A Review of U.S. Health Care Institution Protocols for the Identification and Treatment of Victims of Human Trafficking

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1 Journal of Human Trafficking ISSN: (Print) (Online) Journal homepage: A Review of U.S. Health Care Institution Protocols for the Identification and Treatment of Victims of Human Trafficking Hanni Stoklosa, Mary Beth Dawson, Francisca Williams-Oni & Emily F. Rothman To cite this article: Hanni Stoklosa, Mary Beth Dawson, Francisca Williams-Oni & Emily F. Rothman (2016): A Review of U.S. Health Care Institution Protocols for the Identification and Treatment of Victims of Human Trafficking, Journal of Human Trafficking, DOI: / To link to this article: Published online: 08 Oct Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at Download by: [National Childrens Advocacy Center] Date: 11 October 2016, At: 10:43

2 JOURNAL OF HUMAN TRAFFICKING A Review of U.S. Health Care Institution Protocols for the Identification and Treatment of Victims of Human Trafficking Hanni Stoklosa a, Mary Beth Dawson b, Francisca Williams-Oni b, and Emily F. Rothman c a Brigham and Women s Hospital, Harvard Medical School, Boston, Massachusetts, USA; b Boston University School of Public Health, Boston, Massachusetts, USA; c Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA ABSTRACT The purpose of this study was to characterize and assess human-trafficking (HT) identification, treatment, and referral protocols of U.S. health care service provider institutions. A total of 30 protocols from 19 states and 2 national organizations were analyzed. Across the protocols, the most commonly listed indicator of HT victimization was patient history of physical- or sexual-abuse victimization, which was included in 73% of the protocols. In addition, the majority (70%) of the protocols listed 1 medical-symptom indicator of HT victimization (e.g., bruises, scars, frequent injuries), 1 indicator based on a patient s apparent dependence on another person (e.g., patient not in control of personal identification), and 1 indicator related to how the patient communicates (e.g., inconsistencies in the patient s story about his or her medical condition). A smaller proportion of protocols included indicators of HT that pertained to housing (60%), the patient s appearance (47%), the patient s mental health (63%), sexual history (63%), or technology-related indicators such as the patient possessing explicit digital photos of himself or herself with another person(20%).we conclude that additional research is needed to establish ideal protocol content but propose that in the interim protocol developers consider using practice-informed and evidence-based information that pertain to six areas of victim identification and assistance. KEYWORDS Human trafficking; prostitution; sex trafficking; sexual exploitation Introduction Human trafficking (HT) is now recognized as one of the most urgent criminal and public health issues in the world. HT is estimated to be the second-largest criminal industry worldwide, affecting 20.9 million people globally and, according to the International Labor Organization (ILO), generating profits of more than $150 billion annually (ILO, 2012, 2014). Although the complexity of identifying victims makes estimating the prevalence difficult, the most recent assessment suggested that in a single year between14,500 17,500 individuals were trafficked into the United States from other countries (U.S. Department of State, 2004). Due to the extreme and severe harm HT causes for individuals, families, CONTACT Emily F. Rothman, ScD erothman@.bu.edu Department of Community Health Sciences, Boston University School of Public Health, Floor 4, 801 Mass Ave., Boston, MA 02118, USA. Hanni Stoklosa is an Emergency Physician at Brigham and Women s Hospital, Harvard Medical School, and Executive Director of HEAL Trafficking. Her areas of research expertise include interpersonal violence and human trafficking. Mary Beth Dawson is a graduate of the Boston University School of Public Health with five years of experience in program management and sociobehavioral research. She is passionate about preventing interpersonal violence from a public health perspective. Francisca Williams-Oni is a graduate of the Boston University School of Public Health, a former heath care provider who transitioned to public health. She passionately advocates for women s reproductive and sexual healthcare policies to ensure women are able to access their healthcare needs. Emily F. Rothman is an Associate Professor at the Boston University School of Public Health. Her areas of research expertise are intimate partner and sexual violence and human trafficking prevention. Color versions of one or more of the figures in the article can be found online at Taylor & Francis

