Human Trafficking in the ED – What you need to know

Human trafficking is a devastating crime, where a human being’s labor is exploited through force, fraud, or coercion, for someone else’s profit (1). For survivors, connecting to support in the community can be incredibly difficult, and may come at the expense of their personal safety (1, 2).

The emergency department (ED) is a rare exception, with some studies estimating that over 60% of trafficked persons will present at some point during their exploitation to the ED (3). Unfortunately, less than 5% of emergency physicians report feeling confident in their ability to identify a trafficked person, citing confusion around patient characteristics and their role as a provider (4).

By learning more about human trafficking, ED providers can better prepare themselves to identify and provide appropriate support to those who experience human trafficking.

What can I do to be ready in the ED?

  • Understand what human trafficking is and its consequences
  • Recognize personal bias
  • Become familiar with how to identify, assess, document, and refer cases of human trafficking
  • Know your options for survivor advocacy

Click to view full-size image.

human trafficking overview infographic

Just the Facts – Human Trafficking

What is Human Trafficking?

Human trafficking always involves 3 components –an act, a means, and a purpose.

  • The “act” refers to the role a trafficker is playing in exploiting the person
  • The “means” refers to the use of force, fraud, or coercion to exploit a person
  • The “purpose” is what type of labor they are exploited for (1)

Often human trafficking will overlap with other crimes such as assault, domestic violence, rape, and child abuse (5). Of note, anyone under the age of 18 engaged in commercial sex is considered to be sex trafficked regardless of whether a means is present, as they cannot provide consent.

How many people are affected?

Human trafficking is widespread, but is often undetected, making true estimates of size difficult.

For example, human trafficking prevalence estimates may fail to account for survivors who do not recognize they are being exploited or are afraid to disclose (6, 7).

Who is trafficked?

 While no identity is spared, there are certain populations that are at greater risk. These may include:

  • People of color
  • Children in welfare and juvenile justice systems
  • Runaway and homeless youth
  • Children working in agriculture
  • Indigenous patients
  • Migrant laborers
  • Foreign national domestic workers
  • Patients with limited English
  • Patients with disabilities
  • Members of the LGBTQ community
  • Patients with limited education
  • Patients who use substances (6,8)

Why are they targeted?

The only thing all trafficked persons have in common is their vulnerability (1). Trafficking determinants can be conceptualized as “push” and “pull” factors. Push factors lead people to away from their current situation to trafficking (e.g., abuse, poverty, family conflict). Pull factors, drive an individual to something new that increases the risk of trafficking (e.g., income, housing, access to substances) (9, 10).

Who are the traffickers?

In the same way that anyone can be trafficked, anyone can be a trafficker.

Traffickers may be well known in the community, recruiting victims from places of employment or education (1). They may be a family member. They may also lure at-risk individuals by acting as a romantic partner, or by providing emotional affirmation, financial assistance, and material goods (1).

How do traffickers coerce survivors?

A number of tactics can be employed by traffickers, each tailored to the individual survivor but can include any combination of the following (1).

  • Physical violence
  • Sexual violence
  • Emotional violence
  • Withholding basic needs (food, water, shelter)
  • Intimidation
  • Coercion and threats
  • Economic coercion
  • Social isolation 

Specific situations to be wary of:

  • Runaway or homeless youth – greater incidence of “survival sex,” where sexual acts are exchanged for basic necessities (1, 11)
  • Recent immigrantswithholding documentation/ fear of deportation are used as powerful coercion tactic (1, 5, 6)

What are some of the health consequences of Human Trafficking (6)?

  • Physical abuse (traumatic injury, chronic pain)
  • Sexual abuse (sexually transmitted infections, pregnancy)
  • Emotional abuse (post-traumatic stress disorder, suicide ideation)
  • Poor living conditions (malnutrition, dehydration, exposure injuries)
  • Substance use, overdose
  • Death

10 Common Misconceptions of Human Trafficking

    human trafficking misconceptions

Click to view full-size images

Guide for Emergency Department Providers

What are the primary goals of an ED visit with a potentially trafficked patient?

