“We measure what we value”: Building the science to equitably respond to labor and sex trafficking

Over 10 years ago, JCJL was brought to an emergency department (ED) after he passed out from heat exhaustion and pesticide exposure.1 His medical issues were treated, but the fact that he was being labor trafficked was missed. JCJL’s experience was not unique, because we know that the majority of trafficked persons access health care while being trafficked, and of those, most have some interaction with an ED.2 The screening tool for sex trafficking put forth by Kaltiso et al.3 reflects that emergency medicine is making strides as a field toward placing value in identifying instances of trafficking and supporting survivors. The efforts of the authors to engage in staff education, conduct data review, and advocate for supportive accommodations for trafficked persons, should be lauded. We appreciate the candidness and thoroughness with which the authors describe their process to develop and implement the tool. However, emergency providers should be careful to understand the limitations of this tool, and not conflate its publication in Academic Emergency Medicine with its validation. As emergency medicine builds the evidence upon which to base our responses to trafficking, we must do so with an equity lens, with rigor that builds on the person-centered approaches from decades of interpersonal violence literature. There is a proverb that goes, “We measure what we value and we value what we measure.” As Kaltiso et al. note about their tool, “all likely HT patients reported sex trafficking; there were no labor-trafficked patients identified.” Unfortunately, labor trafficking is routinely overlooked, even though globally it is more common than sex trafficking.4 The just-released U.S. Department of State's 2021 Trafficking in Persons Report highlights this labor trafficking deficit, noting the U.S.’ “continued lack of progress and sustained effort to address labor trafficking … including in efforts to identify victims.”5 This widespread omission of labor trafficking in antitrafficking efforts reinforces structural inequities that we have seen through the United States’ history in responding to trafficking. The devaluing of people experiencing labor trafficking, who are likely to be people of color, including immigrants of color, has roots in racism and xenophobia.6, 7 Labor trafficking disproportionately impacts people-of-color, who have historically been exploited and intimidated within labor systems that have been maintained among a backdrop of racism, disenfranchisement, and unchecked employer control. As emergency medicine scientists explore how we can best respond to trafficking, we must not perpetuate existing biases present in the larger antitrafficking response. As researchers build on lessons learned from implementing the tool by Kaltiso et al., we recommend hiring those vulnerable to labor trafficking and those who have experienced it as advisors and employing other debiasing strategies.8 The medical field has a culture that reveres accurate and succinct mechanisms for diagnostic reasoning, yet often neglects to consider that identifying experiences of violence among our patients is distinct from diagnosing medical illness. A screening tool for trafficking may not be effective unless an environment of trust is also established between patient and provider; trafficking survivors report feeling judged by health professionals or having immigration fears in the health care setting as examples of reasons they may not share about their exploitation.9, 10 In other words, diagnostic tools for exploitation must go beyond a short list of questions; rather, the impact of such tools lies in how questions are asked and the physicial and emotional safety a patient feels. The intimate partner violence literature, utilizing a randomized cluster methodology, demonstrated more connection with resources for patients when three key pillars were adopted: 1) confidentiality, 2) universal education and empowerment, and 3) support (CUES).11 Fundamentally, from a trauma-informed perspective, the goal of an encounter with someone who is being exploited is not disclosure. In fact, this takes power and control away from someone who has already lost it. Tools, adapted for the ED environment, should be conceptualized to exist as guideposts for a larger conversation that focuses on understanding patients’ emotions, fostering resilience, administering prevention education, and creating personalized care plans. It is certainly possible to implement screening tools and complementary CUES-like steps in the ED in an efficient manner. One natural place for integration of exploitation and trafficking-related inquiry is in the context of assessing for and addressing social determinants of health.12 In summary, it is erroneous to believe that a screening tool, even if validated, acts alone in answering the call to provide person-centered care to those with experiences of trafficking. Emergency medicine has an opportunity and responsibility to conduct high-quality research that will ensure that all patients with an experience of trafficking, including those with a labor trafficking experience like JCJL, are set on a path of healing. The authors have no potential conflicts to disclose.