Identifying Human Trafficking in the Hospital Via an Abuse Screening Tool

Introduction:

Human trafficking (HT) is a human rights violation that occurs worldwide. The Trafficking Victims Protection Act of 2000 defines sex trafficking as a “commercial sex act that is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age” (United States Department of Justice, n.d.). Labor trafficking is defined as the “recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” (United States Department of State, n.d.). The US State Department estimates that at any given time, there are over 27.6 million trafficked persons worldwide (United States Department of State, n.d.). The International Labor Organization estimates 49.6 million individuals are affected by forced labor and marriage worldwide. Historically, human trafficking was thought of as a threat seen in foreign countries. However, it has been reported in all 50 states in the US. An annual report from the National Human trafficking hotline in 2021 demonstrated that there were over 50,000 tips reported to the hotline and 10,360 cases identified within the US that year (National Human Trafficking Hotline, n.d.). This number is likely a gross underrepresentation of the actual number of trafficked persons due to the covert nature of trafficking, as well as the fact that there is no required reporting to a centralized data collection agency.

Human trafficking is a violation of human rights and a public health concern. Healthcare providers in all fields play a crucial role in the identification and subsequent assistance of trafficked persons. Studies show that between 68%−88% of trafficked persons report that they interacted with a healthcare professional during the period when they were actively trafficked (Chisolm-Straker et al., 2016; Kaltiso et al., 2018). Upon identifying trafficked persons in healthcare settings, healthcare professionals can provide referrals to systems where they may receive various types of support including, but not limited to, physical, psychological, and legal support. There are, however, barriers to the identification of trafficked persons. Across the nation, these barriers include a lack of formal education and training in the identification and management of patients affected by human trafficking, and a lack of implementation of validated screening tools (Hachey & Phillippi, 2017).

Trafficked persons do not fit one specific profile. They may be of any race, gender, age, socioeconomic status, nationality, sexual orientation, or other demographic variable. In an attempt to mitigate bias that may allow trafficked persons to fall through the cracks, screening tools have been developed to identify individuals suspected to be affected by human trafficking. There are currently several screening tools for human trafficking including the Vera Institute of Justice Human Trafficking Victim Identification Tool (TVIT) and the US Department of Health and Human Services Adult Human Trafficking Screening Tool (Hainaut et al., 2022; Simich et al., 2014). However, the number of validated screening tools for use in the healthcare setting is sparser (Hainaut et al., 2022). The Greenbaum “Short Screen for Child Sex Trafficking” is a validated screening tool for minors. However, this tool has its shortcomings in that it is only applicable to English-speaking minors between the ages of 12–18 who present to the emergency department (ED) with a clinical presentation suspected to be related to sex trafficking (Greenbaum et al., 2018). More recently, the Rapid Appraisal for Trafficking (RAFT) screening tool was developed and validated for use for adults >18 years in the healthcare setting (Chisolm-Straker et al., 2021). It is a brief four-item screening tool that demonstrated 100% sensitivity (95% CI, 100%–100%) and 61% specificity (95% CI, 56%–65%) in an external validation study (Chisolm-Straker et al., 2021).

Study Objective:

A large level-1 trauma center in the Midwest added three questions related to human trafficking to their existing mandatory nursing screening tool, the “Abuse Risk tool.” This new tool, “Abuse Risk + HT tool” was implemented on March 31st, 2021. These questions were asked to address both labor and sex trafficking in patients aged 13 and older.

This research project sought to estimate the prevalence of human trafficking among all patients who screened positive on the Abuse Risk + HT screening tool. It also sought to evaluate if the presence of three human trafficking specific questions identified individuals who would have been missed on the previous Abuse Risk screening tool. This project is unique in that both sex and labor trafficking were addressed, and it included minors aged 13 and older.

Methods:

This was a retrospective cohort study approved by the local Institutional Review Board who determined this evaluation to not be human subjects research.

Screening Tool

The Abuse Risk + HT screening tool consists of seven core questions listed in Table 1. Three of those questions (those starred in Table 1), were geared at identifying patients affected by human trafficking and were added to the existing Abuse Risk tool on March 31^st, 2021. A positive screen prompted a consult to social work. Data from the screening tool administration collected from April 1^st, 2021 to February 28^th, 2023 was used for this analysis.

Table 1:

Abuse Screening Questions

• Are you in an unsafe relationship?

• Does your partner/boyfriend/girlfriend hit, kick, hurt, or threaten you?

• Have you suffered any injury as a result of abuse in the past year?

• Does your partner/boyfriend or girlfriend ever try to control you by threatening you or your family?

