In healthcare settings, another person who poses as the patient’s friend or relative may accompany the trafficked person. The companion to the patient is sent to reinforce the trafficker’s omnipresence, serving as a minder. The minder (companion)
will insist on staying with the patient throughout the clinical encounter (Baldwin et al., 2014). The minder is actively a part of the trafficking system and may report to the trafficker or may even be the trafficker.
CLINICAL SIGNS AND SCREENING TOOLS
clinical symptoms and diagnoses as cues can lead to better identification of trafficked individuals. Clinicians can use social history and contextual cues when identifying trafficked persons. The healthcare professional needs to draw connections between the methods and patterns of trafficking and the health consequences (Table 1).
Individuals who are trafficked are exposed to various health risks, including occupational exposures and physical, sexual, psychological, and social trauma (IOM, 2009; Zimmerman et al., 2011). Health conditions such as mental health disorders, including depression and anxiety, and substance use disorders may persist even after successfully escaping trafficking (IOM, 2009). Potential trafficked patients may present with one telling symptom or multiple comorbidities. Recognizing these Signs and symptoms of trafficking Many maladies can be attributed to the effects of trafficking, and some are more common than others depending on the type of trafficking. Note that some of the signs of trafficking are not unique to trafficking. For example, there may be overlap in cases of intimate partner violence. Regardless, further screening is warranted to help identify patients who may be victims of trafficking or other violent crimes (IOM, 2009). Psychological Trafficked persons often experience posttraumatic stress disorder (PTSD), depression, suicidal ideation, drug addiction, and associated symptoms as a result of psychological violence (Dovydaitis, 2010). Lederer and Wetzel (2014) reported that 54.7% of 106 trafficked individuals reported experiencing PTSD during trafficking; 88.7%, depression; and 41.5%, attempted suicide. According to Lederer and Wetzel (2014), substance abuse was frequently used by trafficked individuals to mentally escape the trafficking and also was used by the trafficker to exert control. Many psychological symptoms that trafficking patients present with are a direct result of the manipulative measures their traffickers use, such as the Biderman’s framework (discussed in Table 1; Baldwin et al., 2014). One study found that restricted freedom is both a core factor of human trafficking and a large risk factor for poor mental health (Kiss et al., 2015). The authors reported that trafficked persons who were severely restricted in their activities were two times as likely to have symptoms of PTSD, anxiety, and depression compared with trafficked individuals with fewer restrictions. Psychological coercion methods affect the mental health of patients as well. Shame, guilt, poor self-esteem, and fear for family members (based on threats by traffickers) create complex psychological stress that affects trafficked individuals negatively and can feed into the cycle of victimization and traumatization (de Chesnay, 2013). It is important to note that a healthcare visit can derail efforts to help the victim if they perceive healthcare providers as judging them or if interactions trigger past traumas. Physical Signs of physical violence are common among trafficking patients, ranging from broken bones to missing hair to bruising. Physical and sexual violence are prevalent among trafficked women. Hossain et al. (2010) reported that 92.6% of trafficked women experienced sexual violence, and 77% experienced physical violence from being hit or kicked. Injuries may appear to be at multiple stages of healing or untreated, suggesting chronic trauma and perhaps a delay in seeking care. Because social isolation is prevalent in this population, trafficked persons may not have access to health care for injury treatment. Screening for trafficking Once there is a suspicion of human trafficking, obtaining information from the patient can be vital in terms of providing the best quality care and empowering the patient by providing the most appropriate resources. It can be challenging to find a balance between asking important questions of the patient
Pelvic inflammatory disease, STIs, ectopic pregnancies, and HIV/ AIDS are a few of the medical conditions seen in sex-trafficked individuals. Labor trafficking can leave a person with physical injuries related to occupational exposures, including accidents related to poor personal safety equipment, abuse from supervisors, or ailments resulting from inadequate living conditions (NHTRC, 2015b). Poor ventilation, sanitation, and nutrition, as well as airborne and bacterial contaminants, are health risks associated with labor exploitation (IOM, 2009). Working long hours with little rest can also contribute to work-related injuries. Other common physical health symptoms seen with labor and sex trafficking include headache, fatigue, dizziness, back pain, and memory problems (Kiss et al., 2015; Oram, et al., 2012). Branding (i.e., intentionally inflicting burns or cuts to create symbols) is a common way for traffickers to demonstrate ownership (IOM, 2009; Oram et al., 2012). Those who are being trafficked may have their trafficker’s name, a pseudonym, or a bar code tattooed or etched into their skin to signify the trafficker’s permanent ownership. Asking about a tattoo’s significance during a healthcare visit may elicit details about the patient’s social history. Social Contextual indicators are important to help the clinician identify potential trafficking. Clinicians should pay attention to who attends the patient’s appointments and how the patient behaves in the office or examination room. A minder posing as a partner or family member often will speak for the patient when questions are asked (Zimmerman et al., 2011). Separating the patient and minder may free the patient to disclose information during an interview. Even when alone with a healthcare professional, a trafficked person may be fearful or hesitant to answer questions. Separating the trafficked individual from their minder may be difficult. One strategy is that an X-ray may be ordered when the suspected perpetrator is present; the order can be cancelled when the patient gets to the X-ray room if it is not needed. During X-ray procedures, health care providers have an excellent opportunity to separate the victim from anyone accompanying them, allowing the victim to answer questions. In the case of foreign individuals who are being trafficked, English may be a second language, making it even more difficult to discover the trafficking through an interview. In these cases, clinicians should use a professional interpreter, not a family member or the minder.
and limiting the risk of retraumatization. The provider should avoid yes/no response questions, as they do not provide enough accurate information. Questions should be open ended an allow victims plenty of time to respond.
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