Healthcare Provider Training and Education
Training of health care providers in the identification of trafficked persons is severely lacking. One study that surveyed 168 health care professionals in Wisconsin, found that 63% of the respondents had never received such training. Of those surveyed that had received training, 68% worked in an urban setting (Beck, 2015). Educational programs to train healthcare providers have expanded greatly in the last several decades. Although many training programs and resources are available, most lack any evidence of effectiveness, have not been published in the peer-reviewed literature, and very few have examined behavior changes as a result of training and education (AHN, 2013). Many organizations offer continuing education credits for completion of their programs, but many of these offer credit for simply reading or reviewing trafficking-related resource material and completing post-test assessments. Some educational resources use pre-test and post-test assessments to evaluate the impact of the trainings on the provider’s knowledge and self-efficacy in handling suspected trafficking incidents. However, most studies lack rigorous evaluation designs and only a few have examined whether these education materials and trainings are effective in enhancing clinical practices or improving identification, treatment and referral of victims in the long term. One study randomized 20 of the largest emergency departments in the San Francisco Bay area into an intervention consisting of a standardized presentation of human trafficking or a delayed intervention comparison group. Findings indicate that educational interventions can increase provider knowledge of human trafficking and the identification of who to call when encountering a human trafficking victim. This study also demonstrated that those receiving education on human trafficking were more likely to suspect their patients were victims of human trafficking than those in the delayed intervention group (Grace, 2014).
Researchers indicate that human trafficking education is highly variable and there is a need to build a body of evidence-based programs for health professionals (Powell, 2017). Moreover, a greater understanding of how best to introduce training, establish the format for trainings, and tailor training for various healthcare audiences is needed. Additional rigorous evaluations of existing educational resources are needed including an assessment of content validity and effectiveness in impacting clinical outcomes. These training programs and educational resources are critical to changing the way healthcare providers identify, assess, and refer trafficking victims. Training in and of itself, however, is not sufficient for healthcare organizations to have an impact. Healthcare organizations must also develop supportive policies and procedures that are tailored to their context and environment.
Screening
Although many screening instruments and protocols exist, few have been validated. A review of the literature revealed only six studies published in the peer-reviewed literature that examined the feasibility or validity of human trafficking identification within a healthcare setting between 2010 and 2019. Table 2 shows the population, type of trafficking, and medical setting that the six articles evaluated. Validity is measured using sensitivity and specificity. Sensitivity or the true positive rate measures the proportion of those screening positive for human trafficking and are actual human tracking victims. Specificity or true negative rate measures the proportion of those screening negative for human trafficking and are not human tracking victims.
Table 2: Human Trafficking Studies Evaluating Feasibility and Validity
| Author, Year, and Title | Population (adult, youth, or both) | Type of Trafficking (labor, sexual, or both) | Medical setting |
| Egyud (2017) Implementation of Human Trafficking Education and Treatment Algorithm in the Emergency Department | Both | Both | Emergency department |
| Greenbaum (2018a) A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting | Youth | Sexual | Pediatric emergency department and child protection clinic |
| Greenbaum (2018b) Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings | Youth | Sexual | Emergency departments, child advocacy centers, and teen clinics |
| Mumma (2017) Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program | Adult | Sexual | Emergency department |
| Kaltiso (2018) Evaluation of a Screening Tool for Child Sex Trafficking Among Patients With High-Risk Chief Complaints in a Pediatric Emergency Department | Youth | Sexual | Pediatric emergency department |
| Raj (2019) Incorporating Clinical Associations of Domestic Minor Sex Trafficking Into Universal Screening of Adolescents | Youth | Sexual | Primary care clinic |
Table 3 displays the items used in the various studies. The number of items in most human trafficking screening questionnaires varies from seven to 17. One study used the
Department of Health and Human Services Screening Tool for Human Trafficking to identify both labor and sex trafficking (Egyud, 2017). Another study used similar items, to screen for sex trafficking. The remainder of the surveys included questions that were specific to sex trafficking. The following section describes each of these studies (Mumma, 2017).
