Sex trafficking is an under-recognized public health issue. The percentage of sex trafficking survivors who interact with healthcare providers (HCP) varies across studies, with the highest being 87.8% (N=98) (Byrne, Parsh, & Ghilain, 2017; CdeBaca & Sigmon, 2014; Lederer & Wetzel, 2014). Literature agrees that HCP represent an integral connection to the world of sex trafficking. Those who are trafficked may visit a variety of health care settings “for disorders affecting nearly every organ system” (Byrne, Parsh, & Ghilain, 2017, p. 50), from private offices and independent clinics to emergency rooms to large, public medical facilities (CdeBaca & Sigmon, 2014; Lederer & Wetzel, 2014; Ross et al., 2015). Unfortunately, literature reveals a discrepancy between sex trafficking survivors’ level of exposure to HCP and HCP level of awareness. A study by Lederer and Wetzel (2014) concludes that 87.8% (N=98) of survivors who had interacted with healthcare professionals were neither identified nor offered assistance. In another study, approximately 78.3% (N=613) of staff members across 10 hospitals in England reported insufficient training in assisting trafficked persons (Ross et al., 2015). Though educational resources are available to healthcare professionals, very few studies evaluate the effect of the education on behavior outcomes (Ahn et al., 2013; Egyud, Swanson-Bierman, Stephens, & Whiteman, 2017; Powell, Dickins, & Stoklosa, 2017).
The literature suggests an ongoing need among healthcare providers for education on sex trafficking. Thus, the purpose of this project is to equip nurses to identify and care holistically for the adult sex-trafficked population. Raja et al. (2015) describe the elements that compose TIC. Patient-centered communication lays the foundation. Though healthcare interactions may cause all patients a measure of anxiety, survivors of trauma may be particularly susceptible (fearing powerlessness, bodily exposure, touch, etc.). Taking time to explain procedures, creating space for questions, and asking how to make the patient more comfortable may help mitigate these anxieties. A second aspect of TIC is a working understanding of the health effects of trauma. The nurse must consider that trauma affects all areas of a person’s wellbeing (Raja et al., 2015). Neurobiological studies confirm that exposure to severe stressors, as in the case of sex trafficking, directly affects brain structures and hormone levels. Trauma impairs the prefrontal cortex, which governs logical thinking, encodes memories, and directs attention. It also sensitizes the amygdala, which assists in emotional learning, sympathetic nervous system initiation, and memory regulation. Trauma can chronically activate the hypothalamus-pituitary-adrenal axis, leading to blood vessel damage, coronary disease, and insulin resistance. Over time, the brain becomes more vulnerable to stressors, and the traumatized individual becomes trapped in a vicious cycle (Levine, 2017; Raja, Hasnain, Hoersch, Gove-Yin, & Rajagopalan, 2015; Wilson, Lonsway, Archambault, & Hopper, 2016). Instead of labeling a patient based on the patient’s condition, the nurse must consider the possibility that the patient’s presenting symptoms and affect stem from trauma. These responses, when reframed, demonstrate creativity, self-preservation, and determination (Substance Abuse and Mental Health Services Administration, 2014). Thirdly, as Raja et al. (2015) note, TIC involves interprofessional collaboration. Though the individual nurse certainly ought to partner with the patient and impart dignity, the nurse should have a list of references available for patients who disclose trauma. This gives the patient access to resources beyond the nurse’s scope of knowledge. A fourth aspect of TIC involves the nurse’s understanding of personal trauma history and reactions. Without this self-awareness, the nurse may avoid addressing patient trauma, so as not to retrigger feelings. Alternatively, the nurse may experience compassion fatigue. Either way, care is compromised; self-awareness is key to providing effective care. Raja et al. (2015) denote screening as the final aspect of TIC. Fear of repercussions, shame and stigma, inability to pay for services, and judgmental treatment by HCP may all deter an individual from disclosing a trafficking situation (Hachey & Phillippi, 2017). Thus, the nurse must know how to identify cases. According to the National Human Trafficking Hotline (n.d.), some indicators of sex trafficking include restrictions on activity; involvement in the commercial sex industry; exhibition of fearful, anxious, submissive, or tense behavior; avoidance of eye contact; signs of malnourishment and abuse; inability to speak for oneself in the presence of a controlling individual; loss of sense of time; and numerous inconsistencies in story. The patient may also have a history of substance abuse and sexually-transmitted diseases (Lederer & Wetzel, 2014). With an established understanding of trauma and a practical knowledge of indicators, the nurse is equipped to care holistically for survivors of sex trafficking.
There lies much potential in the application of trauma-informed care to sex trafficking survivors. There also exists a tremendous gap in literature, especially regarding the effectiveness of implementation. Thus, application-driven research is recommended. The National Human Trafficking Resource Center (2016) has developed an algorithm for recognizing and responding to trafficking in the healthcare setting. One project might evaluate HCP behavior outcomes post-implementation of this algorithm. Another project might evaluate short-term and long-term behavior outcomes of HCP who have received TIC training specific to sex trafficking. Though difficult to obtain, interviews of sex trafficking survivors receiving TIC services may also yield valuable insights. The acronym “CARE” represents a series of recommendations for the individual nurse: (a) consider personal perspectives on trauma, (b) assess for signs of sex trafficking, (c) recognize trauma as a possible underlying cause of symptoms, and (d) endorse the implementation of standardized TIC screening assessment tools. Equipped individuals have the potential to effect change at both personal and organizational levels, bringing transformation to entire communities.
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