INTRODUCTION

Human trafficking is defined by the United States Trafficking Victims Protection Act of 2000 as “the recruitment, transportation, transfer, harboring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose, including forced labor or sexual exploitation or the involvement of minors (persons under 18 years of age) in commercial sexual activity.”1

Studies suggest that 37% to 88% of trafficked persons encounter healthcare professionals during their captivity. This creates a crucial opportunity for intervention. One survey of 192 trafficking survivors found that 63% reported ten or more concurrent somatic symptoms including headaches (82%), fatigue (81%), dizzy spells (70%), back pain (89%), memory difficulty (62%), stomach pain (61%), pelvic pain (59%), and gynecologic infections (56%).2 Other commonly reported issues include anxiety, depression, PTSD, suicidal ideation, and complications from unsafe pregnancy terminations.3

Our community-based hospital serves a multicultural population with a high density of undocumented individuals and limited English proficiency, making it a vulnerable setting for trafficking particularly for individuals working in occupations that are considered “red flags” such as massage parlors and nail salons for minimum or no pay. In an attempt to address this growing concern, New York State has mandated that hospitals develop policies and protocols to identify, support and provide appropriate resources to victims. However, to date, there is no validated screening tool for identifying adults who are being trafficked, as each community has its own particularities, making it difficult to determine a uniform standard. Various organizations and institutions - such as the Vera Institute and Polaris Project have developed tools of varying content and length to fill the void in this area, however none have been widely disseminated or adopted.4–6

Our research question is to see whether a trauma-informed screening tool can be developed for adult victims of human trafficking that is practical for use in emergency room settings?

The goal of this systematic review was to identify core themes from existing tools and design a practical, community-specific screening framework for use in inner-city hospitals.

Figure 1
Figure 1.Flowchart of methods used to review articles.

METHODS

This study followed a systematic review methodology using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework.

A comprehensive search was conducted across PubMed, Scopus, PsycINFO, and Google Scholar for articles published between January 2000 and October 2021. Keywords included “human trafficking,” “screening tool,” “identification,” “questionnaire,” and “red flags.” Boolean operators were used as follows: (“human trafficking” OR “sex trafficking” OR “labor trafficking”) AND (“screening tool” OR “questionnaire” OR “identification” OR “red flags”) NOT (“child” OR “pediatric”).

Inclusion criteria:

  • Articles published in English

  • Studies involving adult populations

  • Articles describing or evaluating a screening tool, questionnaire, red flags, or identification method for trafficking

  • Studies conducted in healthcare or clinical settings

Exclusion criteria:

  • Articles focused solely on pediatric populations

  • Ethical discussions or case reports without reference to screening or identification

  • Non-English publications

  • Duplicates

Three reviewers independently screened titles and abstracts for relevance. Full texts were then assessed against the eligibility criteria. Discrepancies were resolved through discussion, and when consensus could not be reached, a fourth senior reviewer acted as the tiebreaker.

The final sample included 30 articles. Questions from each tool were extracted and categorized into recurring themes to inform the development of a streamlined screening questionnaire.

RESULTS

In the 30 articles chosen, there were a total of 12 questionnaires available for review, comprising 87 questions. After removing duplicates and consolidating similarly phrased questions, 38 unique components remained. Upon thorough analysis, these questions consistently fell into five core categories:

  1. Freedom of Choice – 7 questions

  2. Living Conditions – 6 questions

  3. Identification – 6 questions

  4. Forced Labor or Sexual Activity – 13 questions

  5. Safety – 6 questions

These categories became the basis for a dual-layered screening tool designed for both brief and comprehensive clinical use.

The brief triage version, intended for use in high-volume or acute care settings, includes five representative questions:

  • Do you have to ask permission to eat, sleep, go to the bathroom, or talk to others?

  • Do you have a place to live that is safe?

  • Do you have access to your identification documents?

  • Have you been forced to engage in unwanted sexual activity or labor?

  • Have you been physically harmed or threatened?