3 2 H. STOKLOSA ET AL. communities, and nations, President Obama has called it one of the great human rights causes of our time (Obama, 2012, para. 1). Health care providers can be vitally important players in the interruption of human trafficking (Clause & Lawler, 2013; Stoklosa, Grace, & Littenberg, 2014). Trafficked people who are physically or psychologically controlled and monitored by captors may go to emergency departments or other health care settings if they develop urgent-care problems (Barrows & Finger, 2008; Lederer & Wetzel, 2014). For this reason, the Institute of Medicine (IOM) has argued that health care professionals can play a critical role in efforts to prevent, to identify, and to respond to trafficking victims (IOM, 2013) and the U.S. Office of Trafficking in Persons has made educating health and human service providers about HT one of their three priorities (Office on Trafficking in Persons, 2015). Recent research suggests that 28 88% of trafficking victims in the United States who come into contact with health care professionals while in captivity are not recognized as experiencing HT victimization by those providers (Family Violence Prevention Fund, 2005; Grace et al., 2014; International Organization for Migration, United Nations Global Initiative to Fight Human Trafficking, & and London School of Hygiene and Tropical Medicine, 2009; Lederer & Wetzel, 2014). Very few health care providers in the United States have received training on responding to HT and the majority believe it does not affect their own patient population. A recent cross-sectional survey of 180 U.S. emergency department workers found that only 5% had ever received formal training on HT, and 73% believed that their patient population was not affected by trafficking (Chisolm-Straker, Richardson, & Cossio, 2012). Unsurprisingly, less than 5% of the sample were confident that they could identify an HT victim among their patients (Chisolm-Straker et al., 2012). Similarly, a 2015 study of health care personnel of 10 National Health Services (NHS) sites in England found that only 7.8% had received training in trafficking, and only 13% knew what questions to ask patients to determine if they might be HT victims (Ross et al., 2015). Three quarters of the NHS health providers did not realize that calling law enforcement could put victims in greater danger (Ross et al., 2015). Training health care providers to recognize and respond appropriately to victims of HT makes little sense unless the hospitals or other institutions in which they see patients has a set of procedures in place to guide decision making and action. Individual providers are unlikely to be able to safely intervene and provide help to HT victims unless their efforts are coordinated with other members of the medical team, local victim resource organizations, law enforcement, and in many cases child-protection services. For a team to work together effectively to recognize and act on behalf of HT victims, all must share a common understanding of what HT is, how they can identify indicators of victimization in patients, the best way to talk with and treat a patient experiencing HT, and how to evaluate which course of action is likely to lead to the most optimal outcomes for that individual. In other words, the multiple calls for increased training of health care providers on the topic of HT should be accompanied by similarly strong calls for comprehensive and evidence-informed protocols at the organizational level. At present, the proportion of the 5,686 hospitals in the United States that have adopted guidelines regarding the identification and treatment of HT is unknown, although the leadership of the public health-focused professional organization Health Education, Advocacy and Linkage (HEAL) Trafficking believes it to be less than 2% (J. Barrows, personal communication [October 1, 2015]). To our knowledge, this study represents the first effort to collect and analyze the content of U.S. health care entity protocols for the identification, treatment, and referral of victims of HT. The study was designed to answer the following two research questions: (a) What types of indicators that a patient may be a victim of HT are being provided to health care workers via existing protocols? and (b) what type of information or guidance on assisting patients who may be experiencing HT, other than indicators of victimization, is being provided via existing protocols? The goal of the study was to characterize existing health care protocols on HT, to assess which indicators are being utilized to identify victims in patient populations, and to characterize the content of the protocols.

