Editorials

Human Trafficking: How Family Physicians Can Recognize and Assist Victims

 

Am Fam Physician. 2019 Aug 15;100(4):202-204.

The Victims of Trafficking and Violence Protection Act of 2000 defined human trafficking as the inducement, recruitment, harboring, transportation, obtaining, or providing of a person by force, fraud, or coercion for commercial sex and/or labor services. Understanding this definition is important clinically to determine if a patient is being trafficked; it distinguishes between willing engagement in an activity (e.g., sex work) and exploitation (e.g., sex trafficking). A practicing physician can consider using the AMP (action, means, purpose) tool1 to assist with this determination. Sex trafficking is the most common type of trafficking reported in the United States, and the most commonly affected groups include adult, female, and minority status individuals.2 Labor trafficking in its various forms is thought to be significantly underreported.

Human trafficking is widespread, and the health care sector is among the few that interact with people while they are being trafficked.3 However, clinicians report that they are poorly prepared, lack the skills and knowledge to engage with human trafficking victims, and do not know how to locate resources for these patients.4 Many physicians misunderstand the issue, fail to recognize its scope, or falsely believe trafficking does not occur in their communities. Human trafficking has been reported in all 50 states and the District of Columbia, and the number of victims and people at risk is in the hundreds of thousands.2,5,6 Physicians who believe they do not care for trafficking victims are wrong: these people come to their practices but are not recognized.

The American Academy of Family Physicians has issued a policy on human trafficking (https://www.aafp.org/about/policies/all/human-trafficking.html). In it, the organization underscores the scope of the problem and discusses family physicians' ability to identify and treat this vulnerable patient population. The policy recognizes the current knowledge gap and makes a formal call for education and training on human trafficking. Despite this growing awareness, family physicians have received little to no education on this subject, and most residency programs provide minimal, if any, training.7

Some are working toward improvement. The largest nonprofit health care organization in California, Dignity Health, has implemented systemwide training for employees and developed protocols and education freely available for adaptation by other hospital systems. The state of New York recently issued a mandate for health care professionals to receive training on human trafficking, and Northwell Health, the state's largest health care provider, has begun to respond. Some federally qualified health centers have launched programs geared toward primary care for patients with histories of exploitation, such as the PurpLE (Purpose: Listen and Engage) Clinic at the Institute for Family Health in New York City. The Dignity Health Methodist Hospital of Sacramento (Calif.) Family Medicine Residency developed a Medical Safe Haven for patients who have experienced trafficking, which includes an educational curriculum for residents and manuals for clinical replication in a private practice or residency clinic. This model is being replicated at Dignity Health residency programs throughout California. Including these programs in primary care residency clinics is one potentially viable method of providing low-cost, widespread care for patients who have experienced trafficking while also training future family physicians to address the issue.

Identifying a trafficking victim requires an understanding of the law as well as knowledge of risk factors and signs and symptoms of exploitation (Table 1). It should be noted that the victim-centered approach built into clinical protocols follows a harm-reduction model, which does not necessarily threaten the trafficker. This is important because many victims have been exploited from a young age and may have significant loyalty to their trafficker despite the trauma inflicted; these people may be in a precontemplative phase of change. Interaction and treatment with a person who has experienced trafficking requires trauma-informed, victim-centered care techniques that are gender and culturally responsive and that use survivor-informed practices. HEAL (health, education, advocacy, linkage) trafficking listservers, SOAR (stop, observe, ask, respond) training, and the National Human Trafficking Hotline (888-373-7888) are reasonable starting points (Tables 2 and 3).

