CASE STUDY 2 Elena, a 23-year-old Romanian woman, reports to the emergency room with persistent vaginal bleeding. She is dressed in a worn dress that seems inappropriate for the cold weather. Her vital signs are B/P 142/88, pulse 122, respirations 20, and temperature 98˚F. She seems withdrawn and very quiet. She is attended by an older Hispanic male who guides her by holding her upper arm when she walks. Her history includes a vague report of irregular menstrual periods and three previous pregnancies, but no living children. The outcomes of the previous pregnancies or the gestation time when the pregnancies were lost are not known by Elena, or she is averse to disclosing how
the pregnancies were terminated. She has been bleeding for about 10 days. On examination, scarring around the vagina is evident, with recent abrasions of the labia. The examination of the cervix shows evidence of previous pregnancies and multiple lines of scar tissue indicative of forced abortions. The man with her refuses to leave the room during her examination, and she agrees for him to stay. She continuously looks at the floor and speaks only in brief one-word answers, but she seems to comprehend English. Diagnostics studies include various blood work, pregnancy test, testing for sexually transmitted diseases, and an abdominal X-ray.
INTERVENTION STRATEGIES FOR HUMAN TRAFFICKING VICTIMS
Assessing possible victims Recognizing that a patient is a suspected victim is the first step, but often is difficult because signs can be quite subtle. It can be challenging to find balance between asking important questions of the patient and limiting the risk of retraumatization or triggering memories that make the patient relive the trauma. A trauma-informed, caring approach is often more important than the specific questions asked. (Note that trauma-informed care refers to patient-centered care that acknowledges the potential traumas that each patient may have experienced) (SAMHSA- HRSA, 2015). The goal for every clinical encounter is to provide quality care that minimizes harm to the patient and addresses their health needs. While disclosure of trafficking may occur, it is never the primary goal of the patient encounter. Pressuring patients for a disclosure reduces their agency and could contribute to mistrust in the medical system. In 2019, Dignity Health’s Human Rights Clinic put forth guidelines based on survivor informed practices for improved screening. Creating the PEARR (Privacy, Educate, Ask, Respect, and Resources) tool, Dignity Health presents a framework for engaging with any patient whom may be trafficked (Dignity Health, 2019). The privacy section of the PEARR tool highlights the need to have discussions of potential trafficking without the presence of any other individuals that the patient may have arrived with as well as insuring that the interview space is away from the eyes and ears of others. The educate portion focuses on discussing in general terms what trafficking is, coming to a mutual understanding with the person who may be trafficked about its definition. This is important as many may not identify as being trafficked (Dignity Health, 2019; ICMEC, 2019). The ask guidelines can be approached from a variety of ways. Some may use similar questions to those put forth by other screening guidelines. It may also be asking if the signs and symptoms reviewed in the education portion apply to the patient. The respect guidelines include acknowledging the patient’s right not to answer specific questions as well as using trauma-informed care to avoid re-traumatizing them. Finally, the resources portion includes providing the tools and services that the individual needs moving forward. Whether the person is attempting to leave their trafficker, or are only ready to receive directed medical care, there are a variety of basic needs that may need to be met (Dignity Health, 2019; ICMEC, 2019). The National Institute for Health and National Human Trafficking Training and Technical Assistance Center (NHTTAC) also developed a human trafficking screening tool for adults (2018). The training and toolkit share similar principles as the PEARR method, with establishing a
relationship and reviewing indications of trafficking. The training also discusses safety planning for patients. The following questions help healthcare professionals assess for possible human trafficking (Owen et al., 2015): ● Are there bruises of other signs of physical abuse? ● Are there signs of psychological abuse? ● Is the person submissive or fearful? ● Is the person being controlled? ● Is the person being deprived of food, water, sleep, medical care, or other life necessities? ● Is the person allowed to be in public alone? ● Can the person freely contact friends or family? ● Is the person a minor engaged in commercial sex? ● Does a minor appear to be in a relationship with a much older person? ● Does the person fear his employer? ● Can the person leave her job if she wants? ● Has someone threatened the person’s family? Although this list may not be definitive for every situation, the questions focus on the trafficking parameters that can lead to identification of the crime. Obtaining a health history from a child may require subtle questions. A child may not identify what has happened to him as abusive. Asking more fill-in-the-blank or open-ended questions can yield better information than direct ‘yes/no’ questions. Instead of asking if he is given enough to eat, the clinician should ask the child something like, “Can you tell me what you usually have for breakfast/lunch/dinner?” It may be useful to ask questions such as, “Where do you usually sleep?” or “Can you tell me about this bruise?” Using probes, such as repeated words that the child has said or rephrasing his response for clarification, may also help elicit the actual situation. The clinician should avoid letting an adult who may be attending the child answer the questions (Dignity Health, 2019; ICMEC, 2019). ● Does the person have identification? ● Does the person know his address? Healthcare Consideration Professional Consideration: Avoid using ‘yes/no’ response questions. Such questions do not provide enough accurate information. Keep questions open ended and allow victims plenty of time to respond. The first priority should always be ensuring the safety of the patient and staff. The concept of safety encompasses the physical and psychological safety of the patient who may have been trafficked, as well as the staff (SAMHSA, 2015). Patients need to be certain that they are not in danger, either from their trafficker or from the authorities. Many patients are hesitant to volunteer information or cooperate with authorities, because their trafficking experience
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