Human Trafficking Awareness for Rehabilitation Professionals

Original Editor - Stacy Schuirring

Top Contributors - Stacy Schiurring, Tarina van der Stockt and Kim Jackson  

Introduction

Rehabilitation professionals and healthcare workers are in the unique position to identify trafficked persons and provide assistance if that person is willing and in the position to accept help. To learn more about the types of human trafficking, and the legal considerations around the topic, please see this article.

This article will discuss how healthcare providers can identify, assess, and assist survivors of human trafficking.

Red Flags and the Health Impact of Human Trafficking

"Polyvictimization, also known as complex trauma, describes the experience of multiple victimizations of different types, such as sexual abuse, physical abuse, bullying, exposure to family violence, and more. This definition emphasizes different kinds of victimization, rather than just multiple episodes of the same kind of victimization, because it signals a generalized vulnerability. Research shows that the impact of polyvictimization is much more powerful than even multiple events of a single type of victimization." - National Children’s Advocacy Center

Survivors of human trafficking suffer physical, mental, emotional, and psychological injuries. Their independence and autonomy is taken from them. Their quality of life is hugely and devastatingly affected. A study by Hossain et al. interviewed more than 200 survivors of sex trafficking and assessed for mental health and quality of life. They found 55% had high levels of depression symptoms, 48% had high levels of anxiety symptoms, and 77% were potentially suffering from PTSD.

The following table is a summary of red flags for human trafficking:

Physical Health

Reproductive/sexual health: frequent treatment of sexually transmitted infections or injuries, multiple unwanted pregnancies, lack of sexual desire or over-sexualised behaviours Signs of physical abuse: fractures or burns, bruising, signs of concussion, traumatic brain injuries or unexplained memory loss Gastrointestinal problems Malnutrition Changes in sleep: sleeplessness, sleep disturbances, nightmares and/or night terrors, and/or insomnia Fatigue Skin or respiratory problems caused by exposure to agricultural or other chemicals Communicable and non-communicable diseases Oral health issues, including broken teeth Chronic pain Tattoos or branding of ownership

Emotional/Psychological Health

Unable to concentrate or provide basic information including age, address or time Substance abuse Self-harm and suicidal ideation Depression, anxiety, panic attacks Fear of being alone, distrust, and fear of strangers Guilt, shame, and/or self-blame Post-traumatic stress disorder Eating disorders Suspicious behaviour: appears nervous or avoids eye contact; seems overly fearful, submissive, tense, or paranoid Has a lack of autonomy or independence. Person will defer to another before giving information, no control over identification documents Cultural, linguistic barriers and isolation Withholds information. The person can be unwilling to answer questions about their health, and gives confusing or contradicting information

Optional in-depth reading:

• Please read here for a list of Red Flags of Labour Trafficking provided by the State of Texas, USA.
• Please read here for a list of Red Flags of Sex Trafficking provided by the State of Texas, USA.

The following table lists population-specific healthcare needs for survivors of human trafficking.

Immediate and short-term needs	Chronic pain Complications from unsafe abortions Oral health problems Headaches Vaginal and anal health concerns Anxiety, depression, suicidal ideation Post-Traumatic Stress Disorder (PTSD) Somatic disorders Substance abuse-related health issues: abscess, HIV+, Chronic Venous Disorders
Long-term needs	Physical abuse counselling Head/neck/spine injuries Fractures, Burns, Wound care Sleep deprivation, Psychosis Dehydration/malnutrition, Gastrointestinal problems, Ingestion of poisons and drug use Vaginal/anal pain and lacerations, Unintended pregnancy, Sexually transmitted infections (STIs), HIV exposure, Contraception

Interaction and Assessment of a Trafficked Person

Healthcare professionals can affect human trafficking with accurate identification of trafficked persons. Proper identification requires healthcare professionals to be familiar with vulnerabilities and red flags of human trafficking that may be revealed during routine assessments, especially when taking a detailed social history. A small number of human trafficking screening tools are available for use in the clinic. Unfortunately, there are only a handful of validated screening tools available for clinician use. Many of the tools would be of limited practical use in the health care environment because they (1) lack evidence-based support, especially for the health care environment, (2) have long administration times which may be difficult to utilise in the fast-paced medical setting, (3) require the administrator to have expertise in human trafficking, and (4) are only available and/or validated in the English language. Please see the resource section at the end of this article for downloadable options.

