Human Trafficking and Healthcare: Helping Without Harming

Human trafficking has traditionally been viewed as a criminal/legal issue in the United States and abroad. More recently, however, trafficking also has been considered a serious public health concern, and researchers continue to examine the ways in which human trafficking and healthcare intersect, the role of healthcare organizations and providers in identifying and helping victims, evolving best practices for trauma-informed care, and solutions to upstream issues that contribute to human trafficking.

Studies have shown that victims of human trafficking are likely to seek healthcare services,^[i] putting healthcare organizations and providers in a unique position to help these patients and also play a role in addressing the persistent and destructive role of trafficking in society. 

Yet, in these situations, a fine line exists between help and harm; organizations and providers need awareness, knowledge, and a cautious approach when helping patients who have experienced trafficking. Failure to implement a well-informed plan[MG1]  in your chiropractic practice could result in further traumatization of victims, loss of trust, and poor outcomes for patients and communities.

Building Awareness

Estimates vary, but some studies suggest that more than 80 percent of human trafficking victims interact with the healthcare system while being trafficked; yet, healthcare providers and staff members often are unaware of these patients’ situations.^[ii] This lack of awareness can contribute to cascading harm in terms of the victims’ physical and emotional health and safety, overutilization of the healthcare system and associated costs, and the continued proliferation of trafficking and its toxic effects on society.

Building knowledge within the healthcare community about human trafficking — including at-risk populations, potential red flags, and barriers to identification — is a critical first step in reframing trafficking in the context of public health and helping providers and staff members support patients who can have a range of needs as a result of their experiences.

Although many people, including those who are highly educated, might feel that they understand the basics of human trafficking, some information may come as a surprise. For example, trafficking does not have to involve transportation of individuals (although it can), and victims often are recruited by people they know — even spouses and family members.

Simply put, human trafficking is a crime involving modern day slavery or servitude. It occurs when an individual (trafficker) uses force, fraud, or coercion to compel another individual (trafficking victim) to engage in commercial sex acts or labor against their will. Trafficking also occurs when minors are involved in commercial sex acts, regardless of whether force, fraud, or coercion is involved.^[iii]

Chiropractors [MG2] and their staff members should be aware that trafficking affects people of all ages and all backgrounds, although some individuals and groups are at higher risk, such as:

• People who have histories of abuse or neglect, experience social disconnection or exclusion, have physical or cognitive disabilities, or suffer from substance abuse issues or mental health conditions
• Certain vulnerable groups, such as refugees, migrants, people in the LGBTQIA+ community, and survivors of violence^[iv]

The signs, or “red flags,” of human trafficking also are diverse and can include numerous physical, behavioral, and environmental factors. Examples include:

Unfortunately, no single factor or combination of factors is a definite indicator of human trafficking, which can complicate efforts to identify victims and offer support. 

Additionally, barriers at both the patient and provider/staff levels can present identification and support challenges. Trafficking victims may have language barriers, fears of retaliation, fears of law enforcement, feelings of guilt or shame, and/or lack of knowledge about victimization and legal rights. Compounding these issues, healthcare providers and staff might have a poor understanding of human trafficking and related laws, worry about the implications of getting involved, have inadequate training or awareness of appropriate resources, and/or be affected by stereotyping or implicit biases.

The complexity of these issues and the gray areas inherent in providing appropriate and ethical care to vulnerable patients (a) reflect the importance of increasing awareness around the issue of human trafficking, and (b) reinforce the need for healthcare organizations to develop appropriate response plans and training.

For more information and resources to help raise awareness, see MedPro’s Risk Resources: Human Trafficking and Trauma-Informed Care. 

Developing a Trauma-Informed Approach

While seeking healthcare services, trafficking victims might interact with various people throughout a healthcare system — including providers, chiropractors, technicians, front desk staff, administrators, etc. — and these interactions can color their perceptions of trust, transparency, and safety. Thus, healthcare organizations should strive to adopt a patient-centered and trauma-informed approach to care and communication at both the organizational and clinical levels.^[v]

The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed guidance for trauma-informed care that is based on four key assumptions and six principles.

