Identifying and Responding to Potential Cases of Human Trafficking in the Emergency Department
Ellen Feldman
March 1, 2024 32 minutes read
AUTHOR
Ellen Feldman, MD, Altru Health System, Grand Forks, ND
PEER REVIEWER
Vida Farhangi, MD, FACP, Director, Outpatient Residency Clinic, Florida State University-Sarasota Memorial Hospital, Sarasota, FL
EXECUTIVE SUMMARY
According to International Labour Organization estimates, 27.6 million people are victims of human trafficking worldwide. In the United States, the National Human Trafficking Resource Center gathers statistics based on tips and calls to their hotline. Since its inception in 2007, the center has received nearly 400,000 calls with a trend to increased reporting, but the accurate concept of the scope probably is widely unrecognized.
- The effect for practitioners is that multiple studies have shown that up to 88% of trafficked individuals seek medical care, with more than 60% presenting to the emergency department at some point during their exploitation.
- The top five risk factors for trafficking in the United States are recent migration/relocation, substance abuse, runaway/homeless youth, mental health concerns, and involvement in the child welfare system.
- Most persons being trafficked will not readily disclose information about their situation out of fear, shame, or guilt. If the trafficking involves sexual exploitation, the patient may feel an additional layer of stigma because of cultural expectations. In one study of survivors, 80% reported not disclosing a trafficking situation to healthcare providers because of shame, but almost as many (76.9%) noted they were never asked about trafficking and so never disclosed their situation.
- The principles of trauma-informed care attempt to shift from thinking about what is “wrong” with the patient to what happened to the patient.
- A common tip-off is the presence of an accompanying individual who appears to be controlling the interaction by answering questions and refusing to leave the patient in the room alone with the practitioner.
The emergency department (ED) often is the crossroads where critical healthcare meets acute social challenges — a concept well illustrated when delving into the complex issue of human trafficking. This paper aims to equip the emergency physician with essential knowledge and practical skills to identify and respond when confronted with potential cases of trafficking. By doing so, it aims to bridge the gap between routine medical care and the urgent need for a nuanced, informed approach to this hidden crisis.
This paper starts with a concise overview of the scope of the problem and highlights the relevance to everyday practice. The core of the paper introduces trauma-informed care principles, demonstrating how these approaches can be seamlessly integrated into various aspects of patient interaction — from the waiting area, to the exam room, to engagement strategies and survivor-specific treatment methodologies.
An emphasis on brief motivational interviewing provides a framework to enhance the interview process. Clinical scenarios are used throughout to illustrate key concepts and response strategies with an aim to bring to life the theoretical concepts discussed. Real-world applications and strategies for a responsive and informed emergency care environment are reviewed.
The following case introduces Justine, a fictional patient whose history and experiences are based on events reported by actual patients.
“There’s something unusual about your next patient,” says the nurse, after rooming 19-year-old Justine. It is late evening, and the department is a hive of activity with cases ranging from minor injuries to critical emergencies. “Or maybe it’s her companion. The two of them just seem extraordinarily uncomfortable, like they’re on edge.”
Entering the exam room, the physician immediately notices Justine’s fragile appearance. She sits slightly bent over on the ED gurney, eyes downcast, her hair disheveled. Faint bruises are visible on her arms, and her hands are tightly gripping the side rails, an instinctive reaction, thinks the physician, of someone in constant fear. At her side stands a slightly older woman, her phone clenched in one hand while the other foot taps the floor impatiently.
After brief introductions, the physician addresses Justine directly,“ I understand you are here because of pain.”
Justine shrugs slightly, but before she opens her mouth to speak, the older woman cuts in. “Yes, she is always in pain. I’m Justine’s sister and I want to make sure she gets the right treatment. She sometimes has a hard time remembering details.”
Whether it is due to the so-called sister’s overprotectiveness or Justine’s physical signs of distress, the clinician senses something is not right. Maintaining a non-threatening stance, the clinician says, “Justine, would it be OK for us to discuss this alone, while your sister waits outside?”
“No,” says the sister. “She wants me here.” Both the clinician and sister look at Justine, who continues to look down, then sighs and, in a low voice barely more than a whisper, says, “She can stay.”
