Preparing Health Care Systems to Provide Trauma-Informed Care: The Unique Case of Trafficking Victims
By Kathleen M. Franchek-Roa, M.D., FAAP
Cancer InCytes Magazine - Volume 4, Issue 1, Summer 2015
Published June 30, 2015
Managing Editor: Benjamin Lok, M.D.
Cover Art: Ping Cao
Human trafficking (HT) is a horrific violation of human rights and is a multibillion dollar business in the world today. The awareness of this form of slavery is emerging in the United States. Research is starting to evaluate the affect that HT has on the short- and long-term health of victims and studies are finding that many victims of HT are accessing health care during their enslavement. As a result, health care providers are uniquely positioned to identify and respond to HT victims. The recognition of the health impact on victims highlights the need for health settings to develop trauma-informed systems to address and respond to the physical and mental health manifestations of violence and abuse. This article presents ‘lessons learned’ by our university health care system as we began to transform our medical setting into a trauma-informed system in order to effectively respond to victims of trauma, including the significant trauma of human trafficking.
Violence victimization is a major public health threat in the United States (U.S.) (1). Intimate partner violence (IPV) is the most common form of violence victimization against women (2) and research has linked IPV victimization with many of the health indicators noted in the Healthy People 2020 Initiative (3). Health care costs associated with IPV victimization are estimated to be in the billions (4, 5).
As a result, research has provided the evidence needed to recommend screening female patients for IPV victimization (6). However, an overlooked and understudied form of violence against women (VAW), and one that can cause significant adverse health consequences, is human trafficking (HT). Human trafficking victims suffer significant acute and long-term health issues (7, 8). A recent survey (9) of 106 female survivors of sex trafficking in the U.S. found that 105 (99.1%) had at least one physical health problem during trafficking. Medical conditions that were particularly prevalent within this study group, and which may serve as ‘red flags’ in the health care setting, included malnutrition (35.2%); memory problems, insomnia, and poor concentration (82.1%); suicide attempt (41.5%); and post-traumatic stress disorder (54.7%). The reproductive health issues described by the women in this study were staggering. More than two-thirds had histories of sexually transmitted infections (STIs) (67.3%). Of 64 respondents, about 55% had experienced a miscarriage and/or reported at least one induced abortion. This is about three times higher than the average loss of pregnancies due to abortions in the U.S. (10). Importantly, 87.8% of respondents reported accessing health care during their enslavement.
The medical community is in a unique position to identify, intervene and provide resources to trafficking victims; however, health care providers (HCP) are poorly trained in the essential skills needed to intervene with HT victims. In addition, pediatric HCP need to be aware of factors that place youth at risk for trafficking such as growing up in homes with family dysfunction, experiencing maltreatment, being involved in the child welfare system, and being homeless (11).
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Sex Trafficking and Cancer Risk
Although there is a paucity of research linking sex trafficking with increased risk for cancer (12) in female victims, there are studies that find that other forms of VAW increase women’s risk for cancer, particularly cervical (13-15), breast, (15) endometrial (15) and ovarian cancer (15). Proposed mechanisms for this increased risk of cancer in victims of VAW include increase acquisition of STIs (e.g., HIV and HPV) (14, 15), more frequent acute care visits than preventive health visits (15), and decrease immune function due to stress (15). It is reasonable to extrapolate from these data that the sexual violence experienced by victims of sex trafficking would infer the same or greater risk of cancer acquisition as in women with other forms of violence victimization. The lack of knowledge and training of HCP to recognize and intervene with HT victims further impacts the health and well-being of patients.
Lessons Learned From a Hospital-wide Domestic Violence Initiative
I would like to share some of the ‘lessons learned’ at my institution as we are transforming our health care setting into a trauma-informed medical community. Intimate partner violence research provides significant parallels in preparing health care settings to respond to victims of HT. Our hospital system formed a Domestic Violence (DV) Committee to address the health care response to patients who are victims of abuse and violence, including victims of HT. Using model hospital policies that address domestic violence (16-19) our Committee began the task of revising our hospital’s policy on abuse, neglect and/or exploitation to make it a useful and useable document for physicians and staff by providing easily accessible, pertinent information about best practices and available resources for traumatized patients. As a result of the increasing awareness of trafficking in our community and state, our hospital policy addresses not only intimate partner violence, vulnerable adult abuse, and child maltreatment but also HT.