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TABLE 1

Risk Factors and Red Flags for Human Trafficking

Risk factors

Foreign national

History of abuse or neglect

Involvement in child welfare system

Lesbian, gay, bisexual, transgender, or queer

Mental health problems

Personal or family/friend involvement in sex trade

Racial or ethnic minority

Recent migration or relocation

Runaway/homeless youth

Substance abuse

Behavioral red flags

Acting in sexually provocative ways; clothing inappropriate for weather or venue

Body language: fear, anxiety, submission, or anger inappropriate for context

Controlling third party, possibly same age or sex

Frequent testing for sexually transmitted infections or pregnancy

Late presentation of illness not otherwise explained

Patient not in control of his/her own documents or money

Refusal or hesitation to provide pertinent medical history

Signs and symptoms

Anal or genital trauma

Avoidance of eye contact

Branding tattoos (e.g., trafficker's name, strange symbol)

Emotional lability

Exhaustion

Exposure injuries

Gastrointestinal symptoms

Hidden or unusual trauma (e.g., burns, scars, cuts, bruises)

Protection trauma from blocking physical assaults

Recurrent sexually transmitted infections, urinary tract infections, or abnormal Papanicolaou test results

TABLE 1

Risk Factors and Red Flags for Human Trafficking

Risk factors

Foreign national

History of abuse or neglect

Involvement in child welfare system

Lesbian, gay, bisexual, transgender, or queer

Mental health problems

Personal or family/friend involvement in sex trade

Racial or ethnic minority

Recent migration or relocation

Runaway/homeless youth

Substance abuse

Behavioral red flags

Acting in sexually provocative ways; clothing inappropriate for weather or venue

Body language: fear, anxiety, submission, or anger inappropriate for context

Controlling third party, possibly same age or sex

Frequent testing for sexually transmitted infections or pregnancy

Late presentation of illness not otherwise explained

Patient not in control of his/her own documents or money

Refusal or hesitation to provide pertinent medical history

Signs and symptoms

Anal or genital trauma

Avoidance of eye contact

Branding tattoos (e.g., trafficker's name, strange symbol)

Emotional lability

Exhaustion

Exposure injuries

Gastrointestinal symptoms

Hidden or unusual trauma (e.g., burns, scars, cuts, bruises)

Protection trauma from blocking physical assaults

Recurrent sexually transmitted infections, urinary tract infections, or abnormal Papanicolaou test results

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TABLE 2

Resources for Physician Training on Human Trafficking

ResourceWebsite

Medical Safe Haven implementation

Dignity Health Human Trafficking Medical Safe Haven

https://www.dignityhealth.org/msh

Physician education

National Human Trafficking Hotline

https://humantraffickinghotline.org/

Office on Trafficking in Persons SOAR to Health and Wellness Training

https://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training

Physicians Against the Trafficking of Humans

https://www.doc-path.org/

Protocols for private practices, residency clinics, and hospital systems

Dignity Health Human Trafficking Response Program Shared Learnings Manual

https://dignityhlth.org/2SZvve1

HEAL Trafficking Protocol Toolkit

https://bit.ly/2MiBo36

TABLE 2

Resources for Physician Training on Human Trafficking

ResourceWebsite

Medical Safe Haven implementation

Dignity Health Human Trafficking Medical Safe Haven

https://www.dignityhealth.org/msh

Physician education

National Human Trafficking Hotline

https://humantraffickinghotline.org/

Office on Trafficking in Persons SOAR to Health and Wellness Training

https://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training

Physicians Against the Trafficking of Humans

https://www.doc-path.org/

Protocols for private practices, residency clinics, and hospital systems

Dignity Health Human Trafficking Response Program Shared Learnings Manual

https://dignityhlth.org/2SZvve1

HEAL Trafficking Protocol Toolkit

https://bit.ly/2MiBo36

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TABLE 3

Further Reading for Physicians Caring for Victims of Human Trafficking

Overviews Chambers R, Stokelman T, Chaffin S, et al. Human trafficking. In: Domino FJ, Baldor RA, Golding J, et al., eds. The 5-Minute Clinical Consult. Wolters Kluwer; 2018. Lo V, Chambers R. Human trafficking and the role of physicians. J Fam Med Community Health. 2016;3(3):1084.