Justine’s presentation, while unique in its details, mirrors a larger, often unseen crisis that unfolds daily across the globe. Justine’s subdued demeanor and the controlling presence of her “sister” are not merely individual concerns; they are echoes of a global pattern of exploitation and control that human trafficking embodies. Although these signs are not pathognomonic of trafficking, they are red flags for an aware clinician and can open the door to consider an appropriate management strategy.1
This global scourge of human trafficking, often intersecting with the healthcare system, ensnares millions across all demographics. As ED physicians, recognizing subtle signs and understanding nonverbal cues is pivotal in identifying and assisting persons who are experiencing trafficking and who otherwise may go unnoticed.1,2
Defined by the Trafficking Victims Protection Act of 2000 (and later reiterations) as a “person induced to perform labor or a commercial sex act through force, fraud, or coercion,” human trafficking encompasses a wide spectrum of exploitation. Notably, any minor involved in commercial sexual activity is a trafficking victim, regardless of coercion. In addition, involving a minor in sex for commercial gain is a form of child abuse.1-3
As noted, trafficking takes many forms, with sex and labor trafficking the two most common forms occurring in the United States. Given the association of trafficking with physical, sexual, and emotional/psychological violence, it is not surprising that most trafficked individuals seek healthcare at some point during and after exploitation. Studies reveal that, in retrospect, most trafficked persons report interaction with medical professionals while still under duress.1-3
Scope of the Problem
According to the International Labour Organization, 27.6 million people are victims of human trafficking worldwide, but because of diverse definitions and secretive practices, this number cannot be accurately verified. In the United States, the National Human Trafficking Resource Center (NHTRC) gathers statistics based on tips and calls to their hotline. These most likely reflect only a slice of the total number of individuals working under trafficking conditions.3,4
Since its inception in 2007, the NHTRC has received 399,494 calls, texts, and emails regarding suspected cases and identified 164,839 victims of human trafficking. In 2021 alone (the latest statistics available), more than 50,000 calls, texts, and emails were received and 16,710 victims were identified. These numbers seem to indicate a trend toward more reporting, although they do not give information about any underlying trends in prevalence. Again, the secretive nature of human trafficking makes it difficult to truly identify the entire scope of the problem in the United States.3,4
What does all of this have to do with healthcare? After all, this is not a medical problem that can be worked up with laboratory tests, imaging studies, or any other objective measure. However, multiple studies have shown that up to 88% of trafficked individuals seek medical care in the course of being trafficked. Typical concerns include infections, trauma sequelae, injuries caused by sexual abuse, malnutrition, and dental disease, as well as disorders of mental health, including anxiety, panic episodes, and post-traumatic stress responses. When seeking care, individuals caught up in trafficking are most likely to present to an ED or urgent care. An astute ED physician has a unique opportunity to educate, intervene, or assist a patient at this point, should the individual be looking for this type of intervention.1,2,4,5
It is worth noting that in a healthcare setting, when dealing with adults in a trafficking situation, the clinician is likely to have the most positive effect by recognizing the situation, providing a safe and nonjudgmental environment, and educating the patient regarding options. This is not the time or setting to look at rescue unless that is the request of the patient. If so, a knowledge of area resources is critical.2,4-6
When a minor is involved, an immediate referral to local child protective services is indicated.1,2,4-6
Although trafficking occurs in individuals of all ages, backgrounds, races, and ethnicities, the NHTRC lists the following as the top five risk factors for trafficking in the United States:4
- recent migration/relocation;
- substance use;
- runaway/homeless youth;
- mental health concerns;
- involvement in the child welfare system.
More broadly, risk factors include racial and ethnic minorities (particularly American Indian and Alaskan Native women and girls), recent immigrants (lawful or unlawful), migrant workers, persons with disabilities, individuals who have experienced domestic violence, individuals with substance use disorder, individuals identifying with minority sexual orientations, children in the foster care system, and runaway or homeless youth.1,3-5
Take-home message: Be aware of risk factors associated with human trafficking. Remain alert to the potential involvement of patients in your care, since a considerable number of trafficked individuals encounter medical services during their ordeal.
Recognition of a Patient Involved in Being Trafficked
The first step in recognition is awareness. Understanding the possibility that a patient may be in a trafficking situation helps put actions and reactions into a new perspective. Emergency physician Wendy L. Macias-Konstantopoulos, MD, founding director of the Human Trafficking Initiative at Massachusetts General Hospital, likens today’s awareness level of trafficking to the recognition of child abuse and neglect in the 1960s — an issue that researchers and physicians of that time brought to the forefront.7
There are a number of screens available for use in healthcare situations to identify potential trafficking situations. As of this date, several of the screens are in the process of being validated for clinical use.
