found in all areas of healthcare.

Do I interact with the woman at the end of the ramp? What’s the right thing to do? The jury is out on the one best answer here. Giving money is obviously what is desired by the victim. But is that helping or actually hurting? I asked the instructor of the human trafficking course what to do. She suggested providing the woman with a laminated card with the numbers to the National Human Trafficking Hotline (phone call: 1-888-373-7888) and BeFree Textline (text: HELP to 233733 [BEFREE]). These resources provide survivors with vital support and a variety of options to get help and stay safe. I now have a stack, and I hand them out whenever I encounter a panhandler. I also recognize the value of information: I share, I educate and I care.

Spread the word. What do you think about the role of the healthcare provider in identifying victims of human trafficking?

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