• Are you currently being forced to engage in sexual activity? *

• Are you being forced to work? *

• Are you being abused or threatened in your work or home environment? *

^*Indicates new human trafficking question

Retrospective Medical Record Review

The medical record numbers for any patient who had a positive screen for any of the questions in the Abuse Risk + HT tool during the study were pulled from the electronic medical record. A positive screen was defined as the patient answering “yes” to any of the questions on the Abuse Risk + HT tool. If a patient had more than one screening during their encounter it was only counted as an additional screening if it was 24 hours from the last screen. Retrospective chart review of patients’ medical records was conducted to determine if the patient had documentation highly concerning for human trafficking. Criteria for documentation included any one of the following parameters: social work or a provider documented concern for human trafficking in a note, social work filed a report for human trafficking (in the case of a minor), social work provided the patient with human trafficking resources and documented this, and social work designated concern for human trafficking in their workflow for the patient. All charts were reviewed by one researcher and a second researcher reviewed 5% of the charts selected at random. Additional data including patient age, chief complaint, department of positive screen, details regarding social work follow-up, and documentation of other types of abuse in the chart were also extracted from the medical record.

Data analysis

Descriptive statistics of frequencies and proportions for all categorical variables and measures of central tendency for continuous variables were obtained. Abuse experienced by patients were categorized in multiple ways: 1) experiencing any human trafficking as a dichotomous variable; and 2) human trafficking alone, human trafficking and other abuse, or other abuse alone.

Results:

Abuse Risk + HT Tool Positive Screens

During the project period, there were 1,013 positive screenings on the Abuse Risk + HT tool. In total, 898 unique patients had a positive screen, 106 of these patients were screened more than once. A total of 718 screenings were from adults and 295 (29.1%) were minors under the age of 18. A total of 422 positive screens took place in the ED, 121 in psychiatric inpatient units, and 470 in other inpatient units. The average age of adults with a positive screen on the Abuse Risk + HT tool was 43.3 years. The average age of minors with a positive screen on the Abuse Risk + HT tool was 14.8 years.

HT Questions on Abuse Risk + HT tool

Of the 1,013 positive screenings, 336 (33%) screenings were positive for at least one of the human trafficking questions in the Abuse Risk + HT tool. These 336 screenings were associated with a total of 303 unique patients. In about 44% of these positive screenings, the social work team documented meeting with the patient to discuss the positive screen on the Abuse Risk + HT tool. In contrast, in 43% of these positive screenings, social work only documented a discussion regarding transportation or vague discharge planning with the patient. There was no documentation by social work or the provider regarding the positive screen. In about 13% of these positive screenings, there was no documentation of social work follow-up with the patient. Of all positive screenings to the HT questions, 24.7% (n=83/336) screened positive only on at least one of the three HT questions and had a negative screen on all other questions in the Abuse Risk + HT tool.

Documentation Highly Concerning for HT with Positive HT Screen

Of the 303 unique patient screenings with a positive screen for the HT specific questions, there were 25 screenings (20 adults, 5 minors) who had documentation highly concerning for HT exploitation. For the remaining 278 screenings, documentation was either incomplete or too vague to determine if the patient was exploited by trafficking. Of the 25 screenings with documentation highly concerning for HT exploitation, there were 20% (n=5/25) of these patients who screened positive only on one of the three HT questions and had a negative screen on all other questions in the Abuse Risk + HT tool. For those screenings with documentation highly concerning for HT (n=25), 17 were exploited by sex trafficking, and for 8 the trafficking type was unable to be determined. The average age of adults was 30.5 and the average age of minors was 15 years.

The most common chief complaint among those who had a positive screen on the HT questions and had documentation highly concerning for trafficking was related to mental health which accounted for 72% (n=18/25) of the chief complaints. The next highest chief complaint categories included assault and substance use, both of which were the chief complaints for 8% (n=2/25) of the screenings. The remaining screenings had chief complaints categorized as neurological, trauma/injury, other, and not listed. One screening had a chief complaint that fell under both categories of assault and mental health.

Similarly, among those with documentation highly concerning for HT who had a positive screen on the HT questions (n=25), the HT question receiving the most positive screens was, “Are you being abused or threatened in your work or home environment?” Four of these screenings had a positive screen for all three human trafficking questions. The age range of these 25 patients with documentation highly concerning for HT exploitation was 13–48 years old, and the average age was 27.4 years old. Within this cohort, 84% (n=21) of these screenings were among females and 16% (n=4) were males.

