Mandatory reporting The awareness of trafficking has risen greatly over the past decade, and new laws address this crime. Healthcare professionals should make it a point to research and keep up to date with what laws are passed. It is important to know the legal requirements of reporting within the state of practice and to proceed accordingly. The National Conference of State Legislatures (2016) provides a list of human trafficking laws specific to each state as well as a breakdown of laws related to mandatory reporting by state (see Resources). Reasons for not wishing to report cases of human trafficking are complex and largely center on the need to maintain the patient’s trust. Trafficked individuals often have a powerful distrust of authority, especially law enforcement. They fear legal repercussions for themselves, especially when involved in commercial sex exploitation. Additionally, trafficked minors may worry about the potentially rage- filled retribution they may suffer when their traffickers find out they contacted the authorities. Being aware of these complexities and the existing laws will aid in selecting the appropriate course of action. Reporting suspected cases of human trafficking is a professional responsibility of all healthcare personnel. Accurate documentation and reporting are the only ways lives can be saved and this type of modern-day slavery can be stopped. Patients who will be treated in the emergency department or clinic with suspicious injuries, behavior or affect changes, and other red flags of appearance and history should always be treated as potential human trafficking victims. Health Care Professional Consideration: An estimated 100,000 to 200,000 American children are sexually exploited, some as young as five years old. Another 400,000 to 500,000 are involved in child labor in agriculture. At least a third of these children will end up seeking medical care, and the majority will not be recognized as trafficking victims (Domoney et al., 2015). With the Child Abuse Prevention of Treatment Act of 1974 (CAPTA) mandates that in order to receive federal funding for child abuse and neglect programs, states must have child abuse reporting laws (English, 2017).) With subsequent reauthorizations of the amendment, child abuse has been broadened to include sexual exploitation and abuse of minors as being means for mandatory reporting. There are differences in specific state laws where some states have included human trafficking, while others do not (English, 2017). Establishing trust Those who have been trafficked may be fearful that they are in danger, from both their traffickers and the authorities. This fear and history of exploitation may translate to distrust of health professionals, distrusting both the advice from and confidentiality of health professionals. Key principles of building and maintaining trust are to discuss these issues forthrightly and to avoid making promises that one cannot keep (Dignity Health, 2019; ICMEC, 2019). Basic interpersonal sensitivity and caring must be used to prompt trust in suspected victims. Sitting at eye level with the patient, attempting to see the patient without the person who accompanied her, and displaying patience will help to establish trust. Asking nonjudgmental questions while making it clear that the patient’s safety is a priority will aid in eliciting needed specifics (Edmonson et al., 2017). If needed, the services of an interpreter should be obtained if the victim is having trouble communicating in English.
Personal distance, gender crossing, and touching vary dramatically across cultures. Trauma-informed care implies sensitivity to the victim’s culture as well as her need for safety and empowerment (Mather & Feldman-Jacobs, 2015). All care procedures should be conducted with gentleness. Victims should be touched only with permission. Ask, “I need to touch you here to check for injuries. Is that OK?” But with victims of violence, taking part of the history after some trust is established may increase the information obtained. Women and girls that are sex trafficked often experience rape while in transit, establishing an early element of control and fear. PTSD, depression, mood disorders, and anxiety are the common reactions to this trauma (ICMEC, 2019). Symptoms of PTSD—hyperarousal, or feeling jittery; flashbacks, or reliving the events; changes in feelings or beliefs; paranoia; and avoidance or keeping busy to avoid thinking—are all part of the clinical picture (ICMEC, 2019). These pervasive symptoms also contribute to the use of alcohol and street drugs. Assessment of the victim’s body Children victims may be encouraged to simply nod their head if a named part of the body is hurting them because they may be unwilling to put the pain into words (ICMEC, 2019). Skin inspections should be done on any suspected trafficking victim and a detailed documentation made in his chart. Exposing skin areas in segments will help to maintain the patient’s privacy and dignity and to build trust. Traumatic alopecia, bite marks, and wounds or cigarette burns are red flags of abuse (Edmonson et al., 2017). Scattered bald spots, particularly on the top of the head, can indicate physical restraint by hair pulling. The clinician should examine the extremities, neck, groin, and axillae for needle marks, tracks, or any signs of IV drug use. Transparency, or openly sharing all parts of any procedure before and while they occur, being clear with regarding the examination process is paramount (ICMEC, 2019). As is discussed later in the section on mandatory reporting, there are instances when state law requires that authorities be contacted. Informing patients about this process before they reveal sensitive information can build trust. It may affect how much the patient reveals, but ultimately it will build a relationship with the patient and likely make him or her feel more comfortable returning if given the chance. Healthcare providers who gain the trust of their patients must ensure that they keep that trust (ICMEC, 2019). Assessing for sexual abuse in sex trafficking victims Performing gynecological examinations and testing for STIs and hepatitis B is vital. Pregnancy tests should also be included. Children should not be overlooked in an examination. However, because few pediatricians are prepared or comfortable performing examinations of sexual trafficking victims, a gynecologist may need to be consulted (ICMEC, 2019). The gynecological exam should focus on signs of trauma, such as lacerations, bruises, and scarring. Traffickers may have forced victims to use cotton and sponges to block menstruation in order to avoid any down time in sex services. Evidence of female genital mutilation, though not always considered abuse, should also be carefully documented as a human rights issue (Barron et al., 2016). Vaginal injuries, changes in menstrual cycle, acute and chronic pain, and urinary tract infections are common consequences of rape and forced prostitution (Edmonson et al. , 2017). Victims who choose to leave the clinic or emergency department after receiving only immediate care need to be
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