The two screens most well suited for the fast pace and rapid assessment needs of ED settings are the eight-question Adult Human Trafficking Screening Tool (AHTST) and five-question Rapid Appraisal For Trafficking (RAFT.)8,9
The available screens are summarized with general information about each in Table 3 of this article: https://onlinelibrary.wiley.com/doi/10.1002/emp2.12638
With no clinically validated screen for trafficking in adults yet available, recognition currently relies on a detailed interview and clinical observations. Appearing to be under the control of another person is one of the most prominent indicators that a patient may be being trafficked. This includes (but is not limited to) having another person handling all paperwork or having another person responding to screening questions. Although this may occur in many patients with language barriers, it is most prudent to use translation services available in a healthcare facility so as not to involve a potential trafficker in a medical evaluation. Finding a reason to interview and/or examine all patients in a private setting is critical.1,2,4,7
Moving frequently, not knowing their address, living with multiple people in cramped spaces, having unclear or inconsistent history, appearing malnourished or dehydrated, and worrying about a debt owed to an employer all are among the indicators of potential involvement in being trafficked.1,2,4,7
Other suggestive signs on a physical exam are injuries from physical violence and/or any signs consistent with forced sex, especially in cases where a patient has had multiple abortions or treatment for sexually transmitted diseases.1,2,4,7
Be aware that most persons being trafficked will not readily disclose information about their situation out of fear, shame, or guilt. If the trafficking involves sexual exploitation, the patient may feel an additional layer of stigma because of cultural expectations. In one study of survivors, 80% reported not disclosing a trafficking situation to healthcare clinicians because of shame, but almost as many (76.9%) noted they were never asked about trafficking and so never disclosed their situation.1,2,10
In contrast to adults, the Short Screen for Child Sex Trafficking (SSCST) is a clinically validated, six-question tool for use in children ages 11 to 17 years in the United States. This screen is meant to be used both to identify trafficking as well as to identify at-risk youth. It is accompanied by a suggested introduction that briefly covers confidentiality and situations where confidential information must be shared, such as if there is a clear threat to life or a legal obligation to release. It bears repeating that any minor involved in trafficking must be referred to local child protective services.11
The screen also includes information about appropriate language to use when conducting a follow-up interview and touches on the importance of trauma-informed care.11
Take-home message: Identifying a trafficking victim in a clinical setting can be difficult and rarely is straightforward. Appearing to be in the control of an accompanying individual may be a tip-off; try to interview and/or examine the patient in a private setting, including using unbiased translator services to facilitate confidential communication.
Trauma-Informed Care
A basic understanding of trauma and knowledge of the widespread effect that trauma of the past as well as ongoing trauma has on medical care is a preliminary step in providing trauma-informed care (TIC).12
The pivotal Adverse Childhood Experiences (ACEs) study in the 1990s established a correlation between the extent of ACEs and increased adult morbidity and mortality. The authors of this work were among the first to call for coordination and communication among medical specialties and training for clinicians to effectively recognize and treat patients presenting with psychological trauma and improve medical outcomes.
Growing from these early roots with input from trauma survivors, policy makers, and professionals from multiple disciplines, TIC is an approach to medical care that emphasizes thinking about trauma history when diagnosing and treating patients. For example, staff trained in TIC will attempt to shift from thinking about what is “wrong” with a patient to what happened to the patient. This approach emphasizes developing and supporting an emotionally, physically, and culturally sensitive and safe environment for staff and patients alike.12,13
The principles of TIC begin with recognizing that trauma is ubiquitous and often invisible. Thus, TIC is recommended to be applied universally; this is not an approach reserved for individuals who have been exposed to traumatic experiences. However, the essential nature of this approach for a person experiencing human trafficking cannot be understated.12-14
Concrete examples illustrating the six themes or pillars of a trauma-informed clinic that are appropriate for all patients, but that are particularly helpful when caring for patients who have experienced trafficking, include:
• Safety: An unsafe environment (or the perception of such) can exacerbate anxiety. Examine the department’s physical layout and accessibility to ensure it is well-lit and easy to navigate. Provide a waiting area that offers both space and privacy, as this initial environment helps establish a foundation of trust.
• Trustworthiness and transparency: Patients who have been traumatized often have barriers to establishing trust. While it is difficult to manage wait times and clinician consistency in a busy ED, try to maintain openness regarding these issues to foster a sense of comfort and ongoing trust.
• Peer support: All individuals involved in the healthcare system are at elevated risk for experiencing trauma as a function of interaction with patients. Support groups and initiatives that allow clinicians and staff to share and process traumatic experiences are crucial. Be mindful of the effect that hearing about trauma can have on clinicians, potentially causing secondary trauma. Team support is key to a clinic’s effective functioning.
• Collaboration: The inherent power imbalance in medical settings can be re-traumatizing and lead to power struggles. Reduce this imbalance by actively involving patients in aspects of care, such as timing of appointments, treatment options, and care plans. Encouraging patient participation can lead to increased responsibility and engagement in their own care.
• Empowerment: Trauma survivors may feel helplessness, even years later. Reminding them they have a voice can contribute to recovery. Implementing patient feedback methods and/or a patient advisory board can validate the integral role of patients in the healthcare system and encourage sharing of experiences.