The four key assumptions are that trauma-informed care:

• Realizes the impact of trauma on individuals, families, groups, organizations, and communities.
• Recognizes the signs and symptoms of trauma.
• Responds by incorporating knowledge about trauma and trauma-informed principles into policies, procedures, and practices.
• Resists practices that could lead to re-traumatization. 
• The six principles of trauma-informed care are:
• Safety. Patients and staff feel physically and emotionally safe.
• Trustworthiness and transparency. Transparency is incorporated into decision-making with the goal of building and maintaining trust.
• Peer support. Individuals who are trauma survivors and have lived experience are incorporated in the healing and recovery process.
• Collaboration and mutuality. Hierarchy and power differences between staff and patients and among staff are leveled to promote partnership.
• Empowerment, voice, and choice. Patients and staff are empowered through validation and recognition of their strengths as well as promotion of shared decision-making and goals.
• Cultural, historical, and gender issues. Organizations strive to provide culturally competent care, address stereotypes and biases, and recognize historical trauma.^[vi]

Although comprehensive implementation of trauma-informed policies and procedures throughout an organization requires an investment of time and resources, “there are relatively simple, foundational steps that providers can take to move toward fully adopting a trauma-informed approach to care.”^[1]

Within each of the four key assumptions and six principles of trauma-informed care, opportunities exist for incremental changes that will contribute to overall success. Examples include building awareness about trauma and the benefits of trauma-informed care, gaining leadership support and identifying program champions, implementing changes to support a safe physical and emotional environment, seeking input from trauma survivors and incorporating their feedback into policy development and service delivery, and developing protocols that help avoid re-traumatization of victims. 

As healthcare organizations expand and refine their trauma-informed approaches to care and communication, additional considerations might include:

For additional information and guidance, see MedPro’s checklist Providing Trauma-Informed Care, SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach, and the Trauma-Informed Care Implementation Resource Center.

Educating and Training Providers and Staff

Becoming a trauma-informed healthcare organization requires comprehensive and well-designed staff education and training opportunities. As noted earlier, an initial educational opportunity involves raising awareness about human trafficking and trauma to help providers and staff understand these issues in the broad sense and in the context of healthcare. 

Beyond general education on these topics, chiropractors also should consider training related to:

• Local and regional human trafficking trends and their relation to the geographic location of the healthcare organization.
• Integration of trauma-informed principles into various clinical and nonclinical functions across the organization.
• Organizational protocols related to identifying, assessing, and responding to suspected victims of human trafficking.
• Key aspects of cultural competence and strategies for addressing stereotypes and implicit biases.
• Multidisciplinary approaches and responses to trauma, including care coordination and appropriate referrals to support networks within and outside of the organization.
• The guiding principles of medical ethics and their role in treating human trafficking victims and survivors. An insightful article in the AMA Journal of Ethics discusses applying the ethics of care model to guide decision-making when caring for trafficked patients.
• Legal and regulatory considerations that might be of particular concern or interest to potential trafficking victims, such as HIPAA requirements and mandatory reporting to law enforcement.

Organizations should tailor education and training about human trafficking and trauma-informed care to individual roles and ensure that training reinforces important boundaries in providing trauma-informed care. 

Providers should understand that the goal is never to force patients to admit that they are victims or to disclose sensitive details against their will, nor is it the provider’s job to serve as an investigator or determine a crime. Rather, providers should seek to understand each patient’s situation, identify the patient’s immediate needs, and determine referral services.^[3]

Healthcare organizations might find it helpful to use a training framework, such as SOAR. NHTTAC administers SOAR, which is a nationally recognized, accredited training program. Visit NHTTAC’s SOAR webpage to learn more about educational options.

Supporting Healthcare Workers

Caring for trafficked patients, as well as other patients who have suffered trauma, can take a toll on healthcare workers and chiropractors. They cannot provide effective trauma-informed care without recognizing their needs as well as those of their staff members, some of whom may suffer from their own trauma or experience vicarious trauma as a result of their work. 