Table 3: Human Trafficking Screening Questions
| Study | Question Items |
| Egyud, 2017 | 1. Can you leave your job or situation if you want? 2. Can you come and go as you please? 3. Have you been threatened if you try to leave? 4. Have you been physically harmed in any way? 5. Describe your working or living conditions. 6. Where do you sleep and eat? 7. Do you sleep in a bed, on a cot, or on the floor? 8. Have you ever been deprived of food, water, sleep, or medical care? 9. Do you have to ask permission to eat, sleep, or go to the bathroom? 10. Are there locks on your doors and windows so you cannot get out? 11. Has anyone threatened your family? 12. Has your identification or documentation been taken from you? 13. Is anyone forcing you to do anything that you do not want to do? |
| Kalitso, 2018 | 1. Have you ever broken any bones, had any cuts that required stitches, or been knocked unconscious? 2. Some kids have a hard time living at home and feel that they need to run away. Have you ever run away from home? 3. Kids often use drugs or drink alcohol, and different kids use different drugs. Have you used drugs or alcohol in the past 12 months? 4. Sometimes kids have been involved with the police. Maybe for running away, for breaking curfew, for shoplifting. There can be lots of different reasons. 5. Have you ever had any problems with the police? 6. Added question for transition into sexual history: Have you ever had sex of any type? (penis in vagina or penis/finger in “butt” or mouth on penis or mouth on vagina) 7. How many sexual partners have you had? 8. Have you ever had a STI, like herpes or gonorrhea or chlamydia or trichomonas? |
| Greenbaum, 2018a | 1. Have you been to see a nurse, doctor or other health provider in the last year? 2. Have you ever broken any bones or had any cuts that needed stitches? 3. Have you ever been knocked unconscious (“knocked out”)? 4. Have you ever run away from home or been ‘kicked out’ of your home? 5. Have you used drugs or alcohol in the last 12 months? 6. If yes, do you remember how old you were when you first tried alcohol or drugs? 7. Have you ever had any problems with the police? 8. Has a boyfriend or girlfriend in a dating or serious relationship ever physically hurt you or threatened to hurt you (hit, pushed, kicked, choked, burned or something else)? 9. Have you ever had sex of any type? 10. If yes, when you had sex, what did it involve (vaginal, anal, oral) 11. Since the first time you had sex, how many partners have you had? 12. Which of the following best describes you? (Heterosexual (straight), Homosexual (Gay or Lesbian), Bisexual, Transgender, Not sure 13. Have you ever had any sexually transmitted infections, like herpes, gonorrhea, chlamydia or trichomonas? 14. Have you ever traded sex for money, drugs, a place to stay, a cell phone, or something else? 15. Has a boyfriend, a girlfriend or anyone else ever asked you, or forced you to have sex with ANOTHER person? (If asked, did you have to actually do it?) 16. Has anyone ever asked or forced you to do some sexual act in public, like dance at a bar or a strip club? (If asked, did you have to actually do it?) 17. Has anyone ever asked you to pose in a sexy way for a photo or a video? (If asked, did you have to actually do it?) |
| Greenbaum, 2018b | 1. Is there a previous history of drug and/or alcohol use? 2. Has the youth ever run away from home? 3. Has the youth ever been involved with law enforcement? 4. Has the youth ever broken a bone, had traumatic loss of 5. consciousness, or sustained a significant wound? 6. Has the youth ever had a sexually transmitted infection? 7. Does the youth have a history of sexual activity with more than 5 partners? |
| Mumma, 2017 | 1. Do you have to ask permission to eat, sleep, use the bathroom, or go to the doctor? 2. Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened or made to feel physical pain for working slowly or for trying to leave? 3. Has anyone threatened your family? 4. Is anyone forcing you to do anything that you do not want to do? 5. Do you owe your employer money? 6. Does anyone force you to have sexual intercourse for your work? 7. Is someone else in control of your money? 8. Are you forced to work in your current job? 9. Does someone else control whether you can leave your house or not? 10. Are you kept from contacting your friends and/or family whenever you would like? 11. Is someone else in control of your identification documents, passports, birth certificate, and other personal papers? 12. Was someone else in control of arrangements for your travel to this country and your identification documents? 13. Do you owe money to someone for travel to this country? |
