Recognizing and Responding to Human Trafficking in Texas, 2nd Edition _ ____________________________
ASSESSMENT General considerations during physical exams are related to looking for signs of malnutrition, dehydration, and/or physical exhaustion (Stocklosa et al., 2022; Tiller & Reynolds, 2020). Signs may also be visible on the skin. Look for signs of burns, bite marks, ligature wounds, bruising, traumatic alopecia, and tattoos that are sexually explicit or suggestive of ownership (Richie-Zavalet et al., 2021; Stocklosa et al., 2022; Tiller & Reynolds, 2020). When possible, always speak to the patient alone and use an independent, trained interpreter if required. If trafficking is suspected, anyone with the patient could be a potential trafficker. Additional patient situations, behaviors, or emotional states may suggest human trafficking (National Human Trafficking Resource Center, 2016). • Paying cash or having no health insurance • Lacking control of identification documents (e.g., state-issued ID or passport) • Having few or no personal possessions • Due to large debt, being reticent when asked to consent for additional testing or services • Inability to: ‒ Leave home or place of work ‒ Speak for oneself or share one’s own information • Feeling helplessness, shame, guilt, self-blame, and humiliation • Experiencing a loss of sense of time or space; not knowing where they are or what city or state they are in • Feeling emotional numbness, detachment, disassociation RESPONSE AND FOLLOW-UP Victims of trafficking do not often disclose their trafficking situ- ation in clinical settings (Alpert et al., 2014). Research indicates that up to 88% of victims interact with healthcare providers while they are in a trafficking situation (Smith, 2022. Many healthcare systems and facilities do not have policies in place that standardize screening and response protocols. One study found that only 39% of healthcare centers, departments, hos- pitals, and clinical settings such as dental and OBGYN offices in Michigan and Texas had screening policies in place, and only 62.5% had response protocols in place (Munro-Kramer et al., 2022). Healthcare providers must be thoughtful and careful about engaging with patients if human trafficking is suspected. Before beginning any conversation with a patient, assess the potential safety risks that may result from asking sensitive questions. Recognize that the goal of your interac- tion is not disclosure or rescue, but rather to create a safe, nonjudgmental place that will help you identify trafficking indicators and assist the patient (National Human Trafficking Resource Center, 2016).
• Victims may present with frequent and repeated injuries or other signs of physical abuse and may be vague/inconsistent in their description of the injuries. Common physical injuries include broken bones (jaws, legs, arms, ribs, eye sockets, etc.), significant bruising from being hit/punched/ thrown, and work-related injuries resulting from unsafe occupational conditions. • Victims may also present with obvious mental health concerns such as generalized anxiety, major depression, dissociation, and deliberate self-injury/ suicidal ideation. A study by Zimmerman et al. (2006) found that survivors of human trafficking reported the following symptoms of anxiety and depression: Nervousness or shakiness inside (91%), terror/panic spells (61%), fearfulness (85%), feeling depressed or very sad (95%), and hopelessness about the future (76%). • Victims may display obvious sexual health concerns such as risky sexual behavior (having multiple partners), repetitive and frequent STI screenings, frequent visits for reproductive healthcare and/or abortions, and signs of sexual trauma. • Other potentially obvious red flags include a delay between injury/illness onset and seeking care or concerning prescription filling patterns. By taking a more nuanced history about the presenting complaint, along with a brief social history assessing home and work environments, providers may be able to discern a potential trafficking situation. Carefully reviewing medical records is essential and an effective way to supplement or clarify a patient-reported history when it is vague, misleading, or untrue. A study of sex- trafficking survi- vors from two major U.S. cities revealed that most participants who took part in the study reported visiting the same health- care clinic on several different occasions for various injuries (Richie-Zavaleta et al., 2021). The authors use this to highlight the importance of reviewing patients’ medical records when identifying patients who may be victims of human trafficking. Additional red flags may be seen in a victim’s companion/guest and include behaviors such as refusal to leave when trying to conduct one-on-one patient interviews, insistence on speaking/ translating for the patient, controlling/interrupting the flow of care, having the patient’s documents in their possession, and an employer demanding access to medical information. Traffickers may employ strategies such as pretend- ing to be the victim’s partner, family member, or close friend. Another potentially obvious red flag is a trafficker accompa- nying multiple victims to the same healthcare facility. Some traffickers may visit a certain healthcare facility so frequently that they try to build rapport with providers in order to deceive these of their “goodness.”
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