11. Have you been physically harmed in any way? 12. Is anyone forcing you to do anything that you do not want to do? 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 questions, while she remains sitting quietly on the examination 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 findings, 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 physical 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 relevant injury or lesion. Patients should be informed that they have a right to refuse photographic documentation altogether or to restrict photographic
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. 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. 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 otherwise 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. Therefore, 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 trafficker) 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: advocates, 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
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 communicating 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 clinicians 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 suggestions 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.
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