| Raj, 2019 | 1. History of childhood maltreatment 2. History of running away or truancy 3. History of child welfare (i.e., child protective services [CPS]) involvement 4. History of sexually transmitted infection (STI) 5. History of recurrent STIs (i.e., ≥2 times) 6. History of substance use 7. History of self-harm 8. History of suicidal ideation 9. History of psychiatric diagnosis 10. Public or private insurance |
A 2017 study by Egyud and colleagues tested a multi-pronged approach to identify human trafficking victims in a level two trauma center in a southwestern Pennsylvania community hospital (Egyud, 2017). First, they initiated screening at the registration desk, where staff looked for signs of human trafficking (no insurance, offer to pay cash, no personal identification, no guardianship documentation, or a patient who is with a person who does all of the talking). If registration staff identified these signs or a patient answered yes to existing questions on a domestic violence survey, the emergency nurse completed the Department of Health and Human Services Screening Tool for Human Trafficking (Egyud, 2017).
In addition, a silent notification system was implemented by placing signs in the bathroom and asking potential victims to place a blue dot on their specimen cup. The blue dot would alert staff to ensure that the patient was in a safe area when answering the screening questionnaire. Screening could also be triggered if emergency nurses or physicians noticed common physical health symptoms such as urinary tract infection, pelvic or abdominal pain, suicide attempt, or psychogenic nonepileptic seizures during the health assessment (Egyud, 2017).
The implementation of this multi-pronged screening approach was measured for five months. Study findings indicated that the screening protocols were adhered to with a 100% compliance. The process yielded a total of 38 potential trafficking victims. Medical red flags identified 20 patients, and the silent notification process identified 18 patients. Intervention and rescue were offered to all patients identified as possible victims. Four (11%) of the adults accepted help, and one minor received mandatory intervention because of child abuse laws. Three of the five victims who accepted interventions were identified by nurses or physicians through their physical examination. One victim was identified through the blue dot identification process. There were 17 other patients who placed blue dots on their urine specimen and were assumed to be victims but changed their minds once they were questioned by a health care provider. The validity of the screening questionnaire was not measured (Egyud, 2017).
Mumma and colleagues assessed the validity and feasibility of a 14-item survey and an independent physician’s personal assessment among 143 females aged 18-40 years visiting the emergency department. A positive screen was defined as having a “yes” answer to any question on the survey or having physician concerned about trafficking. Of those enrolled, 27% screened positive including 10 females who were ultimately identified as a sex trafficking victim. The survey’s sensitivity was 100% compared to the physician’s assessment of 40%. Conversely, the physician’s assessment had greater specificity (91%) than the screening survey (78%). All of those who were determined to be trafficking victims answered yes to at least one question on the screening survey (Mumma, 2017).
Kalitso and colleagues assessed sex human trafficking screening methods among a convenience sample of adolescents (10-18 years old) visiting a pediatric emergency department for complaints related to high-risk social or sexual behaviors in an urban area (Kalitso, 2019). The study evaluated the sensitivity and specificity a six-item screening questionnaire. A positive screen was defined as answering “yes to at least two items on the questionnaire. An adolescent was classified as a true trafficking victim if any information during the visit confirmed that their circumstances met the federal definition of child sex trafficking. The study enrolled 203 adolescents, and 49% screened positive on the questionnaire. The total number of adolescents who met the federal definition of child sex trafficking was 11 (5.4%). The study found a sensitivity of 90.9% and a specificity of 53.1% for adolescents who answered “yes” to at least two items of the screening questionnaire. They also found that among those who screened positive for child sex trafficking, 10% were determined to meet the definition of sex trafficking by federal standards (Kalitso, 2019).
