Trauma-informed care (also known as trauma-sensitive or trauma- aware care) is one way to provide effective and compassionate care for patients who may be trafficked or are otherwise traumatized. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a program, organization, or system that: 24 1. Realizes the widespread impact of trauma and understands potential paths for recovery. 2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system. 3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices. 4. Seeks to actively resist re-traumatization. Taking a history No evidence-based recommendations guide assessment and evaluation processes in the context of known or suspected human trafficking. Practice-based evidence, however, has been used to generate recommendations for screening and inquiry in these situations. Survivors of trauma report that disclosure may be more likely if health care providers are perceived to be knowledgeable about abuse and violence, nonjudgmental, respectful, supportive, and use a trauma-sensitive approach to evaluation and treatment. 8 Given the impact of adverse childhood experiences and other traumatic exposures on later physical and mental health and well-being, some experts recommend embedding specific questions about trafficking after a trusting relationship has been established. The length of time it takes to establish such a relationship with a victimized individual varies widely—it may take just a few minutes or require multiple separate visits. Once rapport has been developed with the patient, and confidentiality (along with its limits) has been communicated clearly, questions about possible human trafficking and other forms of coercive control can be asked. If you suspect human trafficking, try to start with indirect questions. Enlist the help of a staff member and/or interpreter who has knowledge of the patient’s language and culture after confirming there is no conflict of interest. Attempt to interview the patient alone without raising suspicions. You may need to be creative in finding opportunities to interview the patient alone, Physical examination A physical examination should be performed carefully and sensitively, guided by the clinical presentation and by information gleaned from the history. In cases involving sexual violence and other forms of trauma, forensic evaluation and evidence collection should be offered when appropriate (e.g., if the most recent sexual assault has occurred within 120 hours of presentation, and with the patient’s consent or in conjunction with mandated reporter responsibilities).8 Forensic evaluation and evidence collection should be performed using approved sexual assault evidence collection kits. If available in your area, sexual assault/forensic nurse examiners, who have specific training in forensic evaluation and evidence collection, should be used. Case study: Clinical consideration part 1 A young woman, Jessica, presents to the local clinic requesting evaluation for genital sores and vaginal discharge. You notice on her intake information that she is paying cash for this visit, and further review of her records reveals that she does not have a permanent address and has presented on multiple occasions to the clinic with similar symptoms. She is accompanied by her boyfriend, Mark, who largely speaks for Jessica, answering the
Trauma-specific intervention programs generally: ● Acknowledge the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. ● Address the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. ● Collaboratively work with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers. Other trauma-informed approaches support the need for fundamental safety throughout the healthcare system (e.g., the Sanctuary model. Information at http://sanctuaryweb. com/) Additional intervention information can be found in a manual about trauma-informed care published by SAMHSA and available at: https://store.samhsa.gov/product/TIP-57-Trauma- Informed-Care-in-Behavioral-Health-Services/SMA14-4816 as traffickers may accompany patients to their visits and insist on staying with the patient throughout the encounter. Requesting that the patient leave the room for specific tests, such as x-rays, or urine testing, even when not necessary, may provide time away from the escort to ask questions in a confidential environment. Examples of probing questions: 1. Has your identification or documentation been taken from you? 2. What are your working or living conditions like? 3. Where do you sleep and eat? 4. Can you leave your job or situation if you want? 5. Do you sleep in a bed, on a cot or on the floor? 6. Do you have to ask permission to eat, sleep or go to the bathroom? 7. Can you come and go as you please? 8. Have you ever been deprived of food, water, sleep or medical care? 9. Are there locks on your doors and windows? Do you lock them or does someone else? (e.g., so you cannot get out) 10. Have you been threatened if you try to leave? 11. Have you been physically harmed in any way? 12. Is anyone forcing you to do anything that you do not want to do? 13. Has anyone threatened your family? Abuse and violence, including that resulting from human trafficking, should be suspected when any of these physical findings are noted: ● Bilateral or multiple injuries. ● Evidence consistent with rape or sexual assault. ● Evidence of acute or chronic trauma, especially to the face, torso, breasts, or genitals. ● Pregnant woman with any injury, particularly to the abdomen or breasts; vaginal bleeding; or decreased fetal movement. ● Body tattoos that are the mark of a pimp or trafficker. ● Occupational injuries not linked clearly to legitimate employment. questions, while she remains sitting quietly on the examination table. Jessica appears withdrawn and does not make eye contact with you. She appears to have superficial abrasions and bruises in various stages of healing on her upper extremities. 1. Take a moment to consider the many clues of this encounter that could indicate this young woman may be a victim of human trafficking.
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