Once a trafficked person has been identified, the healthcare professional should interact with them in the following ways:

1) With respect for their autonomy

• Use the term "trafficked person" or "trafficking survivor" rather than "trafficking victim" to change the misconception that persons who have endured this form of trauma are "helpless victims."It should be noted that when interacting with the survivor, they should be the leader of the language exchange. Many survivors do not self-identify as a trafficked person.
• Treat trafficked persons as moral agents who have retained or can regain capacities for self-determination and decision-making power.As with all patient care, this interaction should be individualised for each person. Not all trafficking survivors are comfortable with too much autonomy too quickly and may find "either/or choices" as helpful tools to share information.
• Trafficked persons deserve dignified respectful healthcare, which includes rights enjoyed by all patients such as: privacy in their care, and use of a professional medical interpreter. This also includes an explanation of the legal limitations of medical confidentiality due to the mandatory reporting requirements of human trafficking to the proper authorities.

Special Topic: Professional medical interpreters

It is best practice, and federal law (Title VI of the Civil Rights Act) requires interpreter services for all patients who are receiving federal financial assistance) for medical and rehabilitation professionals to use a professional medical interpreter when interacting with a person with limited English proficiency.

Benefits of using a professional medical interpreter include:

• Fewer communication errors
• Interpreter can act as a "cultural liaison" and provide clarification and context to the healthcare professional
• Interpreter can clarify patient meaning beyond language
• Interpreter can function as a link between a trafficked person and the healthcare system

While there are times when a professional medical interpreter is not available and the use of an "ad hoc" interpreter such as a family member (including children) or friend are the only option. However, use of such an interpreter can lead to the following issues:

• Non-professional interpreters may provide unsolicited advice or input
• There is no guarantee of confidentiality around topics discussed
• The medical professional may lose control of the interview due to off-topic conversations
• Scope of inquiry may be limited by embarrassment or discomfort around about intimate or sexual issues
• Unfamiliarity with medical terminology can lead to misunderstanding and errors in interpretation
• Children should not be used as interpreters except in emergencies due to limited understanding of adult issues

2) With nonmaleficence and beneficence

• All healthcare professionals have an obligation to first do no harm (nonmaleficence) and to act in the best interests (beneficence) of our patients. Examples of positive interactions between patients and healthcare providers include (1) the removal of harm, (2) the prevention of harm, and (3) the promotion of good.
• The principle of nonmaleficence cautions against pressuring for a disclosure that they are being trafficked, especially in the presence of the trafficker. Aggressive attempts can be psychologically harmful to the trafficked person, and can potentially trigger intense stress, anxiety, fear, and retraumatising the individual.
• A trafficked person's decision over disclosing their situation and whether to accept clinical assistance are based on the individual person's firsthand experience and knowledge of the potential trafficker repercussions. For this reason, the patient's decisions must be respected to the extent possible when mandatory reporting laws do not apply.Discretion of the healthcare provider is of utmost importance.

3) Considering justice

• The unique circumstances surrounding the care of trafficked persons often challenge the concept of justice (the fair distribution of resources) by limiting trafficked persons’ ability to access appropriate and affordable health care outside of acute injuries and illnesses.
• Many healthcare professionals do not receive appropriate education and training to recognise the signs and symptoms of human trafficking. This is significant as it leaves healthcare professionals unable to comprehensively assess and respond to the complex and challenging healthcare needs of trafficked persons.
• Healthcare professionals must make treatment decisions for trafficked persons while considering the possibility of non-adherence and limited ability to follow through with long-term treatment plans, often for reasons outside of their control. Examples of pressing treatment needs for this population can include communicable diseases, substance use disorders, and mental illnesses. A healthcare professional's decision to not test or initiate interventions due to assumptions about medical adherence must be carefully weighed against potential trafficker repercussions. At times, it may be necessary to make referrals to known and trusted organisations or other providers to find alternative options to manage the unique challenges and circumstances of trafficked persons.

Special Topic: Mandatory Reporting Laws to Address Human Trafficking

These laws include (1) mandatory child abuse reporting laws, (2) domestic violence reporting laws, and (3) laws requiring reports of knife or gunshot wounds.

Texas Mandatory Reporting Law.