4 JOURNAL OF HUMAN TRAFFICKING 3 Methods Study design In June 2015, the research team solicited health care protocols on HT using institutional-level respondent-driven sampling, where a protocol was defined as a document endorsed by the institution and to be shared with clinicians to guide them in the identification, treatment, and referral of victims of HT. First, we made and telephone contact with at least one representative of any U.S. hospital, clinic, or health care organization that was known or suspected to have a protocol in place by any member of HEAL Trafficking. (As described above, HEAL Trafficking is a U.S.-based, international consortium of over 600 interdisciplinary professionals who work to combat HT through a public-health lens and serve as a centralized resource on health for the anti-trafficking community). Two members of HEAL had been compiling a list of health care entities with protocols since 2014, so that list was used as the initial seed. Two master s level research assistants with training in public health contacted representatives at each of the initially nominated institutions to request their protocols and to ask their permission to analyze the protocols for this study. In addition, each representative was asked if they knew of any other health care entities that also had protocols and, if so, that institution was subsequently contacted. This process continued until saturation was reached, meaning that no new health care institutions were being nominated, which took approximately 8 weeks. To supplement the respondent-driven data collection method, an Internet search for protocols was also conducted and yielded an additional nine protocols, which included two from the Institutes of Medicine (IOM) and Federal Emergency Management Agency (FEMA). Protocols were included in the analytic sample if they were from the IOM, FEMA, or a U.S. health care provider institution and were in active use rather than in development. In total, 83 health care entities were contacted successfully with requests for protocols, and of these 30 contributed protocols that met inclusion criteria and were analyzed. Of those contacted, 39 did not actually have a protocol, five were not in the United States, and nine had protocols in development but not ready for analysis. No health care entity with an actively implemented human-trafficking protocol refused to participate in this study. The geographic location of each health care entity that contributed a protocol for the present analysis was plotted on a map of the United States according to its primary address (see Figure 1). Figure 1. Locations of health care entities from which protocols were obtained*.*map shows 25 locations and 30 protocols were analyzed; one health care institution did not want their location identified, and, in four locations, each marker represents two protocols.

5 4 H. STOKLOSA ET AL. Data collection and analysis The research team used a deductive coding approach (Elo & Kyngas, 2008). First, two members of the research team read through all of the protocols to get a senseofthewhole.next,thefour-personresearch team met to develop an analysis matrix; the matrix was a list of primary code categories with subcodes generated for more detailed-level analyses. Third, two research assistants (RAs) applied the codes to two of the protocols. Coding disagreements were resolved via consensus and code definitions were refined where necessary. Fourth, the RAs applied the refined code list to each of the 30 protocols. The RAs tracked the number of coding decisions that were made independently and calculated an interrater reliability coefficient representing the ratio of coding agreements to coding disagreements (1,162 agreements out of 1,230 decisions = 94.5% interrater reliability). Finally, all four members of the team collaboratively summarized the coding results in table format (see Tables 1 and 2). Results A total of 30 protocols from 19 states and two national organizations were analyzed (see Figure 2). Indicators of HT included on protocols One hundred percent of the protocols analyzed included lists of indicators of HT victimization, where the word indicator means a visual, behavioral, circumstantial, or other risk marker that should prompt further assessment. Across the 30 protocols, the most commonly listed indicator of HT victimization was patient history of physical- or sexual-abuse victimization, which was included in 73% of the protocols (see Table 1). In addition, the majority (70%) of the protocols listed 1 medical-symptom indicator of HT victimization (e.g., bruises, scars, frequent injuries), 1indicatorbasedonapatient s apparent dependence on another person (e.g., patient not in control of personal identification), and 1 indicator related to how the patient communicates (e.g., inconsistencies in the patient s story about his or her medical condition) (see Table 1). A smaller proportion of protocols included indicators of HT that pertained to housing (60%), the patient s appearance (47%), the patient s mental health (63%), sexual history (63%), or technologyrelated indicators such as the patient possessing explicit digital photos of himself or herself with another person (20%). Some of the least commonly listed indicators included hair loss (10%), patient not having health insurance and/or paying for medical treatment with cash (10%), patient associating with people in the commercial-sex trade (13%), and the patient uses the Internet or apps to find sex partners (10%). Information and guidance included in protocols In addition to providing lists of indicators, 100% of the protocols provided at least some additional information about what health care providers should do, say, or know about HT relative to their patients. For example, 83% of the protocols provided phone numbers of local organizations that serve victims of HT (see Table 2). In addition, 60% of the protocols provided a formal definition of HT, and 50% explained the different subtypes of HT (i.e., labor and sex trafficking) (see Table 2). More than two thirds (67%) included the National HT Resource Center hotline number, and 67% provided information about mandatory reporting laws that would be relevant for youth victims under the age of 18. Sixty percent of the protocols also provided visually appealing flowcharts, checklists, or cards with screening indicators for health care providers to use to make victimization assessments, and 67% provided example screening questions that providers could use when interacting with a patient suspected to be a victim of HT. More than half (57%) provided information about which clinicians and providers should be involved in the initial patient evaluation (see Table 2).