• Cultural sensitivity: Patients may present with a history of traumatic experiences involving culture, race, gender, or related issues. Make every effort to train all personnel that the ED is inclusive. This ranges from being sensitive to the effect of details such as department decor, pamphlets, and available media to using patient-preferred pronouns and choice of name to understanding any specific privacy issues. Be prepared to use translation services when needed, rather than relying on companions or family members.12-14
As mentioned, the principles of TIC are recommended for application in healthcare settings in general and not specifically in situations where trauma is being addressed. HEAL Trafficking, a multidisciplinary network of survivors, healthcare professionals, and related workers fighting human trafficking, cofounded by emergency medicine physician Dr. Hanni Stoklosa, has more specific recommendations for patients who have been exposed to trafficking. Among other resources, HEAL publishes an online clinician toolkit containing strategies to arrange to interview a patient alone when there appears to be a high risk of trafficking. However, HEAL notes that every case must be considered individually; there may be situations where a suspected trafficker refuses to leave and the potential harm and disruption to care outweighs the benefits of a private interview.15
Back to Justine
The physician, recognizing the need to interview Justine alone (with growing concern that there may be a trafficking situation), replies with careful consideration to Justine, “I understand you want your sister here. We’ll invite her back shortly after completing the standard privacy portion of the exam. This is what we do for every patient,” the physician explains, ensuring Justine feels her situation is not being singled out.
The sister shrugs and turns to leave, saying, “OK, but we don’t have all day.”
After the sister leaves, the physician shuts the door completely ensuring privacy, turns to Justine and says, “It seems like you are carrying a lot on your shoulders. I am here to help, not just medically, but also by listening. I want you to know that you have complete privacy here and this is your time to share anything you think necessary.” After a pause, the physician continues, “I don’t know if the bruises on your arm are connected to your pain, but if you feel comfortable, can you let me know what happened to cause them?”
With a nonjudgmental approach, the physician opens the door for Justine to reveal any coercion or force.
Justine glances up at the physician and replies, “Sometimes the guys get rough. But it’s not usually that bad. We’re sex workers — I wasn’t sure if it was obvious.”
Acknowledging her disclosure without surprise or judgment, the physician responds, “Your trust in sharing that means a lot. We are here to discuss your health concerns, no matter the context.” Justine looks down again and says, “I think I may have an infection — it hurts when I pee. That’s really the only pain I have.”
“Well,” says the physician, “I can do an exam and we can do some tests. Did anyone hurt you in that area of your pelvis — near where you pee?”
Looking up again, Justine says, “Well, yes, sort of. One guy … he kicked me pretty hard. But I think his aim was off — it wasn’t on purpose. My sister — she’s afraid you will call the police … and I also think she wants me to get pain medicine to bring back.”
The physician takes a breath, “How about we do all the tests, and we go over them while your sister is still in the waiting area. It won’t take long. Then you let me know any information you want your sister to have. And I won’t call the police — not unless you want me to. You call the shots here. My concern is your health.”
“Thanks,” replies Justine, looking down again.
“It would help to understand a little more history,” says the physician. “Like how long you have had the pain when urinating and any other symptoms. But first, can we talk about your living situation? I am wondering if you feel safe and able to make choices on your own.”
Justine looks up.” I don’t want to leave, if that’s what you’re asking,” she says. “But I could use your help letting my sister know if I have an infection and tell her I don’t need pain meds except Tylenol or something. Antibiotics are fine.”
The physician nods and says, “I can do that, and I also want to give you a number you can call in case you ever do want to leave or want information about how to leave.”
“Thanks,” Justine murmurs and looks carefully at the number before tucking it away.
Throughout this interaction, the physician exemplifies key principles of TIC, such as ensuring safety by maintaining a private, secure environment and fostering empowerment by allowing Justine to guide the conversation.
When treating an individual who is not a minor or vulnerable adult, the decision regarding the next steps in care rests with the patient rather than with the physician. For those entangled in trafficking, readiness to exit their situation can require time, often necessitating multiple healthcare visits. Although many physicians may find this counterintuitive, respecting the patient’s competence in deciding on a course of action is the most prudent course. Providing resources such as national referral hotline numbers (see Table 1) and addressing immediate medical needs can lay the foundation for building trust in the healthcare system. This established trust can be instrumental for the patient in navigating future medical interactions and potentially life-altering decisions.1,2,4,15,16
Table 1. Resources for Providers and Patients |
National Human Trafficking Resource Center
HEAL (Health, Education, Advocacy, Linkage) Trafficking
The Advocates for Human Rights
American Medical Association
U.S. Department of Health and Human Services
American College of Emergency Physicians
|
Careful documentation of any medical problem or injuries is important in any medical encounter, and perhaps even more so when trafficking is suspected. In the future, this documentation may be part of legal efforts and/or may help other clinicians recognize a pattern.16
Take-home message: A healthcare environment and approach that are attuned to the needs of those who have undergone trauma (such as trafficking) are essential in fostering the trust vital to an effective and therapeutic physician-patient relationship.
