New ICD-10 codes will help shift the paradigm from criminal justice to a public health perspective, but further research is needed on the costs of human trafficking.
On Oct. 1, new ICD-10 codes will go into effect to document conditions that result from forced labor and sexual exploitation, otherwise known as “human trafficking.” Adoption of these codes by the Centers for Disease Control and Prevention attests to the significance of trafficking as a public health issue and the need to gather data on its prevalence and cost.
Because most victims of human trafficking seek medical care at some point, healthcare professionals are in a key position to provide them not only with medical treatment but also with information and other forms of support. But if the victimization is overlooked while focusing on the medical condition, both the underlying problem and its costs remain hidden.
What is Human Trafficking?
According to the HHS Office on Trafficking in Persons, “Human trafficking is a form of modern slavery. It occurs when a trafficker exploits an individual with force, fraud, or coercion to make them perform commercial sex or work.” Trafficking comes in two forms:
Labor trafficking. Individuals are compelled to work or provide services by force, fraud, or coercion.
Sex trafficking. Adults are compelled to engage in commercial sex by force, fraud, or coercion. Minors are compelled to perform a commercial sex act regardless of the presence of force, fraud, or coercion.
Either type of trafficking is a criminal law violation (22 U.S. Code §§ 7101-7114 Trafficking Victims Protection and various state laws), but more than that it is a public health issue that affects not only the victims but also their families and communities. One recent study estimated that sex trafficking was an $810 million industry annually in San Diego County alone. Unfortunately, many clinicians and healthcare leaders are unaware of the problem, and the cost to the nation’s healthcare system because of repeated emergency department (ED) or clinic visits, sexually transmitted diseases, and mental health issues is incalculable.
After pointing out that the United States is one of the world’s largest markets for human trafficking, The Joint Commission states, “If staff at your healthcare organization have not yet encountered a human trafficking victim, very likely they will.” In fact, public health experts assert, those staff almost certainly have already seen a patient who is a trafficking victim without realizing it. Thus, it is important for all healthcare professionals to know how to identify and support these patients.
How to Recognize Human Trafficking
One might suspect human trafficking when, for example, there are inconsistencies in the patient’s story; a controlling individual accompanies the patient; the patient fears being arrested; or there is concern about harm coming to the family if abuse is reported. Other indicators include malnutrition, abnormal behavior such as reluctance to cooperate with a physical exam, or tattoos or insignia indicative of ownership.
The National Human Trafficking Hotline lists nearly two dozen potential indicators of trafficking. The presence of red flags should prompt the healthcare professional to consider further assessment and to embark on a multi-disciplinary, patient-centered response.
See related tool: Potential Red Flags Indicating Human Trafficking
How to Respond to Human Trafficking
Human trafficking situations are as diverse as human nature and the laws vary from state to state, so there is no one-size-fits-all approach. For example, adults cannot be forced to report the crime, and clinicians’ reflexive responses to contact law enforcement can be counterproductive if patients or families have been threatened. (In the case of minors, reporting is likely to be mandatory under state law, but even then, the report must be made with due regard for the possible negative consequences.)
The best response reflects national and state legal requirements, respects patient autonomy, provides necessary health services, educates patients about their options, and empowers them to seek assistance.
Numerous organizations have resources to assist in developing such a response. One is HEAL Trafficking, a “group of multidisciplinary professionals dedicated to ending human trafficking and supporting its survivors from a public health perspective.” HEAL provides a detailed Protocol Toolkit that describes how to develop organization-specific policies and procedures.
According to HEAL’s executive director, Hanni Stoklosa, “Using the protocol will help emergency departments, hospitals, clinics, private offices, or school-based health centers respond appropriately to human traffickingsituations.” She stresses the need to shift from a criminal justice paradigm that is focused on prosecutions to a public-health approach that emphasizes care and prevention and involves a wide variety of professionals and local organizations.
Caution About Documentation
A co-founder of HEAL Trafficking, Makini Chisolm-Straker emphasizes the need for caution in documentation. “While the ICD-10 codes and thorough documentation are useful from a public health and data gathering perspective, if the exploiter sees the details—on a bill or discharge paperwork, for example—it could put the patient in danger.”
The Protocol Toolkit echoes Chisolm-Straker’s concerns:
Because of the complexity of medical-legal issues around HT [human trafficking] cases, and great variation in state and local laws, guidelines for optimal documentation practices … should be developed in consultation with local prosecutors, defense attorneys, and advocates. Depending on the legal climate, entering more or less information in the patient’s chart can either be harmful or helpful.
The toolkit cites a few examples:
- In some states, a patient with HIV seropositivity could be prosecuted for transmitting the virus.
- A patient coerced to sell sex may still be charged with prostitution in some states.
- Sensitive information might not be redacted during legal proceedings depending on whether the state has a “rape shield” law and, if so, whether it applies to trafficked persons. (A rape shield law limits a defendant’s ability to introduce evidence about the complainant’s past sexual behavior.)