• According to Texas Family Code Section  261.101: "healthcare professionals are required to submit a report about suspected child abuse to law enforcement or the Department of Family and Protective Services (DFPS) within 48-hours of learning about the abuse." The duty of reporting the abuse cannot be delegated to another individual. Failure to do so is a criminal offense (Texas Family Code, Section 261.109).
• According to Texas Human Resources Code Section 48.051: "anyone with knowledge about the suspected abuse of a person  65 or older or an adult with a disability must submit a report immediately to law enforcement or the DFPS."

Benefits of these laws: Healthcare professionals are incentivised to report human trafficking under these laws, which should increase the overall awareness of human trafficking and improve education and assessment skills within the healthcare community. Triggering an appropriate investigation can result in protective measures for trafficked persons and prosecution of the traffickers. A growing number of states have created "safe harbor" laws where trafficked persons are not treated as criminals but as survivors needing trauma-informed care and supportive services.

Risks of these laws: While mandatory reporting laws can protect and benefit trafficked persons, they also invoke vulnerability risks of trafficked persons related to their mistrust of authorities, service providers, and health care providers and fear of their traffickers. These reporting requirements also override the confidentiality protections that normally apply in healthcare settings. This has the potential for trafficked persons to lose trust in the healthcare system due to their fear of reprisal by their traffickers, prosecution by law enforcement, or deportation.

To ensure the protection and safety of trafficked persons, healthcare and law enforcement professionals must be properly trained in human trafficking and their roles as part of a multidisciplinary team. Trafficked persons must have access to trauma-informed care, and support systems must have the necessary resources to provide meaningful prevention and protection. With measures in place to ensure that the risks of mandatory reporting laws are limited, healthcare professionals can assume the role of mandatory reporters of human trafficking while meeting their ethical obligations.

4) Considering how you interact

The following table lists provider strategies when interacting with a trafficked person.

Physical posturing	Maintain open and accepting body language Maintain relaxed body posture, neutral positions with hands at side, and be mindful to keep legs together Ask permission to make physical contact every time, and explain the procedure before making contact
Attitudes	Don’t stigmatise, victimise, or ask unrelated questions Normalise the experience for the patient Believe and validate the patient, confront any biases, and empathise
Language	Provide empathetic and empowering statements: “It is normal to feel this way” “Thank you for sharing with me” “You are very brave to tell me” “I am so sorry that this happened to you. No one deserves that” Use non-judgmental language such as “sex without a condom” vs “risky sex” Use the term “survivor” vs “victim” Encourage patient autonomy by saying “Is it okay if I?” instead of “I need to” Ask “What is the most important thing you need right now?

The information in this table is modified from the Healthcare Provider Toolkit by REST.

Optional: to learn more about interacting with suspected trafficked persons, please read this manual supported by the US Department of Justice.

Create and Maintain a Safe Healthcare Environment

In addition to building trust and rapport at an individual healthcare provider level, safety can also be enhanced at a facility and/or organisational level for survivors of human trafficking. Strategies can include:

• installation of a systemwide policy to see patients alone for at least a part of every visit. Examples of policy change can include: (1) posting signage that outlines this policy in plain view in common areas, (2) staff education, (3) completing assessments and interventions only when alone with the patient.
• creation of a separation protocol to allow healthcare providers to examine or question the individual they believe is a trafficked person in a private, safe environment when there is suspicion that they are with a trafficker. The protocol should include: (1) who will carry out the physical separation process, (2) the steps to follow if the suspected trafficker refuses to comply, and (3) having a plan in place with hospital security and/or local law enforcement in case the trafficker becomes dangerous.
• it is important to document that informed consent was obtained when working with adults and to contact local child protective services when working with a minor.

Intervention and Response

Healthcare providers can impact human trafficking using a multi-level approach, advocating for change from bedside care to society level. Within a clinical setting, healthcare professionals can come into contact with trafficked persons in any practice setting, including primary care settings, reproductive health clinics, medical specialities, or most commonly, emergency departments.

The use of an ecological framework will provide the most holistic and wide-reaching response to human trafficking. The levels of responsibility within this framework include: (1) individual-level healthcare provider training, (2) health facility–level screening policies and response protocols, (3) community-level multidisciplinary resources and response teams, and (4) society-level awareness campaigns, funding allocation, and data collection.

