Ideally, health care providers would have one or two validated screening questions they could use during an exam to identify human trafficking victims. Unfortunately those screening questions do not yet exist. Currently there are only a handful of validated human trafficking screening tools. Without the needed research and guidance on human trafficking based questions, we are recommending healthcare providers use the following to guide their policies, procedures, and screening tools.
Trauma-informed care should guide all human trafficking interventions.
Trauma-Informed Assistance
Discuss sensitive topics alone and in a safe, private setting (ideally a private room with closed doors).
Employ competent, trustworthy interpreters if the victim’s first language is not English. The victim must be assured of confidentiality.
Discuss with the person exactly how and when confidentiality will be maintained, and explain the limits of confidentiality (i.e. mandated reporting requirements) before beginning any sensitive discussion.
The priority is to establish trust and rapport, rather than achieve disclosure.
- Educate patient in a manner that is nonjudgmental and normalizes sharing of information (E.g. “I educate all of my patients about [fill in the blank] because violence is so common in our society, and violence has a big impact on our health, safety, and well-being.”) Offer informational materials about abuse, neglect, or violence with information about resources. If the patient declines materials, respect the patient’s decision.
Whenever possible, a follow-up appointment should be scheduled in order to continue building rapport with the patient and to monitor their health, safety, and well-being.
If patients are unwilling or unable to return for ongoing or follow-up care, the clinician should strive to assure patients that they do not deserve to be abused; that they are not to blame; and that the healthcare provider is “always open” as a source of safe, confidential, and supportive care.
Be aware of barriers to disclosure, including, but not limited to:
- Inability to speak privately with the healthcare provider
- Language barriers combined with lack of availability of a trusted professional interpreter
- Stigma and shame
- Fear of harm to themselves, coworkers, friends or family members
- Fear of deportation
- Does not self-identify as a victim
Any human trafficking indicators used in screening tools, including questions in electronic medical records, must address both sex trafficking and labor trafficking.
Too often human trafficking screening questions only address sex trafficking and make labor trafficking victims invisible.
Based on our review of both the validated and unvalidated tools available we recommend the following indicators and screening questions:
Indicators
Accompanying individual who answers questions for the patient or otherwise controls the pace and content of the encounter, insists on providing translation, refuses to leave, or is otherwise hyper-vigilant or attentive
Delayed presentation for medical care
Subordinate, hyper-vigilant, or fearful demeanor
Discrepancy between the stated history and the clinical presentation or observed pattern of injury
Patient unaware of geographic location
Patient does not have control of personal documents or identification
Screening Questions
If there are indicators of victimization, ask about concerns. Example: “I’ve noticed [insert risk factor/indicator] and I’m concerned for your health, safety, and well-being. You don’t have to share details with me, but I’d like to connect you with resources if you’re in need of assistance. Would you like to speak with [insert advocate/service provider]? If not, you can let me know anytime.”
Does anyone hold your identification documents for you?
Have you ever been afraid to leave or quit a work situation due to fears of violence or threats of harm to yourself or your family?
Case Management
If patient denies victimization or declines assistance, then respect the patient’s wishes. If you have concerns about the patient’s safety, offer hotline card or other information about resources that can assist in event of emergency (e.g. local shelter, crisis hotline).
If patient accepts/requests assistance with accessing services, provide a warm referral (e.g., a personal introduction by way of speaking directly to the agency you are referring the patient to) to a local victim advocate/service provider; or, arrange private setting for patient to call hotline:
- National Human Trafficking Hotline, 1-888-373-7888
- National Domestic Violence Hotline, 1-800-799-SAFE (7233)
- National Sexual Assault Hotline, 1-800-656-HOPE (4673)
Sources
1. Trafficking Victim Identification Tool (TVIT)
Vera Institute. (2014).
- Overview
- The TVIT is the most referenced identification tool in the field of human trafficking.
- This tool has been through validation testing (for sex and labor trafficking) and includes evidence-based measures.
- There are two versions of this tool: long and short.