- Information gathered in the forensic examination, including photographs, may sometimes be shared with a defense attorney and even with the traffickers themselves, and the patient may be re-traumatized by a display of the photographs and other information.
These and other considerations augur for a careful balance of the need for information with medical-legal discretion. Consultation with local attorneys familiar with privacy and rape shield laws is strongly advised.
A Sample Protocol
As an example of a hospital system’s protocol, Stoklosa cites Dignity Health, a Catholic health system that operates hospitals in three western states. Dignity Health’s Human Trafficking Response Program “ Share Learnings Manual” was developed “to ensure that trafficked persons are identified in the healthcare setting and assisted with victim-centered, trauma-informed care and services.” The document contains background information on the issues (including a discussion of myths surrounding human trafficking), suggestions for educating staff and the community, procedures for acute-care facilities and clinics, sample forms, and other useful material.
Direct Patient Services
An example of direct patient care services is the University of Miami Miller School of Medicine’s multidisciplinary medical clinic called THRIVE. In cooperation with Jackson Health System, the clinic is a medical home that specifically addresses the needs of human trafficking survivors. According to its website, the THRIVE clinic is unique in Florida and one of only a handful of such models in the country. They offer multidisciplinary, multicultural primary care, gynecological care, psychiatric and behavioral health services, and specialty care services, all in one location. (A few similar clinics are listed in the resources section, and there may be others.)
There are numerous action steps that healthcare organizations should undertake to address human trafficking. Some of the more salient ones are as follows:
- Begin immediately to train coding professionals about the new ICD-10 codes (they take effect on Oct. 1). Use of the codes will enable collection of important data on the cost and prevalence of trafficking and will allow policy makers to devise solutions to improve community health.
- Do a literature search—beginning with the resources listed below—for information that will form the basis of a curriculum to educate all staff who interact with patients.
- Educate all clinical staff on red flags and actions to be taken.
- After Oct. 1, ensure that when possible confirmed and suspected trafficking cases are documented using the new codes (while giving due regard to possible safety and medical-legal ramifications).
- Identify interested community resources, both public and private, and solicit their cooperation and advice.
- Invest “community benefit” funds toward anti-human trafficking efforts.
- Create a task force or working group within your organization to develop protocols, policies, and procedures, including procedures for documentation, external reporting, forensic examinations, and dealing with minors.
- Determine whether there are relevant laws in your state (e.g., California requires EDs and urgent care centers to post a notice about human trafficking).
Human Trafficking Healthcare Delivery
Human trafficking is a global public health problem, and the United States is not immune from its effects. Because healthcare providers frequently encounter patients who are human trafficking victims, it is incumbent on them to be prepared to serve these patients and to document their treatment using the new ICD-10 codes when possible. Only through greater awareness and research will the extent of the hidden problem be revealed and its costs made known.
HEAL Trafficking. HEAL’s various committees assist with direct clinical services, education and training, various technologies, the Protocol Toolkit, and research reports. HEAL offers various education and training resources including a listing of materials from other organizations and a whitepaper describing the essential components of training for health care professionals
Dignity Health, Human Trafficking Response Program Shared Learnings Manual
Isaac, R.; Solak, J.; and Giardino, A. P., ” Health Care Providers’ Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene,” Journal of Applied Research on Children: Informing Policy for Children at Risk: Vol. 2: Iss. 1, Article 8, 2011
Lee, C., and Stoklosa, H., “ The role of health systems in combating human trafficking,” Hospital CFO Report, Becker’s Hospital Review, June 29, 2018
Quick Safety 42: Identifying human trafficking victims , The Joint Commission, June 16, 2018
Factsheet: ICD-10-CM Coding for Human Trafficking , American Hospital Association
Combatting Human Trafficking, American Hospital Association
Institute on Healthcare and Human Trafficking, Children’s Healthcare of Atlanta has education materials and an extensive list of resources on all types of human trafficking
National Human Trafficking Hotline offers background information, statistics, and resources
U.S. Department of State, Annual “ Trafficking in Persons Report”
Adult Human Trafficking Screening Tool and Guide , Health and Human Services Office on Trafficking in Persons
University of Miami Miller School of Medicine, THRIVE Clinic
Organizations offering services for patients who are human trafficking victims:
- The PurpLE Clinic, New York City
- Baystate Health, Family Advocacy Center, Springfield, Massachusetts
- Baylor College of Medicine Anti-Human Trafficking Program
J. Stuart Showalter, JD, MFS, is a contributing editor for HFMA
Interviewed for this article:
Hanni Stoklosa, MD, MPH, is executive director of HEAL Trafficking, Inc., and emergency physician at Brigham and Women’s Hospital, Harvard Medical School, Boston.
Makini Chisolm-Straker, MD, MPH, is a co-founder, treasurer, and interim research committee chair, HEAL Trafficking, Inc., Boston, and assistant professor, Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Brooklyn, N.Y.