Survivors of Trafficking in the Medical Encounter
Understanding the medical and mental health implications of traumatic experiences is crucial, and especially relevant when considering patients who have endured (or still are experiencing) trafficking. Recognizing the medical consequences of trauma begins with a broad comprehension of trauma within a healthcare context.1,3,4
It is estimated that more than 80% of U.S. adults will encounter some form of trauma in their lifetimes. The challenge in accurately quantifying this stems from varied definitions of “trauma,” patient reluctance to disclose such experiences, and physician discomfort in acknowledging and managing the aftermath of trauma. Yet, these damaging experiences have the potential to significantly affect ongoing health problems and mortality rates.17
In recognition of the importance of developing a uniform understanding of “trauma,” the Substance Abuse and Mental Health Services Administration (SAMHSA) published the following definition of trauma:
“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”18
The effect of trauma on mental and physical health has been recognized for centuries. Historical records have documented medical issues related to trauma. Cuneiform tablets from the time of Mesopotamia depict soldiers with symptoms such as slurred speech, nightmares, and flashbacks who were thought to be haunted by ghosts. In classical literature, Herodotus in 490 BC and Shakespeare in the 1500s also described and wrote about characters with stress symptoms post-trauma.19
The Civil War-era term “soldier’s heart” highlighted a constellation of symptoms, including heart palpitations, fatigue, and shortness of breath, seen in returning soldiers. This may represent one of the earliest modern recognitions of medical problems arising from trauma.19
World War I intensified interest in the effects of wartime trauma, with the term “shell shock” encompassing a wide range of symptoms seen in soldiers worldwide, ranging from involuntary tics to functional paralysis to debilitating depression and anger outbursts. Treatment approaches varied significantly, with no comprehensive plan or understanding of the overall syndrome. During World War II, with psychiatrists managing most cases, nearly 4.1 million soldiers were treated for “combat fatigue,” with this diagnosis accounting for a substantial proportion of military discharges.19
The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 categorized trauma-related stress symptoms under depression or as a manifestation of another disorder, such as anxiety or psychosis. Unfortunately, without a specific diagnostic category, opportunity for research and further investigation into this syndrome was limited. It was not until 1980, with the recognition of post-traumatic stress disorder (PTSD) in the third edition of the DSM, that this condition gained specific diagnostic criteria. Twelve years later, in 1992, the International Classification of Diseases (ICD) followed suit.19,20
The 2013 DSM-5 introduced a “Trauma and Stress-Related Disorders” category, encompassing PTSD and other related disorders. This section was retained in the 2022 DSM-5-TR and stands as one of the first major acknowledgments in the medical field that symptoms such as flashbacks, hopelessness, somatic illness, hyper-reactivity, and hypervigilance are noted not only in soldiers returning from war, but also in survivors of a range of traumatic experiences, including human trafficking.19,20
Investigations into quantifying the medical consequences of human trafficking are ongoing. Infections, chronic illnesses, somatic illnesses such as headaches and gastrointestinal distress, malnutrition, dental problems, depression, anxiety, and, frequently, PTSD are among the most commonly identified disorders.1,2,21
The DSM-5-TR takes a broad-based approach to PTSD, whereas the ICD-11 offers a narrower definition but introduces a new diagnostic category called Complex PTSD (CPTSD). This newly recognized, more impairing disorder represents the understanding that prolonged trauma, often experienced in trafficking, can profoundly affect self-perception, emotional regulation, and interpersonal relationships and lead to dysfunction in each of these areas. Although the development of either PTSD or CPTSD is unrelated to the type of trauma experienced, sustained trauma, such as that likely to be experienced during trafficking, is more likely to result in CPTSD.19,20
Take-home message: Flashbacks, hopelessness, somatic illness, hyperreactivity, and hypervigilance are among the symptoms of PTSD; additional symptoms, such as poor self-esteem and emotional dysregulation, point toward the more impairing CPTSD, often surfacing after prolonged trauma like that seen in trafficking victims.
