Division of Emergency Medicine, University of Washington, Seattle, WA, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
Trafficking in persons is a major problem that intersects many facets of society, including the legal system, law enforcement, and healthcare. While some elements of American society have been active in improving awareness and action against trafficking in persons, healthcare has been slow to adopt standardized education and training about this population. There remains some ambiguity regarding how to identify these victims, but some understanding of screening can be correlated from literature surrounding intimate partner violence. An understanding of what is known of the epidemiology, combined with evidence of efficacy of screening techniques for other vulnerable populations, supports targeted screening. Emergency medicine as the front line of the healthcare system has a unique opportunity to access these vulnerable patients and connect them with services. With a review of easily accessible literature, training, and legal documents, we make a case for a comprehensive training program for emergency medicine residents. Our recommended training would include epidemiology of the populations involved, screening and interviewing, training and practice, understanding of ways to access local resources, and education around risk factors and indicators to help identify victims.
Human trafficking in persons (TIP) was defined in 2004 by the United Nations in Article Three, paragraph (a) of the Protocol to Prevent, Suppress and Punish Trafficking in Persons as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.”1
Due to the criminality of TIP there is no accurate way to determine incidence and prevalence. Estimates by various sources place the number of trafficked individuals in the range of 4 to 27 million globally with perhaps a half million of these people being exploited in the 2,3 United States.2,3 The problem in the United States is particularly distressing given our cultural emphasis on freedom and our comparatively robust healthcare, social service, law enforcement, and legal systems. Healthcare offers a clear avenue for identification of victims and an opportunity to bring the victims to safety; however, the medical establishment has been slow to embrace the potential role they could serve in addressing this problem. Several recent review articles have highlighted the great overlap of health care and victims of TIP, with perhaps 50% 4,5
sistency in resource quality and availability, emphasizing the need. It shows evidence that we
within the medical profession.
Emergency medicine as the front line of healthcare in the United States has a special role with regard to identification of victims and there is a clear need for improved education and standards for training. Many have called for the incorporation and standardization of TIP training in medical education and residency training, but the literature has few practical recommendations.7 Using the available literature on TIP and the literature on intimate partner violence (IPV), as well as an awareness of the overall curriculum of emergency medicine residency, we propose a series of guidelines for an emergency medicine curriculum in TIP.
Because the literature on TIP traverses multiple social areas (legal, law enforcement, global and public health, economics, healthcare), a formatted comprehensive literature search was not possible. Therefore, the research team opted to utilize a combination of generalized Pub-Med searches and internet and layliterature sources to gather the most prominent current literature that would be available to residency directors seeking to develop a program. While this non-traditional research method leaves the possibility of key components being missed, it represents a more practical approach to gaining an understanding of a subject that crosses multiple academic lines.
It is presumed that routine screening for victims of human trafficking in the emergency department is beneficial, given that there are few opportunities to identify these victims and that appropriate interventions may impact future health outcomes. The current absence of universal screening recommendations to detect victims of TIP in a healthcare setting is likely due to a limited understanding of this population, minimal research regarding the utility and effectiveness of a standardized approach, and unknown resource availability for those who screen positive. We can look at the extensive but sometimes contradictory literature regarding an analogous population, those suffering from IPV, to help guide our approach to screening for TIP in a healthcare setting. (Box 1)
We can extrapolate from the literature on intimate partner violence to guide our approach to education and training with regard to trafficking in persons. Box 1: Using IPV to help guide approach to trafficking.
Historically, there has not been ample evidence to support routine screening for IPV in healthcare settings. For example, in a small randomized control trial (RCT) conducted in New Zealand, women presenting to the emergency department were randomized to one of two groups. A control group received standard of care and treatment group received risk stratification, a brief IPV screening questionnaire, and education. At short-term follow up there was no significant difference in subsequent IPV
reported by women who had been randomized to either group, but long term implications of this intervention were not evaluated.8
Furthermore, another RCT of IPV conducted in a variety of healthcare settings, including emergency departments, again randomized women to one of two groups. Women in the intervention group completed a survey prior to their interaction with a clinician. The clinician was then able to use his or her discretion to provide referrals or further intervention based on risk assessment ascertained from the survey results. The control group completed the survey as well, but only after the clinician visit. Although women in the intervention group had a lower rate of IPV and better quality of life at follow-up, there was not a statistically significant difference between the two groups.9
More recent research has supported screening for IPV routinely and the United States Preventive Services Task Force recommends that healthcare providers screen for IPV in all women of childbearing age, even in the absence of risk factors. This recommendation is based on a systematic review that highlights multiple screening tools, which are short, simple to administer, and able to identify both those suffering from abuse currently and those at risk of future abuse. Examples of screening questions include “Has your partner pushed or slapped you?” and “Have you ever been afraid of a partner?”10 We can infer that a similar ballot of questions could be specifically designed and utilized to screen for TIP in a healthcare setting. (Box 2)
● Individual: history of abuse/neglect, LGBT, “system child”. ● Family: conflict or dysfunction.
