Case Study 1 A young woman named Rebecca presents to a local urgent care requesting evaluation for genital sores and vaginal discharge. You notice on her intake information that she does not have insurance listed and indicates she is paying cash for this visit. Further review of her medical records shows that she does not have a permanent address listed and that she has presented on multiple occasions to this urgent care—in addition to other clinics/healthcare facilities—with similar symptoms. She is accompanied by a man named Derek, whom she claims to be her cousin, Identification Many victims of human trafficking are not willing to disclose the nature of their situation due to trauma and fear stemming from oppressive conditions and lived experiences. However, many victims and traffickers exhibit signs that can be identified. Potential red flags indicating a patient is a victim of human trafficking may be exhibited by both the patient and the patient’s guest/companion. Some potential patient-specific red flags include repeated physical injuries and signs of physical abuse/neglect, sexual health concerns with repetitive STI screenings or reproductive care, body language, and delayed care (Richie- Zavalet et al., 2021; Stocklosa et al., 2022; Tiller & Reynolds, 2020). ● A victim’s body language may convey that they are fearful, hypervigilant, and ● anxious. Victims may avoid eye contact with providers, may appear disoriented, may be unable to recall or report basic information such as their address, and may even be unable to produce identification documents. ● 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%). 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).
and who largely speaks for Rebecca, answering questions while she remains sitting quietly on the examination table. Rebecca appears nervous and avoids making eye contact with you and other staff members. She has superficial abrasions and bruises around her eyes and mouth as well as on both upper extremities. Take a moment to consider any potential red flags that you, as the healthcare provider caring for Rebecca, notice that would indicate Rebecca is a victim of human trafficking.
IDENTIFICATION AND ASSESSMENT
● 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 survivors from two major U.S. cities revealed that most participants who took part in the study reported visiting the same healthcare 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 medicalinformation. Traffickers may employ strategies such as pretending to be the victim’s partner, family member, or close friend. Another potentially obvious red flag is a trafficker accompanying 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.” ● 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
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Book Code: PCTX1325
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