Developing a culture that supports self-care and resilience can help combat physical and emotional burnout and support the well-being of the workforce. Potential opportunities to foster resilience might include:

• Setting realistic expectations with providers about caring for patients who might be trafficking victims — e.g., the difficulty of determining trafficking with certainty, the elusiveness of resolution in many cases, and the ethical dilemmas that are inherent in trauma-informed care
• Creating policies that support employee wellness and self-care, such as offering flexible schedules, encouraging vacation, and diversifying job tasks
• Allowing and encouraging providers and staff members to draw boundaries based on their personal needs
• Implementing physical and emotional wellness programs, such as reflective meditation, yoga, peer support groups, and professional counseling services
• Creating opportunities for providers and staff members to learn about and discuss trafficking and trauma in a safe environment (e.g., discussion groups or book clubs)
• Modifying the physical environment to make it more aesthetically pleasing, soothing, and comfortable^[4]  

These efforts require time and resources, but organizations that recognize the benefits of a culture of resiliency can begin to make changes and build on successes over time. Doing so can provide the essential support that chiropractors and staff members need to maintain physical and emotional wellness while facing difficult and adverse situations.

In Summary

Human trafficking is an appalling and harmful practice that represents a serious criminal issue as well as a significant public health concern. People who are victims and survivors of human trafficking frequently seek healthcare services — putting healthcare organizations, providers, chiropractors, and staff members in the position to offer much-needed support and resources. 

However, serving as an ally in the fight against human trafficking requires preparation and planning. A well-defined plan should raise awareness about trafficking, incorporate trauma-informed approaches to care, educate and train the workforce, and create a culture of resiliency and support for both chiropractors and patients.

Endnotes

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^[1] Schulman, M., & Menschner, C. (2018, January). Laying the groundwork for trauma-informed care. Center for Health Care Strategies, Inc. Retrieved from www.traumainformedcare.chcs.org/wp-content/uploads/Brief-Laying-the-Groundwork-for-TIC_11.10.20.pdf

^[2] Postgraduate Institute for Medicine & the U.S. Department of Health and Human Services, SOAR to health and wellness (online training module); Substance Abuse and Mental Health Services Administration, SAMHSA’s concept of trauma and guidance for a trauma-informed approach; Lawler, K. (2019, November 12). Building a hospital-based human trafficking identification response program (Webinar). American Hospital Association. Retrieved from https://youtu.be/crogvNjkYP4; Schulman & Menshcher, Laying the groundwork for trauma-informed care.

^[3] Postgraduate Institute for Medicine & the U.S. Department of Health and Human Services, SOAR to health and wellness (online training module). 

^[4] Lawler, Building a hospital-based human trafficking identification response program (Webinar); Postgraduate Institute for Medicine & the U.S. Department of Health and Human Services, SOAR to health and wellness (online training module); Postgraduate Institute for Medicine & the U.S. Department of Health and Human Services. (2020, May 1). SOAR: Trauma-informed care (online training module). Retrieved from https://nhttac.acf.hhs.gov/soar/soar-for-individuals/soar-online

^[i] Chisolm-Straker, M., Baldwin, S., Gaïgbé-Togbé, B., Ndukwe, N., Johnson, P. N., & Richardson, L. D. (2016). Health care and human trafficking: We are seeing the unseen. Journal of Health Care for the Poor and Underserved, 27(3), 1220–1233. doi: https://doi.org/10.1353/hpu.2016.0131

^[ii] Tortolero, G. A. (2020). Human trafficking victim identification and response within the United States healthcare system (IAHSS-F RS-20-02). The International Association for Healthcare Security and Safety Foundation. Retrieved from https://iahssf.org/assets/IAHSS-Foundation-Human-Trafficking-Identification-and-Response.pdf

^[iii] National Human Trafficking Hotline. (n.d.). Human trafficking: What human trafficking is, and isn’t. Retrieved from https://humantraffickinghotline.org/what-human-trafficking; Postgraduate Institute for Medicine & the U.S. Department of Health and Human Services. (2020, June 1). SOAR to health and wellness (online training module). Retrieved from https://nhttac.acf.hhs.gov/soar/soar-for-individuals/soar-online

^[iv] Ibid.

^[v] Center for Health Care Strategies, Inc. (n.d.). What is trauma-informed care? Trauma-Informed Care Implementation Resource Center. Retrieved from www.traumainformedcare.chcs.org/what-is-trauma-informed-care/

^[vi] Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach (HHS Publication No. [SMA] 14-4884). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884

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