  1. Address the acute presenting illness or injury
  2. Establish the ED as a haven from trauma or exploitation
  3. Offer additional resources, if appropriate and available

The goal of the visit is NOT to elicit a disclosure.

Your role as a provider is not to investigate or confirm the presence of trafficking, but to respect the autonomy of the patient in front of you, meet their healthcare needs, and empower them to seek additional support on their terms.

What steps should I take during my encounter?

  1. Capitalize on the same “trauma-informed” principles used to care for survivors of intimate partner violence and child maltreatment.
  2. Encounter tips (1, 6, 12)
    • Separate the potential victim from accompanying persons
  3. If difficult, ask the patient to move to another room for an x-ray or routine test.
    • Use a trained interpreter when required
    • Foster trust and establish rapport
    • Use education about rights and resources as an empowerment tool (12)
  4. Providing nonjudgmental education around violence and safety can normalize the sharing of information and open discussion (12)
    • Be patient
    • Always get consent before proceeding with any next steps (physical exam, diagnostic tests, and involvement of other providers)

human trafficking providers guide part 1     

Click for full-size images

Red flags For Human Trafficking (1, 13)

Patient IndicatorsCompanion Indicators
Delayed presentationRefuses to leave
Discrepancy between history and clinical presentationInsists on translating or speaking for the patient
Scripted/memorized historyControlling, interrupting
Hypervigilance, fearfulHas patient’s documents in their possession
Cannot produce identificationEmployer demanding access to medical information
Work-related injury with unsafe conditions
Fearful attachment to a cell phone (often used for communication and tracking)

Red flags for pediatric patients (1, 14)

  • Accompanied by unrelated, non-guardian adults
  • Material possessions you reasonably doubt they would be able to afford
  • Truancy or running away
  • Multiple sexual “partners”

What are the next steps after my assessment?

Any next steps should always be determined by the patient

  • Consider offering admission if unsafe to discharge
  • Clear and accurate documentation (may be relevant to future legal proceedings)
  • Consider notifying security if appropriate (6)

Unless local criteria for mandatory reporting are met, Police should only be contacted at the explicit instruction of the patient  (6, 16).

Interested in advocacy?

Consider implementing an ED and institutional protocol for human trafficking. A complete protocol guide is available through HEAL Trafficking.


  1. Alpert EJ, Ahn R, Albright E  et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in a Healthcare Setting. Boston, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine.
  2. Human Trafficking. Public Safety Canada, Government of Canada. 2019.
  3. Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2013;23(1):61–91.
  4. Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Heal. 2015;3:1–9. PMID: 25688343
  5. Canada’s Human Trafficking Laws. British Columbia Public Health Agency. 2014.
  6. Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016;68(4):501-508.e1. PMID: 27130802
  7. Global Report on Trafficking in Persons [Internet]. New York; 2014. Available from:
  8. 2021 Trafficking in Persons Report – United States Department of State [Internet]. U.S. Department of State; 2021. Available from:
  9. Macias Konstantopoulos W, Ahn R, Alpert EJ, Cafferty E, McGahan A, Williams TP, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. J Urban Health. 2013. PMID: 24151086
  10. Calhoun C. Push and pull factors. Oxford Dictionary. Soc Sci Oxford Univ Press. 2002;
  11. Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011. PMID: 20799134
  12. PEARR Tool Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health, in partnership with HEAL Trafficking and Pacific Survivor Center. 2019.
  13. Identifying Victims of Human Trafficking: What to look for in a healthcare setting. National Human Trafficking Resource Center. The Polaris Project.
  14. Tracy EE, Konstantopoulos WMI. Human trafficking: A call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012. PMID: 22525917
  15. Meshkovska B, Siegel M, Stutterheim SE, Bos AER. Female sex trafficking: Conceptual issues, current debates, and future directions. J Sex Res. 2015. PMID: 25897567
  16. Zimmerman C BR. Caring for Trafficked Persons: Guidance for Health Providers. Health Providers. Geneva, Switzerland: International Organization for Migration. 2009.

