______________________________________ Human Trafficking and Exploitation: The Texas Requirement
outpatient medical settings for a variety of issues, including sexually transmitted infections, pregnancy, depression (includ- ing suicidality), injuries resulting from assault, substance abuse- related issues, and PTSD [94]. Because medical and dental appointments may allow for more privacy than a victim’s other encounters, they may represent a unique opportunity for healthcare providers to intervene. Yet, many providers lack the training and confidence to identify and assist victims. In a survey of 110 emergency department physicians, nurses, and physician assistants, the majority (76%) reported having a knowledge of human traf- ficking, but only 13% felt equipped to identify a trafficking victim and only 22% were confident in their ability to provide satisfactory care for such patients [95]. Less than 3% had ever received any training on this topic. In a separate survey of healthcare and social service providers, only 37% had ever received training on identification of trafficking victims [96]. This lack of healthcare provider knowledge is the root of some victim’s reluctance to disclose. Because human trafficking and exploitation are, by nature, covert processes, the identification and rescue of the victim can be difficult. As stated, traffickers often move victims from one area to another to reduce the risk of identification, and one of the main problems with the assessment of such individuals is that practitioners may only have a one-time encounter with the victim [97]. Other provider challenges include language barri- ers, the hidden nature of the crime, lack of self-identification as a victim, confusing or contradictory laws/regulations, lack of organizational protocols, and stereotypes/misconceptions [98]. Several barriers exist that prevent survivors from self-disclosing their experiences, including [98]: • Unable to self-identify • Lack of knowledge of services • Fear of retaliation • Fear of law enforcement/arrest/deportation
It is important to use a trauma-informed approach when assessing and caring for potential victims, which requires that practitioners understand the impact of trauma on all areas of an individual’s life [99]. Physical, emotional, and psychological safety is at the heart of trauma-informed care. This approach allows for trust-building and continued communication, two factors that are vital to ensuring that patients receive the care and support they require. Being trauma-informed is a strengths-based approach that is responsive to the impact of trauma on a person’s life. It requires recognizing symptoms of trauma and designing all interactions with victims of human trafficking in such a way that minimizes the potential for re-traumatization. This involves creating a safe physical space in which to interact with survivors as well as assessing all levels of service and policy to create as many opportunities as possible for survivors to rebuild a sense of control. Most importantly, it promotes survivor empower- ment and self-sufficiency. Survivors should also have access to services that promote autonomy and are comprehensive, victim-centered, and culturally appropriate. Additionally, traf- ficking survivors share that one of the most important steps to being trauma-informed is to be survivor-informed [100]. POTENTIAL RED FLAGS Bruises, scars, and other signs of physical abuse may be missed on examination, as victims are often beaten in areas hidden by clothing (e.g., the lower back) so as not to affect the victim’s outer appearance. Physical trauma symptoms may be present, commonly on the torso, breast, and/or genital areas [101]. Burns, broken bones, pelvic pain, and/or STIs (particularly in children) may also be red flags [102]. However, more common physical injuries are also typical with other circumstances, making physical exam of limited value. The entire clinical picture should be considered. It may also be helpful to assess for tattoos and/or other modifications (e.g., branding, piercings). Some perpetrators use tattoos to identify victims or to signify “ownership” [60]. With regard to episodic clinical encounters, recommendations for providing safe assessments in a culturally sensitive manner are lacking. The Department of Health and Human Services Administration for Children and Families maintains a useful website that addresses practical issues of human trafficking for allied professional groups, known as the Look Beneath the Surface Campaign [76]. Included are diagnostic and interviewing tips to help healthcare providers recognize and refer trafficking victims to appropriate services [76]. Emergency and primary care providers should be cognizant of clues that a patient may be the victim of trafficking and prepared to engage in a greater depth of inquiry with special attention to the following indicators [76; 102; 103; 104]:
• Lack of trust • Shame/stigma
• Learned helplessness/PTSD • Cultural/language barriers • Lack of transportation
TRAUMA-INFORMED CARE All interactions with patients, regardless of whether or not they are potential victims of trafficking, should be centered on the patient’s experiences, needs, and preferences. Provid- ing patient-centered care means that care will be respectful of and responsive to individual patient preferences, needs, and values and will reflect the patient’s values. This should be considered at all stages of assessment, intervention, and continued care/follow-up.
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MDTX2026
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