Motivational Interviewing
Survivors of trafficking frequently bear deep-seated trauma and may understandably exhibit guarded behavior and a mistrust toward others, including physicians. In treating such patients, traditional directive medical approaches, despite being well-intentioned, sometimes can prove ineffective or even detrimental. This primarily is because these methods might be perceived as encroaching upon the patient’s autonomy and control — aspects that are particularly sensitive for trafficking survivors who have endured manipulation and coercion.2,4,6,21
Motivational interviewing (MI) is a tool that is particularly effective in building the trust necessary to a form a successful and therapeutic patient-physician relationship that can eventually lead to healthy lifestyle change. This interviewing technique stresses an empathic, patient-centered approach by acknowledging and respecting patient autonomy while building the mutual understanding and collaboration essential for healing and recovery. MI avoids confrontation and instead encourages patients to talk about their needs, desires, and reasons for positive health and lifestyle change. Studies of brief MI techniques in ED settings have shown potential especially in the field of substance abuse, but techniques central to this tool may be used to promote healthy behavioral changes in a variety of areas.22-25
One key to using MI with patients lies in recognizing that the role as a physician in discussing behavioral change is not to direct, but to guide. Change, and motivation for change, must originate from the patient. Physicians act as trusted partners, fostering empathy and assuring autonomy in decision-making, while encouraging patients to articulate their motivations and desire for change. The OARS model (see Table 2) developed by the founders of MI, gives some practical suggestions to assist with this process.22-25
Table 2. The OARS Model |
O: Open-ended questions. These are questions that are not able to be answered with a single yes/no response, thus prompting deeper conversation. Try to avoid “why” questions, since these can promote defensiveness. Ask questions like, “What aspect of your situation troubles you the most?” rather than “Why does this bother you?” since the latter format may be taken as criticism. This approach fosters empathy and understanding, helping patients feel at ease to discuss their health concerns and consider possible solutions. A: Affirmations. Identify and acknowledge the patient’s genuine strengths. This is different from praise; it involves recognizing positive traits revealed during the interview. For instance, a provider may note, “I can see that even with the pain you are in, you continue to carry on and keep trying — that determination is a significant strength.” R: Reflective listening. Engage in attentive listening, reflecting back the core ideas or themes expressed by the patient. It is crucial to ensure an accurate representation of their message. This can involve repeating or paraphrasing their statements, then seeking confirmation or clarification. S: Summarizing: Use summarizing statements both during and at the end of the conversation to encapsulate what has been discussed. For instance, a provider may say, “To summarize what I have understood so far ... please tell me if I am leaving out an important point or misunderstanding any aspect of your situation.”22-25 |
Back to Justine
Justine, now age 26 and the mother of 3-year-old Sophia, presents to the ED with an ibuprofen overdose.
“It was just a stupid mistake,” she explains. “I don’t want to kill myself — I just can’t stand the headaches. As soon as I realized how many I took, I called — and they told me to come here. “
Justine continues, “The headaches come every day, and nobody has been able to figure out why. I’ve had computed tomography scans, magnetic resonance imaging, and some other tests. All my doctors tell me it is from stress, but can stress really hurt so bad?”
A physical exam reveals a thin, appropriately dressed, and groomed woman with multiple well-healed horizontal scars on both forearms. Vital signs reveal a mildly elevated pulse and a low body mass index of 17.0.
The scars present a clue to examine for the presence of present or past trauma. Using a patient-centered TIC approach and open-ended inquiries based on the principles of MI, the physician says, “I noticed some scars during our examination. If it is OK with you, I would like to understand more about them. It can be helpful to know your full health history, but please only share what you are comfortable with.”
Justine hesitates, then replies, “Yes, these were from when I was younger, and life was hard, so I would cut myself. But I would never do that now.”
The physician nods and says, “Thanks for sharing that with me. I know it’s not easy. It’s important that you feel safe and comfortable here.”
“I know,” replies Justine, “but trusting is hard for me.”
The physician nods, “If you are open to it, talking a little more about your past experiences might help us understand the full picture. It’s not uncommon for experiences from the past, especially challenging ones, to influence our health, even years later.”
Here, the physician has followed the patient’s lead in not discussing the details of how Justine’s life “was hard” but is asking if she has considered a link between the trauma of the past to the headaches of today. Knowing the specifics of trauma is not necessary and, in fact, could be retraumatizing if pursued before a patient is ready. In all aspects, the physician is careful to explicitly remind Justine that she oversees what she wants to reveal. By deliberately using pronouns such as “us” (“… talking a little more about your past experiences might help us understand …”), the physician implicitly acknowledges that Justine is part of the process and a member of the treatment team.
Justine hesitates. “Maybe,” she says. “I like to think I have overcome my past. But I must admit it’s hard for me to eat and sleep regularly. It’s like my throat closes when I see food and my brain wakes up when it’s time to sleep.”
“I am concerned to hear about the eating and sleeping problems — these can affect your health significantly, including contributing to the headaches,” says the physician.
“Possibly,” says Justine. “Nobody has ever really considered that before. But I haven’t slept well since I was 10 years old, and the headaches started just a few years ago — actually, when I was getting my life together.”
“Oh,” says the physician, “what do you mean by getting your life together?”
“Getting out of a bad relationship,” says Justine, looking away. “A really bad one.”
Justine is providing an opening to reveal more of what has happened to her. The physician is on solid ground asking if she is ready to say more. Using principles of TIC and MI, the physician is careful to let Justine stay in full control. Note also that Justine is providing a hint at her underlying ambivalence about connecting the trauma of the past with the healthcare issues of the present.
