Human Trafficking in the ED – Part 2

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July 20, 2017 by dailybolusoflr

Seeing the Unseen Patients

By: Katie O’Conor


What Can We Do?

Despite the absence of validated tools and guidelines, there are still many steps that ED providers can take to recognize and assist patients affected by human trafficking:

  1. Awareness of medical conditions found in trafficked persons
  • Injury & trauma: facial, rib, & extremity fractures, head injuries, injuries with different stages of healing
  • Behavioral health: anxiety, depression, PTSD, schizophrenia, dissociative disorders, eating disorders
  • Substance use: dependence, overdose, withdrawal; opioids prevalent
  • Obstetrics: frequent pregnancies, poor prenatal care, IUGR, septic/unsafe abortion, spontaneous abortion
  • Sexual health/gynecology: recurrent sexually transmitted infections with complications from non-treatment, vaginal trauma, dyspareunia, vaginismus
  • Sequelae of poor living conditions: malnutrition, dehydration, skin infections, insect bites and colonization
  • Trafficking stigmata: branding, bar codes, cigarette burns, scars, mutilation, ligature marks, alopecia
  1. Adoption of a trauma-informed approach

A trauma-informed approach means having sensitivity to the many ways patients may manifest the psychological trauma they have experienced. In a human trafficking context, the expectation might be that a patient would be timid, subdued, hesitant to provide details. However, a patient may have been trained to smile and be reassuring when asked if she feels safe. Away from her trafficker, a patient may also demonstrate emotional lability or hostility. During a physical exam, one might expect that trafficked persons would be hypersensitive and avoidant of touch, particularly during pelvic exam. This is often true. However a patient may appear unaffected due to self-training for toleration of unwanted touch and penetration. A patient may even appear inappropriately hypersexual, if she has associated this behavior with less violence or quicker resolution of unwanted touch. In these instances, compassionate and ethical conduct is paramount, as well as recognizing that trafficked persons may present in a variety of different ways, and their behavior cannot rule in or rule out their trafficking status.

  1. Awareness of what you can do as an ED provider

You may not identify many of the trafficked patients who cross your path as a provider. Of those you have concerns about, most will not self-identify or disclose to you. There are still many ways to facilitate a survivor’s journey on her or his own terms.

  • Privacy/confidentiality: clear the room to interview and examine the patient alone, and learn to do it in a manner that does not alert the trafficker’s suspicion.
  • Documentation: ensure excellent EMR documentation of injuries, symptoms, and other features of physical exam. This may be valuable evidence in any legal proceedings or social services applications.
  • Resources and compassion: even if the patient is not ready to disclose or seek help, simply stating that help is available can give a patient hope, and plant the seed that may empower her to seek help in the future.
  • Respect for autonomy: acknowledge the agency these individuals do have, within their trafficking context. Respect their rights to decide what medical and social evaluations and interventions they want to receive, and their autonomy regarding if, when, and how to disclose information.
  • Safely distributed resources: any resources/information should be provided in a way that does not endanger the patient. Traffickers review phone logs, text messages, contacts, and browsing history. Information may be hidden or encoded – shoe cards, numbers stored under alternate name, easily memorized facts.
  • Multidisciplinary collaboration: any exploration of possible human trafficking cases should involve consultation and coordination of law enforcement, social work, case management, behavioral health services, substance use services, safe houses, and social services.

The National Human Trafficking Resource Center has a framework for approaching human trafficking in the healthcare setting that may help ED providers and administrators in developing ED-specific protocols: https://humantraffickinghotline.org/resources/framework-human-trafficking-protocol-healthcare-settings


Links

Maryland Human Trafficking Task Force                             www.mdhumantrafficking.org

National Human Trafficking Resource Center               www.traffickingresourcecenter.org

National Human Trafficking Hotline                                www.humantraffickinghotline.org

Department of Homeland Security: Blue Campaign              www.dhs.gov/blue_campaign

Polaris Project                                                                                           www.polarisproject.org


References

  1. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010 (NCJ 233732). Capital News Service. The Brothel Next Door – Human Trafficking in Maryland. cnsmaryland.org/human-trafficking. Accessed June 20, 2017.
  2. Cassie, R. Children of the Night: Sex trafficking is Maryland’s dirty open secret. Baltimore Magazine. Mar 2017.
  3. Coppola JS, Cantwell R. Health professional role in identifying and assessing victims of human
  4. labor trafficking. J Nurs Pract. 2016 May;12(5):e193-200.
  5. Gibbons P, Stoklosa H. Identification and treatment of human trafficking victims in the emergency department: a case report. J Emerg Med. 2016 May;50(5):715-9.
  6. Hachey LM, Phillippi JC. Identification and management of human trafficking victims in the emergency department. Adv Emerg Nurs 2017 Jan/Mar;39(1):31-51.
  7. International Labour Organization. Summary of the International Labour Organization 2012 Global Estimate of Forced Labour. 01 Jun 2012.
  8. Lederer L, Wetzel C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-91.
  9. Macias-Konstantopoulos WL. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA J Ethics. 2017 Jan 1;19(1):80-90.
  10. Macias-Konstantopoulos WL. Human trafficking: the role of medicine in interrupting the cycle of abuse and violence. Ann Intern Med. 2016 Oct 18;165(8):582-588.
  11. Ottisova L, Hemmings S, Howard LM. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci. 2016 Aug;25(4):317-41.
  12. Polaris Project. http://www.polarisproject.org. Accessed June 20, 2017.
  13. Powell C, Dickins K, Stoklosa H. Training US health care professionals on human trafficking: where do we go from here? Med Educ Online. 2017;22(1):1267980.
  14. Rollins R, Gribble A, Barrett SE, Powell C. Who is in your waiting room? Health care professionals as culturally responsive and trauma-informed first responders to human trafficking. AMA J Ethics. 2017 Jan 1;19(1):63-71.
  15. Salvation Army of Central Maryland. Combat Human Trafficking. salvationarmymwv.org/centralmaryland/help/human-trafficking/. Accessed June 20, 2017.
  16. Shandro J, Chisolm-Straker M, Duber HC, et al. Human trafficking: a guide to identification and approach for the emergency physician. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.
  17. Stoklosa H, MacGibbon M, Stoklosa J. Human trafficking, mental illness, and addiction: avoiding diagnostic overshadowing. AMA J Ethics. 2017 Jan 1;19(1):23-34.
  18. Tahirih Justice Center. Human Trafficking Press Kit. http://www.tahirih.org. Accessed June 20, 2017.
  19. Todres J. Physician encounters with human trafficking: legal consequences and ethical considerations. AMA J Ethics. 2017 Jan 1;19(1):16-22.
  20. United Nations General Assembly. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, 15 Nov 2000.
  21. United States Department of Homeland Security. http://www.dhs.gov/blue_campaign. Accessed June 20, 2017.
  22. United States Department of Justice, Bureau of Justice Statistics. Apr 2011.

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