The first step we undertook in revising our policy was to ‘grade’ our current hospital system’s response to victims of domestic violence by utilizing the Delphi Instrument for Hospital-based Domestic Violence Programs (20). Our Committee recognized that many of the categories (i.e., policies and procedures, physical environment, cultural environment, training of providers, screening and safety assessments, documentation, intervention services, evaluation activities, and collaboration) assessed in the Delphi Instrument could be applicable to all forms of violence that patients experience. Although we scored low at the time of the first assessment, it was a useful exercise in helping us to understand where we needed to improve and provided a baseline measure to monitor our process over time.
The second step was to utilize model hospital policy guidelines (16-19) to address the revision of our policy. We identified the minimal elements needed for an effective hospital DV policy and we used this as a general guideline for developing our protocols with all the forms of violence addressed in our policy. The minimal elements included providing a clear purpose for the policy, guiding principles, definition of terms, information on how victimization affects health, identification and assessment procedures, intervention procedures, our State reporting requirements, confidentiality rules, collection of evidence and photographs, medical record documentation, referral process and follow-up, and plans on the ongoing education of physicians and staff.
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Our Committee found support from the upper levels of administration that saw violence victimization, in all its forms, as an important health care issue for patients and the revised policy was quickly approved. The third step involved educating all of our current physicians and staff (which we are still in the process of doing) and providing training for all new clinical staff on implementing and activating the policy. We are currently developing an online module for our physicians and staff for periodic ongoing training.
The fourth step is an ongoing process in reassessing the usefulness of the policy by reviewing our processes. The policy is available through our intranet system and provides algorithms (see Figure for an example of the HT Algorithm used in our health care setting) for our HCP to quickly access pertinent information. We plan to incorporate this information within our electronic medical record. Our Committee saw that providing a streamlined process to evaluate, aid and educate patients on how victimization may be affecting their health was the first step in developing a trauma-informed health care system.
Understanding that trauma experiences are common, widespread and have lifelong implications on health focuses health care efforts on developing systems that recognize the physical and mental manifestations of trauma. Responding appropriately to our most vulnerable patients is necessary not only to provide appropriate medical management, but also because it is the right thing to do.
*The page numbers are specific to the Reference Document that accompanies the policy.
**Note that the reporting requirements are specific to Utah State Statutes. It is important to know your state’s reporting requirements and limits of confidentiality when addressing issues of violence victimization in the health care setting.
About the Author
Kathleen M. Franchek-Roa, M.D., F.A.A.P. is an Assistant Professor of Pediatrics at the University Of Utah School Of Medicine. She serves as a preceptor to pediatric and family medicine residents and medical and physician assistant students. Dr. Franchek-Roa has a special interest in intimate partner violence (IPV) and how witnessing IPV impacts children’s mental and physical health. She developed a curriculum to teach residents about the role of the health care provider in identifying and assisting victims of domestic violence. Dr. Franchek-Roa is currently teaching this curriculum to Residents at the University Of Utah School Of Medicine. As Chair of the Utah Domestic Violence Coalition Health Care Workgroup, Dr. Franchek-Roa also provides this training to health care providers throughout the State of Utah. In addition, Dr. Franchek-Roa is the Chair of the University of Utah Hospital and Clinics Domestic Violence Committee. The Committee has developed guidelines for assisting physicians and staff in the identification of and interventions for patients who are victims of abuse, neglect and/or exploitation.
[1.] Reprinted from: Dahlberg, L. L. & Mercy, J. A. History of violence as a public health
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http://virtualmentor.ama-assn.org/2009/02/mhst1-0902.html. Accessed May 19, 2015.