6 JOURNAL OF HUMAN TRAFFICKING 5 Table 1. Presence of Specific Indicators of Human-Trafficking Victimization Included on U.S. Health Care Setting Protocols (N = 30). n (%) Total number of protocols 30 (100%) Protocols with abuse-history indicators 22 (73%) Patient history of physical- or sexual-abuse victimization 22 (73%) Patient reports illicit drug use or substance abuse (Note: may be forced) 17 (57%) Protocols with Medical-Symptom Indicators of HT 21 (70%) Bruises 17 (57%) Scars 13 (43%) Evidence of physical or sexual trauma 21 (70%) Frequent injuries 7 (23%) Loss of hair 3 (10%) Malnutrition and/or dehydration 18 (60%) Delayed presentation for care or unusual infections (e.g., untreated STIs, untreated injuries, infections that 16 (53%) may indicate poor working conditions or unsanitary medical procedures by unqualified persons) Protocols with Indicators of HT Based on a Patient s Dependence on Another Person 21 (70%) Evidence that patient has been or is in controlling relationships 5 (17%) Patient not in control of personal identification, documents, or money 19 (63%) Patient does not have health insurance and/or pays with cash 3 (10%) Individual accompanying patient to appointment speaks for him or her 15 (50%) Individual accompanying patient to appointment refuses to leave patient alone 6 (20%) Patient shows fearful attachment to phone/is in constant phone contact with controlling person 6 (20%) Patient has unexplained large sums of money/cash on hand 5 (17%) Protocols with Communication-Related Indicators of HT 21 (70%) Inconsistencies in the patient s story about clinical history or health care condition 15 (50%) Language barrier (i.e., patient does not speak English) 7 (23%) Patient states that he or she is just visiting or just arrived from a different country 5 (17%) Patient is unaware of current location or home address 11 (37%) Patient shows fear, paranoia, or little to no eye contact 10 (33%) Patient avoids engaging in discussion about signs of injury and abuse 10 (33%) Patient uses terminology indicative of sex work (e.g., pimp, escort, player, the life, turn out) 7 (23%) Protocols with Mental-Health-Related Indicators 19 (63%) Patient engages in self-harm behaviors 11 (37%) Patient has depression or anxiety symptoms 17 (57%) Patient has posttraumatic stress symptoms (e.g., flashbacks, panic attacks, nightmares, triggers) 13 (43%) Patient appears to be in crisis 14 (47%) Protocols with Sexual History Indicators 19 (63%) Number of lifetime sex partners is high 9 (30%) History of STIs or frequent request for STI screening 16 (53%) Signs and symptoms that may indicate STIs 8 (27%) Multiple pregnancies or abortions 15 (50%) A minor who reports being involved in the commercial-sex trade 12 (40%) A minor who reports being involved with an adult or much older intimate partner 7 (23%) Patient associates with people in the commercial-sex trade 4 (13%) Protocols with Housing-Related Indicators of HT 18 (60%) Patient living with employer and/or intimate partner 9 (30%) Patient describes unusual or crowded living situation 9 (30%) Protocols with Appearance-Related Indicators of HT 14 (47%) Inappropriate dress (e.g., for age group, weather) 10 (33%) Patient wears expensive items that are not congruent with rest of appearance 6 (20%) Patient has tattoos or branding associated with commercial sex 17 (57%) Protocols with Child-Specific-Indicators of HT 10 (33%) Patient reports poor school performance 4 (13%) Patient frequently truant from school 8 (27%) Patient has developmental delay 3 (10%) Protocols with Technology-Related Indicators 6 (20%) Patient uses apps/internet to find sex partners 3 (10%) Patient possesses explicit digital photos of himself/herself or another person 5 (17%) Information and guidance missing from protocols Some of the protocols did not provide potentially important information about HT prevention. Forexample,80%oftheprotocolsdidnotprovideguidanceabouttheimportanceofscreening friends or relatives who accompany victims of HT tohealthcareappointmentsforhtvictimization (see Table 2). One fifth (20%) were only relevant for emergency-department settings,