- The long version of the tool is 26 items
- The short version is 16 items
Limitations
- Has not been validated in different settings (only victim service organizations).
- Administered in eleven (11) victim services organizations in California, Colorado, New York, Texas, and Washington.
- Can take 60 minutes to administer and requires a human trafficking expert for interpretation.
- Even for the short assessment, it can take more than an hour to ask all the questions, and even more time should be accounted for due to the rapport that must be built prior to asking these in-depth and invasive questions.
- No isolated question results in a clear identification of a trafficking experience, therefore the interviewer must synthesize the data provided to make a trafficking determination.
2. Human Trafficking Interview and Assessment Measure (HTIAM-14)
Covenant House. (2013).
Overview
Validated screening tool to evaluate for trafficking among the homeless young adult population.
Limitations
- Takes up to 45 min to administer and also requires an interviewer with human trafficking expertise
- Tested only amongst youth experiencing homelessness and seeking services at Covenant House New York.
3. Quick Youth Indicators for Trafficking (QYIT)
Chisolm-Straker, M., Sze, J., Einbond, J. (2019).
Quick Youth Indicators for Trafficking (QYIT). Children and Youth Services Review, 98, 72-79. doi:10.1016/j.childyouth.2018.12.014
Overview
- QYIT Questionnaire is brief, and does not require a trafficking expert to administer
- An affirmative answer to at least one QYIT question is 86.7% sensitive and 76.5% specific in identifying a trafficking experience
Limitations
- Tested and designed only for use at social service providers providing services to homeless young adults who have labor and/or sex trafficking experiences
4. Identification of human trafficking victims in health care setting
Baldwin, S. B., et. al. (2011).
Identification of human trafficking victims in health care setting. Health and Human Rights Journal, 13(1). Available at https://www.hhrjournal.org/2013/08/identification-of-human-trafficking-victims-in-health-care-setting/.
- Overview
- Two-part study consisting of 1) face-to-face, in-depth, semi-structured interviews with six (6) key informants who worked closely with trafficking victims, and 2) interviews with twelve (12) female trafficking survivors in Los Angeles County with script developed from data gathered in Phase 1.
- All interviews were done in English, with assistance of professional interpreters in six languages, including Spanish Korean, Russian, other Asian and African languages.
- Survivors were subjected to a mixture of labor and sex trafficking
Limitations
- Extremely small sample size
- Study confined to Los Angeles County
- Because of small sample size, data all qualitative in the form of direct testimony from survivors and Key Informants
- Two-part study consisting of 1) face-to-face, in-depth, semi-structured interviews with six (6) key informants who worked closely with trafficking victims, and 2) interviews with twelve (12) female trafficking survivors in Los Angeles County with script developed from data gathered in Phase 1.
5. PEARR (Provide privacy, Education, Ask, Respect, & Respond) Tool
Dignity Health Human Trafficking Response Program (2019). PEARR Tool.
Available at https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed
Overview
- Tool developed by Dignity Health, HEAL Trafficking, and Pacific Survivor Center to help guide social workers, nurses and other professionals on how to provide assistance to victims/survivors of any form of abuse, neglect, or violence, including human trafficking, in a trauma-informed manner.
Limitations
- Not scientifically validated, but designed based on years of case debriefings with frontline staff, as well as collaborations with subject matter experts.
6. Schwarz, C., Unruh, E., Cronin, K., Evans-Simpson, S., Britton, H., & Ramaswamy, M. (2016). Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors
Health and Human Rights, 18(1), 181-192.
Overview
- Protocol developed by Kansas University School of Law’s Medical-Legal Partnership (MLP Clinic) and the KU School of Medicine’s Department of Public Health and Preventive Medicine for use in the KU Emergency Department (ED).
- Focuses on both identification and intervention to assist trafficked persons, encompassing victims of both labor trafficking and sex trafficking.
Limitations
- Not scientifically validated. Guidelines were developed from most recent protocols and recommendations from multiple field experts, and feedback obtained from physicians, nurse managers, social work representatives, and Sexual Assault Nurse Examiners (SANE).