For more thorough assessments conducted by trained providers, a comprehensive screening tool was developed incorporating expanded language and detailed follow-up prompts. The tool is structured around the five core domains: Freedom of Choice, Living Conditions, Identification, Forced Labor or Sexual Activity, and Safety. Each domain includes multiple open-ended questions designed to explore the nuances of the individual’s experience. For example:

  • Freedom of Choice: Can you make your own decisions about where you go and what you do? Are you able to speak to friends or family freely? Have you ever been punished for making decisions independently?

  • Living Conditions: Can you leave your place of residence freely? Is your housing clean and safe? Are you living with other people who control your movement or actions?

  • Identification: Do you have access to your identification or immigration documents? Has anyone taken or kept these documents from you?

  • Forced Labor or Sexual Activity: Have you been pressured or forced to do work or sexual activities against your will? Are you being compensated fairly? Do you fear consequences if you refuse?

  • Safety: Do you feel physically safe where you live or work? Have you been hurt, threatened, or made to feel unsafe by someone in control of your situation?

Additionally, a direct question is included: “Have you ever experienced trafficking or exploitation?”

At our institution, we actively train our on-call psychiatry team to use this comprehensive version during evaluations. Training is rooted in the Substance Abuse and Mental Health Services Administration (SAMHSA) “4Rs” model of trauma-informed care: Realize the widespread impact of trauma, Recognize the signs and symptoms, Respond by integrating knowledge into practice, and Resist re-traumatization. This model ensures our clinical team is equipped to approach the screening process with empathy, cultural humility, and a commitment to patient safety and empowerment.

DISCUSSION

The primary finding of this review is the identification of five universally recurring categories across all screening tools used to detect adult victims of human trafficking. These five domains—Freedom of Choice, Living Conditions, Identification, Forced Labor or Sexual Activity, and Safety—form the foundation of any comprehensive assessment.

Our approach contributes to the literature by presenting a dual-format screening tool: a succinct version suitable for initial triage, and an expanded tool for detailed psychosocial evaluation. This tiered strategy supports flexible application in clinical settings with varying levels of staffing and trauma-informed training.

Other tools reviewed in the literature, such as those developed by the Vera Institute and Polaris Project, range in length and complexity. However, none have achieved widespread use or validation in adult populations. Our proposed tool aligns with those efforts but simplifies implementation while retaining thematic integrity. Notably, we incorporate a direct question—“Are you/have you been trafficked?”—based on survivor feedback highlighting the importance of explicitly naming the abuse.

Some researchers argue that direct questioning may retraumatize patients or compromise disclosure; however, others emphasize the empowering nature of naming one’s experience. We advocate for a balanced, trauma-informed approach supported by staff training.

Implementation requires more than the availability of a screening tool. Institutions must invest in education around red flags and cultural sensitivity. Screening must occur within a broader system that includes safe referral pathways and survivor-informed care.

Limitations of this study include: exclusion of pediatric-focused tools. Furthermore, while our framework identifies essential screening domains, it has not yet been validated in practice. Community-specific identifiers may emerge through future application and study. Another limitation is the lack of survivor input during the tool’s initial development; although feedback from survivors was incorporated secondarily, future iterations would benefit from more robust participatory design. Additionally, the review did not assess the cultural adaptability or language accessibility of existing tools, both of which are critical for diverse populations. Lastly, we acknowledge that institutional resources and staff variability may affect consistent implementation of the tool across different healthcare settings.

CONCLUSION

All reviewed questionnaires contained five recurring themes. These core categories should be present in any trafficking screening tool. However, as risk factors and presentations vary by community, tools must be tailored to the setting in which they are used. Our community, for example, requires a tool responsive to high-risk industries like massage parlors and nail salons.

While structured tools are essential, their effectiveness hinges on trauma-informed implementation, institutional readiness, and provider intuition. Next steps include piloting and validating the proposed tool in clinical settings to assess sensitivity, usability, and community relevance.

Corresponding Author:

Rachel N Varadarajulu, MD
920 48th Street, Brooklyn,
New York 11218
Email address: rvaradarajulu@maimo.org
ORCID ID: 0000-0002-5738-3052

DECLARATIONS

The authors declare no conflict of interest related to this manuscript. The authors have no financial or personal relationships, conditions or other circumstances that present as a potential conflict of interest regarding the content of this manuscript. There are no sources of funding for the research reported in this article.