7 6 H. STOKLOSA ET AL. Table 2. Characteristics of 30 U.S. Health Care Protocols for Identifying and Assisting Victims of Human Trafficking (HT). n (%) Protocol Provides Background Information About HT Defines and explains HT 18 (60%) Provides information about different types of HT (e.g., sex trafficking vs. labor trafficking) 15 (50%) Includes local prevalence statistics about HT victimization 8 (27%) Compares HT to other forms of violence victimization 9 (30%) Protocol Describes High-Risk Populations for Victimization Identifies LGBTQ sexual orientation as a possible risk indicator for HT victimization 5 (17%) Identifies youth involvement in child-welfare services as a risk for HT victimization 11 (37%) Identifies chronic runaways as a risk for HT 14 (47%) Identifies homelessness as a risk for HT 10 (33%) Protocol Provides Screening Guidance Protocol names the specific clinicians who should be involved in the initial patient assessment for HT 17 (57%) Protocol specifies how to involve interpreter services in HT assessment 9 (30%) Protocol specifies which stake holders should be informed about the suspected case (e.g., law enforcement) 16 (53%) Protocol specifies patient should be isolated from accompanying individuals during assessment 18 (60%) Suggests ways to separate the patient from accompanying individuals 8 (27%) Provides guidance on how to speak to the patient in a trauma-informed manner 16 (53%) Provides guidance on the involvement of security personnel 8 (27%) Provides sample assessment questions 20 (67%) Provides flowcharts, checklists, screening tools, or indicator cards for patient screening 18 (60%) Protocol Includes Referral and Resource Contact Information Provides the National Human Trafficking Resource Center hotline number 20 (67%) Provides local resources/hotlines (e.g., Department of Children and Families (DCF), organizations that work with HT 25 (83%) victims, etc.) Specifies how to make a referral to immigration/legal services 8 (27%) Specifies when and how to make a referral to mental-/behavioral-health services 10 (33%) Specifies when and how to make a referral to social services 13 (43%) Protocol Provides Guidance on Reporting HT Victimization Explains mandatory reporting laws 20 (67%) Specifies whom to contact to report identification of a victim 17 (57%) Explains what to do if adult does not wish law enforcement to be contacted about victimization 11 (37%) Protocol Provides Guidance on Follow-Up Provides guidance for developing a safety plan 10 (33%) Highlights importance of following up with the case 7 (23%) Provides specific guidance for case follow up 4 (13%) Protocol Is Limited in Scope in One or More Ways Only relevant for emergency-department setting 6 (20%) Focuses exclusively or primarily on children 9 (30%) Focuses exclusively or primarily on sex trafficking (as opposed to labor trafficking) 8 (27%) No guidance about screening accompanying friends/relatives for HT victimization 24 (80%) while 30% were exclusively or primarily focused on screening children for HT victimization, and 27% focused exclusively or primarily on sex trafficking as opposed to also being relevant for labor-trafficking screening (see Table 2). Less than one fifth (17%) of the protocols identified Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) sexual orientation as a marker for potentially increased risk for HT victimization, and less than one third (27%) suggested approaches for separating the patient from individuals who may have accompanied them to the health care appointment for the purposes of conducting an HT victimization screening. Less than one third (27%) included guidance about involving security personnel in suspected cases of HT (which can complicate patient and provider safety), and very few (13%) provided guidance on how to follow up with patients once they are identified as HT victims. Five of the protocols (17%) provided guidance on what providers should do when children less than 18 years old decline assistance when it is offered to them, and eight (27%) provided guidance on what to do when an adult declines assistance. Half of the protocols mentioned that providers needed initial training in human trafficking, and seven (23%) mention that providers need ongoing training on human trafficking and/or the use of the protocol. Five (17%) of the protocols included criteria and guidance for forensic examination, and 10 (33%) provided information about whether and how to document something about human trafficking in patients medical records.