Framework level	Examples of Interventions
Individual-level	Training related to human trafficking, including case studies with real-life examples Trauma-informed care training
Health facility–level	Creation and use of screening policies and response protocols Have facility-level resources available in the electronic medical record
Community-level	24-hour hotline Multidisciplinary response teams to coordinate care across the service continuum beyond the hospital or clinic through established, trusted and vetted professional relationships
Society-level	Improving awareness within the healthcare setting and greater community of human trafficking Provide funding for training/education opportunities Collect data to create and add to the profile of human trafficking

The information in the table is based on data from Munro-Kramer et al. 2022.

Healthcare professionals can provide individualised interventions to trafficked persons to address human trafficking vulnerability factors and red flags within the safety of the health care setting. This can include:

• the initiation of established organisational protocols
• referral to trusted and vetted providers or outside organisations
• utilisation of trauma-informed and people-centred screening processes
• education on communicable diseases, substance use disorders, and mental illnesses within your scope of practice

Documentation of human trafficking by a healthcare professional of attempted and successful assessment, care and interventions provided, and referrals made. Examples of documentation include:

• if human trafficking screening has/has not been completed. If screening has not occurred, document the reason why.
• if abuse, neglect, or other signs of trafficking are suspected, even if the patient denies these concerns. It is important to objectively document why trafficking is suspected.
• photographs with the patient's written and verbal consent. It is important to explain that the photographs will become part of their medical record, which is protected by HIPAA (Health Insurance Portability and Accountability Act) and any applicable state or local medical record privacy laws. If a situation arises where the medical record of the trafficked person is needed, legal counsel should be consulted to assist with the release of information.

Optional reading: please review this document by the University of Michigan Human Trafficking Collaborative for more information on healthcare documentation.

Trauma-Informed Care

Special Topic: Trauma-Informed of Care

The trauma-informed approach to care is strongly recommended as a beneficial framework for caring for survivors of physical and psychological trauma, which includes persons who have experienced human trafficking. For these patients, effective care requires a sensitive, compassionate, measured approach with attention to healthcare practices to limit the triggering of fear, stress, shame, and stigmatisation.

Trauma-informed care shares many principles with patient-centered care and is influenced by a healthcare provider's understanding of the impact of interpersonal violence and victimisation on an individual’s life and development.

Examples include mindful sensitive wordage and proper verbal cues when requesting a patient disrobe for examination and assessment, and nonjudgement education on the use of contraception.

According to the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, the trauma-informed approach:

1. Realises the widespread impact of trauma
2. Recognises the signs and symptoms of trauma
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices
4. Seeks to actively resist re-traumatisation

Optional: to learn more about trauma-informed care, please read this link to The Healthcare Provider's Toolkit created by REST.

Multidisciplinary Team and Referral Network

Each survivor of human trafficking is unique and requires a different mix of services and support during their recovery journey. A strong multidisciplinary approach within the medical system and in community-based organisations and services will establish a safety net for safe return to the community. Building a comprehensive referral network will better meet the needs of survivors of human trafficking and their family members.

A referral network should include interactions between:

Healthcare	Provides collaboration with various healthcare professionals to identify and respond to human trafficking including: short and long-term medical treatment dental needs sexual assault forensic examination substance use treatment malnutrition and/or dehydration treatment and education
Legal Aid	provide information regarding legal options and advocates assistance with visa application assistance with orders of protection provide legal representation against their traffickers assist with the documentation needed for eviction and housing issues obtain proper legal documentation, such as proof of age and name at birth assist expungement relief for trafficked persons with a criminal history as a result of their trafficking provide family court services
Community-based Organisations	Often are the leaders in the development of a protocol and serve as a primary referral for a variety of services: housing interpretation/translation services childcare vocational training
Social Services	access to benefits for those with incomes to include: cash, food, or energy assistance childcare Head Start programmes child support offices vocational assistance programmes for individuals with disabilities
Public Health Sector	Can assist in preventing and identifying trafficking in a variety of ways, including: health safety inspectors identifying potential indicators of trafficking in businesses or homes community health workers monitoring the spread of disease and infection among at-risk populations researchers identifying methods for preventing trafficking incidence of trafficking and community surveillance
Law Enforcement	function as part of the criminal justice system provide referrals to local service providers creation of a human trafficking task force provide certification to assist in applying for immigration relief
Behavioural Health	Guide survivors to address trauma through: counselling and therapy services treatment for substance use sexual assault trauma services school-based counsellors medication management
School-based services	school-based health centres counselling and therapy services Head Start programming literacy programmes mentoring programmes childcare parental support activities such as before/after school childcare, parenting classes, GED prep classes accommodations for those struggling with school free or reduced meal programmes referrals to community resources
Connection to other survivors of human trafficking	Survivor engagement allows networks to better serve clients by providing mentorship, identifying challenges and opportunities, and achieving agency missions and mandates.

