In 2017, the National Human Trafficking Hotline registered 10,949 sex and labor human trafficking (HT) cases. Most HT victims seen by health care providers were not identified. Key provider training, patient services, and support resources are described to identify what questions to ask patients and who to tell.
Human Trafficking: What to Ask and Who to Tell?
Pamela Willson, PhD, APRN, FNP-BC, CNE, NE-BC, FAANPGraduate Program Director and Clinical Professor
Texas State University
St. David’s School of Nursing
Round Rock, Texas
Susan K. Lee, PhD, RN, CNE, CPXP
Associate Program Director and Assistant Professor
The University of Texas/MD Anderson Cancer Center
School of Health Professions
Health Care Disparities, Diversity, and Advocacy
e-mail: firstname.lastname@example.org Phone: 512-716-2900
Unfortunately, 88% of human trafficking (HT) victims were seen by a health care provider (HCP) without being identified (Leslie, 2018). Often victims come in contact with clinicians well before social or law enforcement agencies are aware of the sexual or labor trafficking. HCPs astutely screen, treat, refer and report child abuse, intimate partner violence, elder abuse, and community violence. However, HT seems to have slipped off the radar, or perhaps was not included in provider’s initial health care training or encountered during residencies or preceptorships. A priority is to obtain training, followed by ensuring there is a screening protocol in place at their primary care practices, educational settings, or community and faith-based organizations.
The Administration for Children & Families Office of Trafficking in Persons (OTIP) has developed the Adult Human Trafficking Screening Tool and Guide to aid HCPs in providing trauma-informed, culturally sensitive, survivor-informed practices (U. S. Department of Health and Human Services, 2018). HCP education should include:
- Scope of the problem: medical and psychological impact
- HT identification: forensic interview techniques, signs, symptoms
- Trauma-informed care principles
- Psychological treatment
- Safety measures: victim risk assessment, exit strategies, return to non-trafficking life
- Resources: inpatient and outpatient HT treatment
What to ask?
Trauma-informed care (TIC) is patient-centered, gender and culturally sensitive, and sexuality inclusive. This trauma-based care includes current medical, psychological, and safety needs to prevent revictimization (U.S. Department of Justice, 2014). When HT is suspected, talking with patients when the companion (perpetrator) is out of the room, such as during a procedure or when privacy, is necessary. Trust must be built for the victim to reveal the trafficking. Asking open-ended questions and informal language may help. Also asking about the victim’s living conditions, ability to come and go, and if basic needs are provided, are opportunities to reduce barriers and gather information. More difficult questions that may be asked include the occurrence of sexual abuse, being drugged, or harmed. A request to return for a follow-up visit may be useful.
There is a paucity of research to guide HT screening in primary care settings. Unfortunately, screening tools are mostly non-existent, creating a barrier. Additional barriers include a controlling abuser, language differences, and a lack of sufficient examination time. Identifying adult and pediatric sex and labor trafficking victims has primarily focused on emergency department (ED) patients. Using a 14-question survey, female ED patients (N=143) aged 14-40 years were screened for sex trafficking (Mumma, et al., 2017). The screening survey was highly sensitive (100%; 95% CI [70%-100%] for predicting sex trafficking victims. The one survey question positively reported by all victims was, “Were you [or anyone you work with] ever beaten, hit, yelled at, raped, threatened or made to feel physical pain for working slowly or for trying to leave?” (Mumma, et al., 2017). The authors suggested that this one item screen could feasible be incorporated in fast-paced practices. In addition to ED settings, Greenbaum and colleagues (2018), in a 16-site observational study screened adolescents (N=810) at child advocacy centers and community health centers (CHC). The highest rate of positive screens was in the CHCs were the impoverished underserved sought primary care services.
During the physical exam, be astute for visual signs of HT such as tattoos, branding, or burns, as often traffickers mark victims. Tattoo recognition can be instrumental in escape interventions and the recovery process. Tattoos are often unprofessional and of poor quality and include symbols of wealth, abusers’ names, expletives, and hearts (Fang, Coverdale, Nguyen, & Gordon, 2018). Case management, TIC, and mental health services with multi-disciplinary teams and community partnerships are recommended for HT response protocols (Judge, Murphy, Hidalgo, & Macias-Konstantopoulos, 2018).