“Are you comfortable telling me more about that? Maybe we can figure out if there are connections to the headaches. Sometimes, our body responds to stress in ways we don’t fully understand, like with headaches or trouble sleeping. Maybe understanding more will help us find the right path to help you manage these symptoms,” notes the physician.
“I was treated badly as a kid,” says Justine, “and I ran away from home at 16. Then I got caught up with this guy who gave me a place to live with some other girls … and, well, it wasn’t all bad. We took care of each other. But he didn’t take it well when I got pregnant and wanted to leave. That’s when I realized I was … well, trapped may be the best word.”
“It sounds like a very difficult time,” says the physician.
Justine nods as her eyes fill with tears. “It is hard to talk and think about,” she says. “He wanted me to — you know — end the pregnancy. But when I went to an ED after he kind of beat me, I finally asked for help to get out. And now I have a job and housing. I’m doing OK, except for the headaches.”
“And sleeping and eating problems,” says the physician with a smile. “You have shown remarkable strength and resilience in facing such challenging experiences. It’s impressive how you have worked toward creating a better life for you and Sophia.”
Here the physician is using a strength-based approach, empathy, and affirmations, highlighting Justine’s efforts at recovering and improving her situation rather than asking for more information or details about the traumas. A next reasonable step is to address treatment issues.
“Thank you,” replies Justine. “I don’t feel very remarkable, but it is good to hear you say that.”
“If you are interested,” says the physician, “I can connect you with resources that specialize in helping people who have had similar experiences. They can offer additional support alongside your usual care.”
“Maybe,” says Justine. After a pause, she adds, “Do you mean a support group or even a therapist? Maybe. But how about the headaches?”
“It sounds like you have had a pretty comprehensive workup,” says the physician. “I also remember you said that nobody ever connected the headaches to your eating and sleeping problems,” continues the physician, “so maybe that’s another place to start. I see your primary care physician is here at our clinic, and I can send a note about our conversation.”
“Oh,” says Justine, “he just wants me to see a psychiatrist. But what I don’t want to do is dredge up my whole past. I do want to feel better and not have so many headaches, but I want to focus on fixing how things are now, and not worry about my past. ”
Justine is demonstrating “change talk,” an important concept in MI.22-24 By acknowledging that she is in a stressful situation and refraining from offering solutions, the physician elicits Justine’s thoughts about her motivation to change (“… I want to focus on fixing how things are now …”) and gets the sense that her reluctance to look at stress as a cause of headaches with other clinicians may have been caused by her fears of “dredging up the past.”
“Another option in primary care is to work with a health coach on taking care of yourself while parenting a toddler,” says the physician. “That doesn’t have to involve your past at all.”
“That could be OK,” replies Justine. “I have to admit it is hard to remember to take care of me most of the time — I am so focused on Sophia.”
“In the meantime, if you are OK with it, I think it would be helpful for you to check back in with your primary,” says the physician. “Regular check-ins can help monitor your progress and adjust the treatment approach as needed.”
Take-home message: MI, with the physician acting as a guide, can be effective in helping a patient resolve ambivalence regarding lifestyle change. This technique is particularly useful in patients who have been trafficked and are wary of a more direct approach.
With a tentative treatment plan going forward and preliminary trust established, the physician still has a few issues left to address: the accidental overdose that brought Justine to the ED, an assessment of suicidal risk, and an understanding of any comorbid disorders, including substance use disorder.
“In the time we have left, I am hoping we can talk about the accidental ibuprofen overdose that led to your emergency department visit. Can we talk about what happened? It is important for us to understand the context to ensure you are safe and well,” says the physician.
Justine looks up and replies, “I figured you might want to discuss that. I was not wanting to hurt myself, I just lost track. I had a new bottle, and I usually take six to eight a day at the most, and some days none. But that day, Sophia was up early, and I was tired, and my head hurt and I took, well, more than eight at one time. Then I realized I had taken four, maybe an hour earlier. I got worried and told my friend. We called poison control, and they said to come here. But she just texted me that the new bottle had 100 mg tablets and not the 200 mg I was used to.”