Caring for the Fasting Patient in the ED


Millions of Muslims around the world observe the holy month of Ramadan. Some may have mild or chronic medical conditions that can become exacerbated, requiring emergent medical attention. Emergency Physicians ought to have a working knowledge about the religious rules of Ramadan and their medical implications. In this article, we will provide an overview of the significance of Ramadan to Muslims, its practices, and discuss the important considerations for emergency physicians when providing care to Muslim patients in the Emergency Department (ED). Lastly, we will explore ways to mitigate the ethical dilemma when a fasting patient refuses a life-saving treatment or intervention.

The significance of the holy month

Ramadan is the holiest month of the year for 1.9 billion Muslims around the world [1]. Muslims believe that the month of Ramadan is the month during which the prophet Muhammad received the initial revelations of the Quran, the holy book for Muslims [2].

Ramadan is a time of spiritual reflection, self-improvement, heightened devotion, and worship. Muslims are expected to put more effort into following the teachings of Islam. Fasting is one of the five fundamental principles of Islam; known as the Five Pillars of Islam. The pillars include shahada (a declaration of faith: “There is no deity but God, and Muhammad is the messenger of God”); prayer (Muslims pray five times a day); zakat (charitable giving); fasting and pilgrimage (Muslims are supposed to make a trip, or “hajj,” to the city of Mecca, Saudi Arabia, at least once in a lifetime if they are physically and financially able).

The fast begins at dawn and ends at sunset [3]. The act of fasting is said to redirect the heart away from worldly activities. It serves the purpose of cleansing the soul by freeing it from harmful impurities. Muslims believe that Ramadan teaches them to practice self-discipline, self-control, sacrifice, and empathy for those who are less fortunate, thus encouraging actions of generosity and communal charity.

Many mosques (Islamic places of worship) host daily community dinners where Muslims can break their fast together. Since Ramadan is a time for Muslims to be especially charitable and fasting helps Muslims feel compassion for the hungry and less fortunate, many mosques hold food drives or fundraisers for charity during Ramadan. It is also common for mosques to host open houses for their friends and neighbors of other faiths to join them for their fast-breaking feast or iftar at the end of the fasting day.

A 2017 study estimated that 3.45 million Muslims were living in the United States, about 1.1 percent of the total U.S. population [4]. Emergency physicians should be aware of the health considerations for their Muslim patients during the month of Ramadan.

How long do Muslims fast? Are there exemptions to fasting?

Ramadan is the ninth month of the 12-month Islamic calendar, a lunar calendar that’s based on the phases of the moon. The lunar calendar falls short of the solar calendar by 11 days. As a result, Ramadan doesn’t start on the same date each year and instead, over time, passes through all the seasons. In 2021, Ramadan began on April 13th and ended on May 13th. Depending on its timing of the year and the location in the world, some patients may be fasting for up to 20 hours. This extended period without food, water, and medications may pose a serious health risk to patients with certain medical conditions.

Exemptions to fasting include anyone who is traveling, women who are pregnant, breastfeeding, or menstruating, or those with acute or chronic illnesses [5].

However, many Muslims with medical conditions insist on fasting to satisfy their spiritual needs. Although Islam does not recommend it, as medical professionals, we must respect our patients’ choices. Those excused can make up the fast later or feed one poor person for each day missed. “And anyone who is ill or on a journey should make up for the lost days by fasting on other days later. God wants ease for you, not hardship.” (Quran 2:185)

I have a fasting patient in the ED. What should I do?

As previously stated, Muslims with acute or chronic conditions such as diabetes are exempt from fasting. However, they may still choose to fast. They may discontinue their medications or alter treatment regimens with or without involving their primary care physician. As a result, serious complications may develop. Patients can present to the ED with dehydration, syncope, hypo- or hyperglycemia, diabetic ketoacidosis, or congestive heart failure. ED clinicians need to approach the care of these patients with empathy and support, along with shared decision-making regarding their treatment plans and expectations.