8 JOURNAL OF HUMAN TRAFFICKING 7 Figure 2. Sources of health care protocols on human trafficking. Discussion Health care providers are uniquely positioned to identify victims of HT. For this reason, there have been multiple calls for health care provider training and education on HT, and it is logical that numerous health care organizations have now developed protocols to be used in clinical care settings. However, the nascent stage of research and practice related to HT victim identification and the wide variation in what is included on HT health care protocols make it difficult to hold up any particular protocol as a national model. More investigation is needed on ideal content inclusion that will best educate practitioners and serve trafficked patients. In the absence of that research, based on our own experience as clinicians and public health advocates, and our review of 30 existing protocols, we propose that the ideal protocol might be one that (a) uses an evidence-based and practice-informed comprehensive list of potential indicators, (b) provides a formal definition of HT consistent with U.S. and state law, (c) includes information about approaches to screening, including trauma-informed care, the potential dangers of assessing child and adult patients for HT victimization, and specifies possible adverse consequences of screening or reacting to a patient s victimization status without prioritizing his or her safety or needs, (d) relays the chain of events that should take place when victims of HT are identified, including the chain of command for decision making related to referral and reporting to local resource organizations, Child Protective Services, and HTtrained law enforcement and what to do when children or adults decline assistance, (e) provides current contact information for victim advocates employed at local resource organizations (updated regularly) and (f) suggests best practices for following up with patients who are identified as victims, including ongoing monitoring and evaluation. While institutions may adopt a setting-specific or patient-population-specific protocol, such as for a general provider/practitioner audience (i.e., all staff of a health care institution), a specific setting (i.e., emergency-department personnel), or a

9 8 H. STOKLOSA ET AL. specific patient population (i.e., children), health care settings should be encouraged to think about establishing an organization-wide protocol as well so that victims can be identified and helped no matter where or why they are seeking health care treatment. Establishing institutional task forces or committees that are responsible for monitoring, evaluating, refining, and maintaining HT protocols on behalf of a health care organization has the benefit of ensuring that a diverse set of stake holders are included in those processes and that there is an ongoing institutional commitment to the issue. Health care organizations that have already established HT committees have included representatives of the following specialties: pediatrics, emergency medicine, social work, domestic- or sexual-violence services, behavioral health, and security. Representation from additional medical specialties, departments, local community-based organizations, and HT advocacy groups is also encouraged. Additional contributions to both research and practice related to health care institution protocols for HT prevention are needed. Data collection through institutions with established protocols will help inform practitioners about whether screening protocols are improving victim detection, and which aspects of the protocols are most useful. Research that demonstrates whether each one of the indicators presently included on the majority of protocols, such as a history of physical or sexual abuse, or having sex-industry-related tattoos, is useful to providers and is consistently associated with improved detection of HT victims would benefit the field. There may be some indicators that are empirically linked to increased HT victimization but are so common in certain patient populations that they lead to excessive HT screening such as signs of physical or sexual abuse. There may be other indicators that are not yet empirically established to predict HT victimization but nevertheless should flag for providers that an HT screening is warranted such as a history of multiple sexually transmitted infections (STIs) or opioid substance abuse. In addition, an improved understanding of whether widespread use of any type of indicator checklists in health care settings leads to better detection and treatment of HT victims would also be extremely helpful for the field. From a practice perspective, accruing knowledge about HT victims typical behaviors in health care settings, including whether there are distinctive patterns of engagement with the health care system, could lead to testable hypotheses about new best practices for identifying potential victims either during medical appointments or from medical records. The technique of identifying potential victims on the basis of their cross-listing on multiple service providers client rosters (such as law enforcement, child-protection services, and substance-abuse treatment) (Bales, Hesketh, & Silverman, 2015) is now being tested in several cities, and developing methods through which health care entities could share information and join service-provider networks that use this method would be an advance. Limitations The primary limitation of this study is that the sample of protocols studies may not be exhaustive of all hospital protocols on HT in the United States. However, the HEAL network is an internationally recognized, established consortium of health care providers with an interest in HT and is extremely well connected to individuals engaged in this relatively nascent area of health care provision and research, meaning that we have confidence that the majority of existing protocols were uncovered via the sampling method. We suspect that the sample of 30 protocols included in this study is representative of protocols that are in use nationally. ORCID Emily F. Rothman Hanni Stoklosa

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