Identifying and responding to signs of exploitation Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36–E49. Mishori R, Ravi A. Addressing suspected labor trafficking in the office. Am Fam Physician. 2015;92(12):1092–1095.

Patient care American Hospital Association. ICD-10-CM coding for human trafficking. September 2018. Accessed December 14, 2018. https://aha.org/system/files/2018-09/icd-10-code-human-trafficking.pdf Dignity Health. Medical safe haven: resources for residency programs and physicians. Accessed December 14, 2018. http://www.dignityhealth.org/sacramento/humantrafficking Greenbaum VJ, Titchen K, Walker-Descartes I, et al. Multi-level prevention of human trafficking: the role of health care professionals. Prev Med. 2018;114:164–167. National Human Trafficking Training and Technical Assistance Center. Survivor-informed practice: definition, best practices, and recommendations. Accessed December 14, 2018. https://www.acf.hhs.gov/sites/default/files/otip/definition_and_recommendations.pdf Ravi A, Little V. Providing trauma-informed care. Am Fam Physician. 2017;95(10):655–657.

TABLE 3

Further Reading for Physicians Caring for Victims of Human Trafficking

Overviews Chambers R, Stokelman T, Chaffin S, et al. Human trafficking. In: Domino FJ, Baldor RA, Golding J, et al., eds. The 5-Minute Clinical Consult. Wolters Kluwer; 2018. Lo V, Chambers R. Human trafficking and the role of physicians. J Fam Med Community Health. 2016;3(3):1084.

Identifying and responding to signs of exploitation Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36–E49. Mishori R, Ravi A. Addressing suspected labor trafficking in the office. Am Fam Physician. 2015;92(12):1092–1095.

Patient care American Hospital Association. ICD-10-CM coding for human trafficking. September 2018. Accessed December 14, 2018. https://aha.org/system/files/2018-09/icd-10-code-human-trafficking.pdf Dignity Health. Medical safe haven: resources for residency programs and physicians. Accessed December 14, 2018. http://www.dignityhealth.org/sacramento/humantrafficking Greenbaum VJ, Titchen K, Walker-Descartes I, et al. Multi-level prevention of human trafficking: the role of health care professionals. Prev Med. 2018;114:164–167. National Human Trafficking Training and Technical Assistance Center. Survivor-informed practice: definition, best practices, and recommendations. Accessed December 14, 2018. https://www.acf.hhs.gov/sites/default/files/otip/definition_and_recommendations.pdf Ravi A, Little V. Providing trauma-informed care. Am Fam Physician. 2017;95(10):655–657.

Address correspondence to Ronald Chambers, MD, FAAFP, at ronald.chambers@dignityhealth.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Polaris Project. Understanding the definition of human trafficking: the Action-Means-Purpose Model. Accessed December 14, 2018. https://humantraffickinghotline.org/sites/default/files/AMP%20Model.pdf...

2. National Human Trafficking Hotline. Hotline statistics. Accessed December 14, 2018. https://humantraffickinghotline.org/states

3. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61–91.

4. Atkinson HG, Curnin KJ, Hanson NC. U.S. state laws addressing human trafficking: education of and mandatory reporting by health care providers and other professionals. J Hum Trafficking. 2016;2(2):111–138.

5. Shrivastava SR, Shrivastava PS, Ramasamy J. Exploring the role of health sector in prevention of human trafficking. Ann Med Health Sci Res. 2014;4(suppl 1):S61–S62.

6. Dignity Health. Human trafficking response program shared learnings manual. May 2017. Accessed December 14, 2018. https://dignityhlth.org/2SZvve1

7. U.S. Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation. Human trafficking into and within the United States: a review of the literature. November 21, 2016. Accessed December 14, 2018. https://aspe.hhs.gov/report/human-trafficking-and-within-united-states-review-literature

 

 

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