you. She appears to have superficial abrasions and bruises in vari - ous 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.
Documentation Clinicians should carefully and accurately document all findings in the medical record, not only because this is standard care for all patients, but because such data may be valuable if the patient seeks legal redress. The patient’s medical history, physical find - ings, and oral disclosures, should be documented in writing, in an unbiased manner, using direct, unaltered quotes from the patient, to the extent possible. Photographic documentation of physi- cal findings may be appropriate, with the patient’s permission. Images should contain the patient’s face and the injury or lesion measured with a ruler or other common object (such as a coin). Additional photographs can document close up views of each rel- evant injury or lesion. Patients should be informed that they have a right to refuse photographic documentation altogether or to restrict photographic documentation to certain specific areas if
they so choose. The words “suspected human trafficking” as a finding, diagnosis, or problem should be included in the chart when appropriate. 8 The Clinical Goal : The clinician’s goal should not be to “get a disclosure” from a patient suspected of being trafficked or oth - erwise abused. 8 Instead, the health care provider should work to create a climate that allows every patient to feel safe, secure, cared for, validated, and empowered to disclose if he or she chooses. Disclosure might occur later if the patient does not feel ready to disclose in the immediate clinical setting. There- fore, each individual clinical encounter should be viewed as a step on a pathway to safety for at-risk patients.
RISK ASSESSMENT AND SAFETY PLANNING
● Increasing or new threats of homicide (or suicide by the traf- ficker) if the patient discloses. ● The presence or availability of lethal weapons in the residence. Detailed safety planning and related case management are best undertaken by those with specific expertise in this area: advo - cates, social workers, and case managers. These expert partners are generally equipped with the time and expertise needed to address each patient’s immediate, short- term, and long-term needs, and to arrange for appropriate follow- up with known and trained community-based resources. ● Restrict access to all doors except the main entrance. ● Pre Program 911 into all phones. Quality improvement programs of various kinds can create and support policy changes regarding safety and high quality health care systems. One training program specific to human trafficking is SOAR to Health And Wellness Training. (SOAR is an acronym for Stop, Observe, Ask and Respond to Human Trafficking.) The program is available at https://www.acf.hhs.gov/otip/training/ soar-to-health-and-wellness-training erode the provider-patient relationship and remove the autonomy patients deserve and need for making informed decisions for their own safety and future. As in cases of intimate partner violence, therefore, health care providers must follow the lead of the pa- tient and respect the decisions of those who decide not to contact law enforcement or accept referrals to other services. Domestic as well as international victims of human trafficking have specific legal rights under federal and state law, but may not know of these rights or be in a position to exercise them. If the patient is willing, a referral to law enforcement, attorneys, or legal service providers is appropriate. with Jessica and Mark, you indicate that she must undergo urine pregnancy testing before beginning treatment and request that she accompany you to the restroom to provide a urine sample. Mark offers to go with her and wait outside of the restroom. You explain that it is not possible as the route to the restroom may pass other patients’ rooms, that the restroom is in a location shared with other patients, and you must protect their privacy. Mark quickly replies that it is impossible for Jessica to be preg- nant, as she is compliant with her oral contraceptives, her periods are normal and questions the necessity of the test. You indicate
If trafficking has been disclosed, clinicians can help the patient by: ● Having the patient assess his or her own personal risk. ● Making an independent judgment about that risk and com- municating this opinion to the patient. ● Talking about safety planning. ● Making referrals to appropriate case management services for more detailed safety planning and case management. Patients may minimize or deny the danger they face, hence clini- cians should note the following “red flag” signs of heightened risk: ● More frequent or severe threats or assaults. ● New or increasingly violent behavior by the perpetrator. Safety and training of health care workers Since traffickers may be involved in various criminal enterprises, protecting health care workers is essential. The following sugges- tions include general safety measures as well as those specifically applicable to health care workers who may help victims of human trafficking: 16 ● Build relationships with local police or security personnel. ● Review emergency plans periodically. ● Restrict after-hours access. ● Improve lighting at entrances and parking areas. ● Install security cameras, mirrors, and panic buzzers.
Legal considerations
“Health care providers are not required to—and in fact may not—report suspected instances of human trafficking that involve a competent adult victim, without the patient’s express consent.” 8
Clinicians should not involve law enforcement and/or social ser- vice providers (e.g., housing/shelter services, legal services, and case management) without first obtaining the explicit informed consent of the patient, or unless otherwise required under rel- evant law. These laws may include mandatory reporting laws for children, disabled adults, elders, and others. Privacy breaches can Case study: Clinical consideration part 2 Continuing Jessica’s visit, you are now beginning her physical ex - amination. Mark indicates he would like to remain in the room during the examination, Jessica agrees and consents to his pres - ence. He stands next to the head of the bed during the pelvic examination. Upon completion, you have identified an outbreak of Genital Herpes, and microscopic examination of the discharge reveals Trichomoniasis, two sexually transmitted diseases. Mark seems unusually undisturbed by the diagnoses. You are concerned about Jessica’s current living situation and would like to question her privately. In discussing the diagnoses
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