● Community: peer pressure, social isolation, gangs.
● Social: lack of awareness, limited resources.
i The Institute of Medicine/ National Research Council Report “Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States,A Guide for the Health Care Sector”. 2013 Box 2: Risk factors, indicators, screening questions, and emergency department practice.
An additional systematic review also determined that current research supports screening for IPV in a healthcare setting. Based on the studies evaluated, there is no evidence of harm due to screening; however, the literature does not clearly identify the best screening modality or intervention. Additionally, a variety of screening tools were determined to be effective, although some of these may be not be appropriate to utilize in the emergency department and it remains unclear which specific tools would be the most efficient and accurate in that setting.11
While the medical literature does not have a validated screening tool for TIP, there exist screening and interviewing techniques employed by those outside of medicine. Some of these tools are widely accepted and validated for use in the legal and law enforcement domains. One such example is the Trafficking Victim Identification Tool (TVIT), which supports our recommendations below.12
Though the global and national burden of TIP is difficult to quantify, there have been efforts on several fronts to increase the awareness and education regarding TIP. The Institute of Medicine National Research Council issued a report regarding trafficking of minors in the US and identified a guide for healthcare providers. They highlight the fact that there is not a strong universal language for communicating about trafficking of persons and that many factors contribute to the poor recognition of this problem, including underreporting, vulnerability of victims, poorly defined protocols, and lack of awareness in recognition.13 In 2013 a collaborative effort from the Administration for Children and Families and the Health and Human Services gave rise to a federal initiative “SOAR to Health & Wellness,” which moved to expand healthcare education regarding human trafficking.14 With a working group of healthcare professionals, survivors, and experts, a pilot training and evaluation was developed and implemented by 180 healthcare providers across the nation. (Table 1)
Other available resources have come from isolated local efforts. The University of Texas School of Public Health, in collaboration with The Houston Rescue and Restore Coalition, developed the “Health Professionals and Human Trafficking: Look beneath the Surface, H.E.A.R. Your Patient” for front line healthcare workers, which provides educational training and 3 month follow-up.15 Children’s Health Care of Atlanta developed a webinar e-learning training with five sessions to provide simi-
• History of victimization, mental health issues, or substance abuse • Have you ever traded sex for drugs or money? • Reproductive or sexual-health related health concern (STD, pregnancy) • Has anyone ever made you have sex when you • Monitoring or controlling behavior of another individual Sex Trafficking • Injuries or unmet health needs • Absence of knowledge of local environment • Works in an industry with known history of abuse, such as massage • Anxious, avoids eye contact • Lacking identification documents Labor Trafficking • Underage and physical evidence of manual labor (injury, etc) • Do you have a work contract? • Monitoring or controlling behavior of another individual • In or from an agricultural or industrial area or one with seasonal employment • From an immigrant population where domestic servitude trafficking is • Have you or your family been threatened? common (Southern and Southeast Asia, the Middle East.)
• Anxious, avoids eye contact • Lacking identification documents Domestic Servitude • Underage and physical evidence of manual labor (injury, etc) • Monitoring or controlling behavior of another individual
• Refuses to answer questions with another individual in • Refuses to engage with someone who speaks their language Immigrant Workers • Works in an industry known for abuse, such as nail salons, massage, • restaurants, convenience stores etc
Table 1. Activity specific trafficking indicators and screening questions.
lar educational efforts.16 Further, the Polaris Project offers free webinars,17 however we have not found a universal curriculum specifically designed for the emergency medicine physician in training.
In an attempt to survey the educational modalities available, a recent literature analysis revealed 27 items providing basic guidance on human trafficking, none of which have been evaluated rigorously.18 The majority of these are geared toward the general healthcare community, not specifically MDs, and none of these evaluated outcomes on practice or successful implementation of curricula. They summarize that “appropriate education and training about human traffıcking in professional school, continuing education, and in-service training can enable the healthcare workforce to become an active, vital partner in human traffıcking identifıcation, intervention, and prevention.” Thus, thoughtful design and development of such training would be the first step in capitalizing on the unique relationship between healthcare providers and victims of TIP.19
The disconnect between the literature showing questionable efficacy of screening and institutional guidelines recommending routine screening creates ambiguity with regard to the implementation of programs in the emergency department. Nevertheless, an understanding of what is known of the epidemiology, combined with evidence of efficacy of screening techniques for other vulnerable populations (IPV), supports at a minimum
Indicators Screening Questions
did not want to?
during medical visit • Does someone control where you go and sleep?