The information provided in this table was adapted from data given by the National Human Trafficking Training and Technical Assistance Center.

Special Topic: Law Enforcement and Human Trafficking

As mentioned above, human trafficking is often underreported due to a lack of awareness of the crime. It is also important to note that trafficked persons are either unable or hesitant to come forward to law enforcement because of the control their trafficker has over their life. This control can include withholding of documents or identification, fear for themselves and for their family, or emotional or psychological manipulation. Trafficked persons may feel ashamed or fearful that they will be held legally accountable or potentially receive threat on their life (or the lives of their loved ones) for engaging with law enforcement. They may also fear deportation or other legal repercussions, such as losing their children or imprisonment, related to their circumstances.

Education, patience, and understanding are needed to help a trafficked person feel safe to disclose and report their situation to law enforcement.

Optional reading: for more information on law enforcement's law in human trafficking, please read this report.

Trafficked persons may feel ashamed and embarrassed about their situation or think that they are to blame for their circumstances. Trauma-coerced bonding, where the survivor forms an emotional attachment to their trafficker despite repeated abuse, can occur. This can prevent the survivor from wanting to leave their trafficker or report them to authorities.

Healthcare professionals also have a wider responsibility to their greater community. As specialised educators and advocates, healthcare professionals can collaborate with community and society-level stakeholders and lawmakers to help bring about change and support for trafficked persons. This can include:

• increasing awareness of human trafficking through healthcare facilities and community-level education programmes
• advocating for local and national policies which promote community health and wellness
• combating social or cultural norms that contribute to human trafficking
• creating and maintaining an evidence-based guide and training programme to prevent future human trafficking

Resources

North American Resources:

• National Human Trafficking Hotline (USA)(English and Spanish)
  • Find local services
  • Downloadable Awareness Materials, available in multiple languages
  • Call: 1-888-373-7888 (TTY: 711)
  • Text: 233733
  • Chat Online: Human Trafficking Hotline Web Chat
• Canadian Human Trafficking Hotline (English and French)**Find local services
  • Downloadable Awareness Materials, available in multiple languages
  • Call: 1-833-900-1010
  • Chat Online: Canadian Human Trafficking Hotline Web Chat
• National Human Trafficking Education Centre | The Joy Smith Foundation (Canada)
• Polaris Project (USA)
• HEAL Trafficking (USA)

Texas, USA

• iWatchTexas: Texas Suspicious Activity Reporting Network (Link functions in the US only)
• The Heart of Texas Human Trafficking Coalition
• Department of Family and Protective Services (abuse reporting website)

Michigan, USA

• Human Trafficking Task Force
• Michigan Law School Human Trafficking Clinic

Ontario, Canada

• Ontario Anti-human Trafficking Services and Supports (Canada)

Clinical Tools and Resources:

• Health, Education, Advocacy, Linkage (HEAL) Trafficking and Hope for Justice: Protocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings. Please follow link to request the toolkit (free resource).
• Real Escape from the Sex Trade (REST) Healthcare Provider Toolkit & Resources
• Guidelines for Administering the Trafficking Victim Identification Tool (TVIT)
• Commercial Sexual Exploitation-Identification Tool (CSE-IT) Training
• Short Screen for Child Sex Trafficking (CST) for the Healthcare Setting
• Adult Human Trafficking Screening Tool (AHTST), available in both English and Spanish
• Comprehensive Human Trafficking Assessment
• Domestic Minor Sex Trafficking (DMST) Practitioner Guide and Intake Tool
• Navigating the Unique Complexities in Familial Trafficking (US Department of State)
• Familial Trafficking Warning Signs (Shared Hope International)

Clinical Tools and Resources on Substance Use Challenges

• The Intersection of Human Trafficking and Addiction (US Department of State)
• Langton L, Planty MG, Banks D, Witwer AR, Woods D, Vermeer MJ, Jackson BA. Sex trafficking and substance use: identifying high-priority needs within the criminal justice system. Rand health quarterly. 2022 Aug;9(4).