Evaluating Suicidal Risk
People who have survived trafficking are at a heightened risk for self-harm and suicidal behavior.25 It is essential for emergency physicians to develop a comfort level with evaluating and managing all patients who express suicidal thoughts and/or who have risk factors for suicidal behavior.26,27
Research indicates that nearly one-half of adults who completed suicide had contact with a medical clinician within a month before death, and 80% had such contact in the year preceding suicide.27 Although patients may be reluctant to directly mention suicidal thoughts, they often respond to open-ended questions. It is vital for the emergency physician to inquire about suicide in a direct yet empathic and nonjudgmental manner, since this can encourage open dialogue.27-29
There are tools available, such as the Columbia Suicide Severity Rating Scale (C-SSRS), that can aid in assessing risk.30 However, these should not replace thorough diagnostic evaluations.29,30
In cases of high suicidal risk and/or suicidal intention, refer the patient to a mental health specialist. The availability of these specialists may vary regionally, and this practical variable often determines referral and consultation patterns. Emerging evidence supports the effectiveness of collaborative care models. These approaches involve a team led by the emergency physician and include mental health professionals, such as psychiatrists, counselors, and case managers, providing comprehensive and effective care for more complex, higher risk patients. Telemedicine consultations often have proven beneficial, especially in extending specialized care to underserved areas.27-29,31
A strong working relationship between emergency physicians and mental health professionals lies at the crux of this collaborative approach. Additionally, equipping patients with information about local support groups and resources, such as suicide hotlines, offers an extra layer of support for these individuals.27-29,31
“I appreciate your honesty,” says the physician. “It seems you hoped more ibuprofen would take care of your pain, but that approach became risky.”
“Yes,” says Justine. “I threw out the rest of the bottle. Nothing ever really helped anyway. Maybe you and the other doctors are right — I must learn to manage stress.”
Looking at Justine, the physician says, “I agree about the stress, but I wonder, have there been moments in your life when you thought about not wanting to live? It’s not unusual for people facing tough situations to consider suicide.”
After a short silence, Justine, keeping eye contact, replies, “Not since Sophia was born.” Looking away, she continues. “I used to do a lot of things I wouldn’t do now — I have too much to live for.”
With this insight, the physician can transition to assessing substance use, given the high-risk history, and to provide complete recommendations.
“It is great that you are focused on healthier choices, for both yourself and Sophia. Regarding your health journey, are there any experiences with substance use — be it drugs or alcohol, in the past or present — that you feel comfortable sharing? Understanding helps us provide the best care tailored to your needs,” says the physician.
Justine nods. “I used to smoke weed — a lot — to help me sleep. But it doesn’t work so well, so I kind of stopped. And I didn’t want Sophia to notice anyway,” she says. “I haven’t had a drink since I got pregnant. I don’t intend to start again. I stayed away from needles — I saw what that did to my friends.”
The physician leans forward slightly and says, “I think what you’re saying is that you’ve recognized that external substances, including alcohol, marijuana, and even ibuprofen, are not the answer for any of your pain — emotional or physical.” Justine’s eyes tear up as she signals agreement.
Winding up the interview, the physician notes, “I am glad you came in and are safe. Your blood tests all look stable. Unless you want to add anything now, let me introduce you to our health coach scheduler so you can arrange a meeting and get information about taking care of yourself while parenting a toddler.”
“Thank you,” says Justine, “Why not? Nothing else has worked. I think starting with cutting down caffeine and probably turning off my phone early in the evening is a place I can begin. And then maybe I can find out more about that therapy you mentioned.”
Take-home message: Evaluate suicidal risk and substance use with or without a screen, but always with an interview including compassionate, nonjudgmental, straightforward inquiries.
Summary
• Remain vigilant to the possibility that patients in your care may be current or former victims of trafficking and understand that, for a variety of reasons, they may have difficulty openly expressing this.
• Be aware of risk factors for becoming involved in trafficking.
• Strive to conduct private interviews and examinations, using impartial translation services when needed, all while ensuring the patient’s confidentiality is maintained.
• Work to understand and integrate TIC principles into everyday practice to address the often-invisible nature of trauma and help mitigate the effect of trauma on health.
• Develop a comfort level with MI; use this approach with patients who are considering lifestyle change to improve their health.
• Prepare to offer and share local, regional, and national resources to patients affected by trafficking who are interested in receiving or seeking this information. Ensure immediate referral of minor patients caught in trafficking to child protection agencies.
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- U.S. Department of Justice. Human trafficking. Key legislation. Updated Aug. 23, 2023. https://www.justice.gov/humantrafficking/key-legislation#:~:text=The%20Trafficking%20Victims%20Protection%20Act%20of%202000%20(TVPA)%2C%20Pub,of%20slavery%20domestically%20and%20internationally
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- Gundacker C, Barry C, Laurent E, Sieracki R. A scoping review of trauma-informed curricula for primary care providers. Fam Med 2021;53:843-856.
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- Partners in Health. Introduction to trauma-informed care. Published Dec. 22, 2021. https://www.pih.org/sites/default/files/lc/LT-CHW_TraumaInformedCare.pdf
- HEAL Trafficking. HEAL’s protocol toolkit. https://healtrafficking.org/heals-protocol-toolkit/
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- Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Published July 2014. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf
- Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Appendix C: Historical account of trauma. Substance Abuse and Mental Health Services Administration (US); 2014. https://www.ncbi.nlm.nih.gov/books/NBK207202/
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This paper aims to equip the emergency physician with essential knowledge and practical skills to identify and respond when confronted with potential cases of trafficking.
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