Greenbaum and colleagues tested the validity of screening items of a child sex trafficking and exploitation screening instrument among adolescents aged 12 to 18 years, who visited three metropolitan pediatric emergency departments or a child protection clinic (Greenbaum, 2018a). Adolescents were classified as suspected child sex trafficking victims if information obtained by the medical provider indicated a high likelihood that the youth had been a victim of sex trafficking based on the definitions of the United Nations and the Institute of Medicine (UNODC, 2004; Diaz, 2014). This information came from a variety of sources (e.g., law enforcement, medical records, parents, other informants, or the youths themselves). Greenbaum and colleagues examined the sensitivity of various cutoff scores for the six-item screen among 108 participants: 25 were classified as victims of human trafficking and 83 as victims of acute sexual abuse, but not victims of child sex trafficking. The authors found that a cut-off score of two positive answers from the screening instrument yielded a sensitivity of 92%, and a specificity of 73%. They reported that half (51%) of adolescents who indicated a “yes” on at least two items on the screening instrument, were classified as having a high likelihood of child sex trafficking (Greenbaum, 2018a).
In another recent study, Greenbaum and colleagues tested the validity of a 10-item screening instrument among 810 adolescents aged 11 to 17 years old visiting one of 16 healthcare settings that included five pediatric department, six child advocacy centers, and five teen clinics (Greenbaum, 2018b). Criteria included being between 11 and 17 years of age, speaking English and, in the emergency department sites only, presenting with a chief complaint sexual abuse, abuse, or child sexual trafficking. Exclusion criteria included refusing to answer questions.
An adolescent was classified as being a victim of child sex trafficking based on the healthcare provider’s opinion. Overall 11.1% (n=90) were classified as victims of child sex trafficking based on the healthcare provider’s opinion. This classification varied by type of healthcare facility and included 13.2% of patients visiting emergency departments, 6.3% at child advocacy clinics, and 16.4% at teen clinics. A positive screen was defined as answering “yes” to two or more items on the screening survey. Overall, authors reported a sensitivity of 84.44% and specificity of 57.50% among the overall sample. One in five adolescents who screened positive on the survey were classified as child sex trafficking victims based on the healthcare provider’s opinion. While the sensitivity of this screening instrument did not vary significantly by the type of setting, the specificity and positive predictive value varied by setting type. The specificity for the emergency departments, child advocacy clinics, and teens clinics were 49.4%, 61.4%, and 64.6%, respectively. The number of adolescents screening positive out of those who were classified as being sex trafficking victims (positive predictive value) was 20.0%, 12.8%, and 26.8% from the emergency departments, child advocacy clinics, and teens clinics, respectively (Greenbaum, 2018b).
The most recent study identified was a 2019 study conducted by Raj and colleagues (Raj, 2019). They compared 36 female patients who were confirmed to be involved in domestic minor sex trafficking with 148 female patients with no domestic minor sex trafficking involvement. Classification of confirmed cases was based on self-disclosure or law enforcement evidence. The females in both groups ranged in age from 11 to 18 years of age, with an average age of 15.6 years of age. The two groups of patients were assessed and compared using a set of screening items taken from medical records. The individual items were assessed for sensitivity, specificity, and likelihood ratio. The sensitivity of the items ranged from 28% (for recurrent sexually transmitted infections) to 89% (for substance abuse). Other variables that had high sensitivity were evidence of runaway or truancy (83%), history of child maltreatment (83%), and a history of psychiatric diagnosis (78%). The specificity of the items ranged from 62% to 95%. Most variables exhibited a specificity of greater than 80% (substance use, runaway or truancy, self-harm, history and recurrence of sexually transmitted infections, child protective services involvement, and suicidal ideation). History of a psychiatric diagnosis exhibited a specificity 62%. The likelihood ratios of the items ranged from 2.1 to 7.3. They found that the items with the highest likelihood ratios were substance use (7.3), runaway or truancy history (6.2), history of self-harm (5.6), and history of sexually transmitted infection (5.4) (Raj, 2019)