• Do you have the freedom to go where you want?
• Are you indebted to someone?
during medical visit • Does your employer control you food and housing?
• Have you been hit or verbally abused?
• Do you have set hours of your employment?
• Do you have the freedom to go where you want?
• Are you indebted to someone?
during medical visit • Do you have a work contract?
• Does your employer control you food and housing?
the room
targeted screening. While this offers the possibility of missing patients, increasing awareness of the problem and highlighting known at-risk populations may yield a greater proportion of victims identified than generic screening tools. For example, tailoring screening questions around the nature of the trafficking, such as farm labor trafficking or sex trafficking, may improve catchment. Standardizing this approach as much as possible has been described as providing a “set of practice protocol and screening questions” for service providers and will give them the tools to identify victims.20
A comprehensive TIP curriculum should be added to the emergency medicine residency program, preferably in the first year to maximize the development and implementation of these skills throughout the duration of training. In addition, as there is no standardization or national requirements of TIP curriculum in medical school, there is no guarantee of baseline knowledge. Familiarity with local resources, from hospital-based social work to law enforcement procedures and community based support organizations, vary considerably and residents should be made aware of what resources are available and how to engage them. Additionally, tailoring scenarios and trainings to match local perceived or known prevalence and patterns of criminal behavior is appropriate and these scenarios should be emphasized to residents. For example, in areas where there is a significant migrant farm labor, male farmers may be the target population, in urban areas and on shipping corridors sex trafficking maybe of highest concern, or in certain populations domestic servants maybe at greatest risk. Site visits to organizations involved with anti-trafficking efforts, as well as simulation cases and provision of literature on TIP, would lead to a more robust curriculum tailored to principles of adult learning.
Identifying those at risk, screening them appropriately, and providing them with available services requires residents to understand the social forces at work, the patients perspective, and to set themselves up for success by maximizing their interview and the practice environment. The following section provides some guidelines for curriculum development, which will need to be augmented with local resources. (Box 3)
• Understanding of local/national/global epidemiology.
• Scenario based screening and interviewing training.
• Local resources and how to access them.
• Warning signs of those being and vulnerable to being trafficked. • Patient responses to disclosure of trafficking.
• Practice to reinforce appropriate and tailored interviewing skills. Box 3: Recommendations for curriculum requirements.
To effectively implement screening in the emergency department, it is important to clearly explain your role as a healthcare provider and advocate while being supportive and non-judgmen-
tal. To encourage engagement of other team members, emphasize your concerns to other health care providers (nurses, Sexual Assault Nurse Examiner, sexual health providers, violence evaluation team, etc.) and ensure their response is appropriate. Employ social work or available social services early to assist in evaluation and management whenever possible. Furthermore, it is of utmost importance to ensure safety and confidentiality of a potential victim while following institutional guidelines regarding reporting requirements, notification of social services organizations, and law enforcement. (Box 4)
• Targeted screening by emergency medicine residents after completing a training program.
• Use of patient specific standardized questions based on an understanding of risk factors and indicators of trafficking.
• Use of case based scenario testing to sharpen interviewing skills of residents.
• Comprehensive understanding of local resources for TIP. Box 4: Recommendation for resident training in human trafficking.
Our greatest limitation was that a thorough and formulaic review of the intimate partner violence and trafficking in persons literature was beyond the scope of our research. We realize an extensive review within the relevant academic and social fields would be useful, however, review of many aspects of social and legal literature regarding this subject is outside the scope of the realm of emergency medicine and thus our researchers.
An institutional review board review was not indicated due to the public nature of documents reviewed.
While the evidence on how to identify and manage the victims of human trafficking is inconclusive, what is clear is that there is a great unmet need with regard to healthcare providers awareness of and education on this subject. By utilizing and understanding the current literature on TIP, lessons learned in other realms, such as screening tools for intimate partner violence, interview techniques and practices from the legal and law enforcement literature, and what is known about the environment of the emergency department, we have constructed a guideline for the development of a curriculum on the subject for emergency medicine residents. This guideline, supplemented with an understanding of local epidemiology and available resources, can allow residency programs to fulfill a portion of the unmet educational need on this important subject.