Documentation Highly Concerning for HT with Negative HT Screen

Eleven screenings (6 adults, 5 minors) had documentation highly concerning for human trafficking but did not screen positive on any of the HT questions on the Abuse Risk + HT tool. The age range of these patients was 14–37 years old, and the average age was 21.9 years. Almost three-quarters (n=8/11) presented with psychiatric complaints and the other 3 screenings presented with chief complaints categorized as cardiac (n=1) and other (n=2). Documentation for these screenings indicated that all were exploited by sex trafficking. All except for one screening (n=10/11) had a positive screen to the non-HT question, “Have you suffered any injury as a result of abuse in the past year?” and six of these screenings had a positive screen for additional non-HT questions as well. Graph 1 is a representation of all unique patient screenings of adults and minors who had documentation highly concerning for HT.

Graph 1. Adults and Minors (<18) with documentation highly concerning for HT.

Of all positive screens on the Abuse Risk + HT tool, there were 83/1013 patients who only answered yes to the HT questions in the tool and screened negative on all other questions. Graph 2 is a representation of all patients who screened positive on the Abuse Risk + HT tool.

Graph 2. All patients with positive screen for Abuse Risk + HT tool.

Discussion:

This study suggests that the addition of three HT questions to create the Abuse Risk + HT tool aided in the identification of patients affected by human trafficking compared to the previous Abuse Risk tool that did not have the HT specific questions. As highlighted in Graph 2, there were five screenings with documentation highly concerning for HT that would presumably not have been identified via screening without the addition of the three HT questions. Among the 303 unique patients who had a positive screen on any of the HT questions in Abuse Risk + HT tool, there were 278 patients who did not have documentation regarding the review of the abuse screen. Due to lack of documentation, we are unable to determine their risk of HT beyond answering yes to the question, but it is possible that an unknown percentage were also being exploited.

There are several possible explanations for lack of concrete documentation of trafficking. One important reason is the use of trauma informed documentation. The healthcare worker may choose to limit documentation if there is concern that someone else may have access to the medical record or if there is concern that harm could come to the patient due to documentation of the trafficking in their medical record. Other potential reasons for lack of documentation include but are not limited to the following: patient declining to see social work, limited social work resources at time, healthcare system challenges, and patients declining to comment further on the screening questions.

The Abuse Risk + HT tool is a mandatory screening at our facility for inpatients and Emergency Department patients that prompts a social work consult for positive screens; other tools such as the Greenbaum Child Sex Trafficking tool only screened high risk patients which may result in certain presentations being less likely to prompt members of the healthcare team to suspect trafficking or question the patient about their social situation (Kaltiso et al., 2018). Though the vast majority of our screenings with documentation highly concerning for HT presented with chief complaints known to be “high risk” for human trafficking (i.e., psychiatric, substance use, and assault), there were a few screenings who had a chief complaint pertaining to a neurological problem or trauma/injury. Similarly, the RAFT screening tool was not mandatory, only patients who met certain criteria were screened (Chisolm-Straker et al., 2021). The results of this project convey the importance of unbiased universal screening for human trafficking for all patients, regardless of their chief complaint or medical profile.

This study also underscores the importance of education concurrent with screening tools when it comes to identifying persons affected by human trafficking. Research on the intersection of human trafficking and healthcare, supports the use of screening tools. The Greenbaum Tool had a sensitivity of 92% and specificity of 73% and similarly, the RAFT tool was validated with a sensitivity of 100% and specificity of 61% (Chisolm-Straker et al., 2021; Kaltiso et al., 2018). Additionally, a study by Mumma et al. showed that screening for human trafficking was more sensitive than provider suspicion alone (Mumma et al., 2017). Despite the efficacy of screening methods, studies show that a multidisciplinary approach inclusive of formal HT education, as well as universal screening is more beneficial than a screening tool alone so that patients with negative screens don’t fall through the cracks unidentified (Marcinkowski et al., 2022). In this project, there were 11 screenings with documentation highly concerning for HT who did not have a positive screen on the HT questions in the Abuse Risk + HT tool. These patients may have been missed if there was sole reliance on the HT questions in the screening tool.

Additionally, there may be overlap between the HT specific questions and abuse questions. An interesting finding from this study was that the most answered non-HT question among those who screened positive on the Abuse Risk + HT tool and had documentation in their chart highly concerning for trafficking exploitation was, “Have you suffered any injury as a result of abuse in the past year?” This highlights some of the nuances in determining active versus past trafficking experiences as that question is geared more to the past and the HT questions are focused on the present. It may be the case that these patients are not actively trafficked but have had recent prior trafficking experiences. While the question, “Does your partner/boyfriend or girlfriend ever try to control you by threatening you or your family?” might indicate intimate partner violence, it may also indicate trafficking. This demonstrates the importance of follow-up to determine the appropriate resources and response to the positive screen.