[2.] Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Chen, J., & Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers For Disease Control and Prevention.
[3.] Healthy People 2020. Office of Disease Prevention and Health Promotion. Accessed at http://www.healthypeople.gov. Accessed May 19, 2015.
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[5.] National Center for Injury Prevention and Control. Costs of Intimate Partner Violence Against Women in the United States. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
[6.] Moyer, V. A. & the U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine (2013). 158(6), pp 478-486.
[7.] Alpert, E. J., Ahn, R., Albright, E., Purcell, G., Burke, T. F., & Macias-Konstantopoulos, W. L. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA and Committee on Violence Intervention and Prevention, Massachusetts Medical Society, Waltham, MA. September 2014.
[8.] Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., Ciarrocchi, R. A., Jahansson, A., Kefurtova, A., Scodanibbio, S., Motus, M. N., Roche, B., Morison, L., & Watts, C. The health of trafficked women: A survey of women entering posttrafficking services in Europe. American Journal of Public Health (2008). 98(1), pp. 55-59.
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[10.] Ventura, S. J., Curtin, S. C., Abma, J. C., & Henshaw, S. K. Estimated pregnancy rates and rates of pregnancy outcomes for the United States, 1990-2008. National Vital Statistics Reports (2012). 60(7), pp. 1-22.
[11.] IOM (Institute of Medicine) and NRC (National Research Council). 2013. Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press.
[12.] Moynihan, B., & Olive, K. Unmasking cancer as a consequence of trafficking: A multidisciplinary challenge. Cancer Incytes (2014). 3(2), pp. 1-6.
[13.] Cessario, S. K., McFarlane, J., Nava, A., Gilroy, H., & Maddous, J. Linking cancer and intimate partner violence: The importance of screening women in the oncology setting. Clinical Journal of Oncology Nursing (2014). 18(1), pp. 65-74.
[14.] Coker, A. L., Hopenhayn, C., DeSimone, C. P., Bush, H. M., & Crofford, L. Violence against women raises risk of cervical cancer. Journal of Women’s Health (2009). 18(8):1179-1185.
[15.] Modesitt, S. C., Gambrell, A., C., Cottrill, H. M., Hays, L. R., Walker, R., Shelton, B. J., Jordan, C. E., & Ferguson, J. E. Adverse impact of a history of violence for women with breast, cervical, endometrial, or ovarian cancer. Obstetrics & Gynecology (2006). 107(6), pp. 1330-1336.
[16.] Connecticut Health Initiative for Identification and Prevention. Model Domestic Violence Hospital Policy. A public health approach to providing optimal care to patients who are or may be victims or perpetrators of domestic violence. Accessed at http://www.vdh.virginia.gov/ofhs/prevention/dsvp/projectradarva/documents/older/pdf/CHIIP_PROGRAM_Domestic_Violence_Hospital_Policy.pdf. Accessed May 19, 2015.
[17.] Maryland Governor’s Family Violence Council. Hospital-based Domestic Violence Programs. February 2010.
[18.] The Ohio Domestic Violence Protocol for Health Care Providers: Standards of Care. Developed by the Ohio Domestic Violence Network and the National Health Care Standards Campaign Committee, Ohio Chapter, 2003.
[19.] Warshaw, C. Establishing An Appropriate Response to Domestic Violence in Your Practice, Institution and Community. In: Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers, Family Violence Prevention Fund, Pennsylvania Coalition Against Domestic Violence, 1995.
[20.] Agency for Healthcare Research and Quality. Delphi Instrument for Hospital-based Domestic Violence Programs. Accessed at http://archive.ahrq.gov/research/domesticviol/dvtool.htm. Accessed May 19, 2015.
[21.] Polaris Project. Potential trafficking indicators for medical professionals. Accessed at
http://www.breakingfree.net/files/breakingfree/files/Warning%20Signs.pdf. Accessed May 22, 2015.
Figure Caption. Algorithm used in our hospital system when suspecting or assessing a patient for trafficking (7, 21).