In summary, when caring for HT victims the multi-disciplinary team must be patient-centered, trauma-informed, and culturally responsive (Powell, Dickins, & Stoklosa, 2017). Health care visits with well-meaning but poorly skilled questions and exams can lead to further trauma (Gordon, Fang, Coverdale, & Nguyen, 2018). HCPs need to be prepared and equipped to recognize and address HT as this problem is under-identified by clinicians who have opportunities to help victims (Grace, Ahn, Macias-Konstantopoulos, 2014). Effective in 2019, the 2018 ICD-10-CM codes added classifying codes for HT abuse. The new codes increase data collection on both adult and child forced labor, sexual exploitation (confirmed or suspected); as well as codes for abuse, neglect and other maltreatment. There are now billing codes for: a past history of labor or sexual exploitation, exam encounter, and observation of exploitation ruled out; as well as an external cause code to identify multiple, repeated, perpetrators of maltreatment and neglect (U. S. Department of Health and Human Services, 2018)
Who to Tell?
HCPs can build their own resource toolbox for developing protocols for reporting and management, finding referral sources, and educating patients about trafficking victims, including undocumented individuals, who are eligible for services and immigration assistance from the resources listed:
- Report suspected HT to law enforcement by calling 911 or the 24-hour National Human Trafficking Hotline at 1-888-373-7888 or Text 233733 or by using online report at https://humantraffickinghotline.org/
- The Referral Directory at the National Human Trafficking Hotline Resources connects the HCP with local and regional services, opportunities and training by city, state, and zip code at https://humantraffickinghotline.org/training-resources/referral-directory
- Know Your Rights is a comprehensive 15 page booklet that is downloadable in 50 different languages and 20 different language videos to outlines a person’s work rights regardless of visa status at https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/temporary-workers.html
- HCPs can become involved in combating HT at the local, state or global arenas with ideas put forth in 15 Ways to You Can Help Fight Human Trafficking (U. S. Department of State, n.d.) at https://www.state.gov/15-ways-you-can-help-fight-human-trafficking/
of women, children, and men are exploited through prostitution or other forms
of sexual exploitation, forced labor or services, slavery, or the removal of
organs (United Nations Office on Drugs and Crime, 2020). The commonalities of HT
victims is their desperation and their limited resources. HCPs must identify,
respond, advocate, treat, and evaluate short and long-term care of trafficked
victims. Key provider training, patient services, and support resources were
described to identify what questions to ask patients and who to tell.
Fang, S., Coverdale, J., Nguyen, P., & Gordon, M. (2018). Tattoo recognition in
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Gordon, M., Fang, S., Coverdale, J., & Nguyen, P. (2018). Failure to identify a human
trafficking victim. Perspectives in Global Mental Health, 175, 408-409. https://doi.org/10.1176/appi.ajp.2018.18010007
Grace, A. M., Ahn, R., & Macias-Konstantopoulos, W. (2014). Integrating curricula on
human trafficking into medical education and residency training. JAMA Pediatrics 168(9), 793-794. https://doi.org/10.1001/jamapediatrics.2014.999
Greenbaum, V. J., Tichen, K., Walker-Descartes, I., Feifer, A., & Rood, C. J., & Fong, H.
(2018). Multi-level prevention of human trafficking: The role of health care professionals. Preventive Medicine, 114, 164-167. https://doi.org/10.1016/j.ypmed.2018.07.006
Judge, A. M., Murphy, J.A., Hidalgo, J., & Macias-Konstantopoulos, W. (2018).
Engaging survivors of human trafficking: Complex health care needs and scarce resources. Annals of Internal Medicine168(9), 658-663. https://doi.org/10.7326/M17-2605
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Mumma, B. E., Scofield, M. E., Mendoza, L. P., Toofan, Y., Youngyunpipatkul, J., &
Hernandez, B. (2017). Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program. The Western Journal of Emergency Medicine, 18(4), 616–620. https://doi.org.libproxy.txstate.edu/10.5811/westjem.2017.2.31924
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