Finally, this project shows the difficulties with screening in general. There were 106 patients who were screened multiple times over the project period. Among these patients, there were inconsistencies on whether they received social work follow-up and if they shared information about trafficking to social work across the different encounters. The purpose of the Abuse Risk + HT tool is to identify trafficked persons and subsequently provide resources. The lack of social work documentation in 13% of the screenings associated with a positive screen on the Abuse Risk + HT tool demonstrates the need for further evaluation into systems solutions that improve documentation, increase social work resources, and empower healthcare workers to provide support to patients who screen positive.

Limitations

The main limitation of this study is the lack of validation. An external validation study was not conducted for this research project and the questions in the Abuse Risk + HT tool are not validated. Another limitation of this study is the retrospective design. In this project the standard for identifying trafficked persons for whom there is concern for human trafficking exploitation is based upon provider or social work documentation in the medical record. Thus, any variability in documentation or incomplete documentation may have impacted this study’s results. One example of this is the protection of Sexual Assault Nurse Examiner notes within the medical record. These notes are not visible in the electronic medical record which makes it possible that there might be individuals who screened positive in the Abuse Risk + HT tool and are highly concerning for trafficking but did not have the documentation in their chart to indicate that due to these protections. If this was the case, our results would have fewer screenings with documentation highly concerning for HT than truly occurred in the population. Along similar lines, with the rise in trauma-informed documentation, information regarding concern for trafficking or exploitation may not have been explicitly documented in the chart. It is important to also consider the role that psychosocial factors such as shame, fear, and distrust have in a individual’s disclosure of trafficking. Individuals whose charts were reviewed in this study may have not felt comfortable disclosing this information, and in some cases, may not have even realized their exploitation.

Like many emergency departments across the country, the emergency department in this study is affected by boarding, extended wait times, and patients examined in curtained and hallway spaces. As a result, some patients leave after triage and are never screened, and other patients may be placed in a space where it is more challenging to ask abuse screening questions. These factors may influence the generalizability of our results to all emergency department patients.

Future Directions

One of the advantages of this study was that the screening questions for human trafficking were added to an already existing mandatory Abuse Risk tool. According to The Joint Commission, every hospital is required to “use written criteria to identify patients that may be victims of physical assault, sexual assault, sexual molestation, domestic abuse, or elder or child abuse and neglect” (The Joint Commission, 2022). Thus, it may be feasible for hospitals without HT screening to use or adapt the HT screening questions utilized in this project and include them in their current screening protocol. Finally, future directions for this specific project could further investigate why in some instances where there was a positive screen, there was a lack of documented follow up by social work or another provider.

Recommendations for Further Research

Further research studies should be conducted to validate the screening tool implemented in this project. Validated screening tools such as the Greenbaum Tool and RAFT screening tools could be included in a comparison study with the tool implemented in this study to determine differences in outcomes between the tools. It may also be beneficial to research whether there is a need for a specific screening tool that contains only validated human trafficking questions or if existing abuse screening tools can be adapted to include questions on human trafficking to reduce the burden of mandatory screening on nursing staff.

While this screening tool was administered in the inpatient and ED setting, further research projects could implement this screening tool in the outpatient setting as well. Within this study there was a patient for whom an outpatient provider documented concern for human trafficking and the desire to screen for HT, but never did. Later, this patient had a positive screen on the human trafficking questions in the Abuse Risk + HT tool while inpatient. This demonstrates the need for universal screening for human trafficking in both inpatient and outpatient settings

Implications for Clinical Forensic Nursing Practice

Literature suggests that individuals affected by human trafficking are often seen by healthcare professionals during the period of trafficking, and screening tools may effectively identify HT (Chisolm-Straker et al., 2021; Kaltiso et al., 2018). Though multiple screening tools have been validated for HT identification, none are designed for both minor and adult patients. The tool in this study screened minors and adults for HT, included the combination of HT and general abuse questions, and is part of a mandatory screening process. A combined tool such as the one employed in this study may lessen the workload of nursing staff by decreasing the number of mandatory screenings whilst increasing identification of patients of all ages affected by various forms of abuse. Additionally, the utilization of a HT screening tool that is mandatory provides nursing staff with an unbiased objective assessment that may result in increased effective identification of human trafficking and allow nursing staff to better provide informed care for their patients affected by HT.

Conclusion:

Based on these results, the addition of three HT questions to create the Abuse Risk + HT tool resulted in an increase in the identification of individuals exploited by HT in this hospital setting when compared with the existing Abuse Risk tool that did not have the three HT questions. While many screenings were positive on the non-HT questions in the Abuse Risk + HT tool, approximately 20% of screenings that were found to have documentation highly concerning for trafficking were positive for the HT specific questions only and may not have been identified without these additional questions. This demonstrates the importance of comprehensive screening tools that include questions designed specifically to identify human trafficking.