Another important aspect of caring for these patients is the knowledge that many ED interventions can invalidate fasting. Intravenous fluid is one such example. Before you empirically order that liter of saline solution for the fasting patient who presents to the ED with dehydration, recognize that it will invalidate their fast and consider other options or have a discussion with the patient and/or their family members. The table below lists some medications and procedures that can be applied without breaking the fast [4,6].


Empathy is key in the critically ill fasting patient who is refusing care

There are unique challenges in managing patients who are critically ill and refuse to break their fast. Spirituality, religiosity, and personal beliefs are essential components of the social determinants affecting patients’ health behavior and acceptance of treatment. Depending on their cultural and religious upbringing, some patients believe their hardship, patience, and perseverance through challenges will grant them God’s mercy and forgiveness. This religious context will help guide the emergency physician when caring for the critically ill fasting patient. Fasting that endangers health or increases morbidity is not in accordance with Islamic jurisprudence. For example, if a patient presents to the ED with an acute illness that requires a blood transfusion, then they are exempt from fasting. A gentle reminder to your patients that even if they break their fast, they can make it up on another day.

Fasting beyond Ramadan

The holy month of Ramadan ends with Eid al-Fitr which is a holiday celebrated by Muslims around the world to mark the end of the sunset-to-dawn fasting of Ramadan. The festivities start with a morning prayer followed by family gatherings and sharing of food and gifts with neighbors and the local communities. It is important for physicians and ED clinicians to know that some Muslims may elect to observe six days of fasting after the day of Eid al-Fitr. In Islamic traditions, these six days of fasting along with the Ramadan fast are equivalent to fasting all year. In Islam, every good deed is rewarded 10 times, hence fasting 30 days of Ramadan and 6 days during the following month (Shawwal) is equivalent to a whole year fast. Many Muslims religiously follow this practice throughout their lifetimes. Some Muslims will follow the tradition (or Sunna) of the prophet Muhammad by fasting on Mondays and Thursdays every week. Therefore, physicians could care for a fasting patient throughout the year, beyond Ramadan, and should have an understanding of the religious and cultural context of the Muslim traditions when caring for these patients in the ED.


  • Millions of Muslims around the world fast during the holy month of Ramadan from sunrise to sunset.
  • Muslims with chronic conditions, those who are critically ill, or present to the ED with acute exacerbation of their chronic conditions are exempt from fasting. However, some may choose to continue to fast despite their underlying illnesses.
  • Some medications and medical procedures are allowed during fasting. Providing IV fluid for hydration will invalidate fasting.
  • It is important for emergency physicians to understand the cultural and religious context of fasting for Muslims in order to improve the experiences of these patients when they are cared for in the ED. Empathy and shared decision-making go a long way.
  • Finally, ways to greet your patients during Ramadan and Eid al-Fitr:
    • Ramadan Mubarak: Blessed Ramadan
    • Ramadan Kareem: Generous Ramadan
    • Aid Mubarak: Blessed Aid (day of festivities after Ramadan)


  1. Islamic world, countries with a cultural Islamic population – Nations Online Project. Accessed May 13, 2021.
  2.  Mubārakpūrī, Ṣafī R. (1998). When the Moon Split (A Biography of the Prophet Muhammad). Riyadh: Darussalam. p. 32.
  3.  Ramadan 2015: Facts, History, Dates, Greeting, And Rules About The Muslim Fast Archived 10 July 2015 at the Wayback Machine, Huffington Post, 15 June 2015.
  4. “New estimates show U.S. Muslim population continues to grow”. Pew Research Center. January 3, 2018.
  5. El-Bahay El-Kholi. Al Siyam, “Fasting”. The Supreme Council for Islamic Affairs, Arab Republic of Egypt. p. 36
  6. Al-Munajjid SM. He Needs to Have an Injection into a Vein – Will that Affect His Fast?
  7. Al-Munajjid SM. Types of Asthma Medication and the Ruling on Taking Them during the Day in Ramadan.

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