![ACA and Trafficking
The Affordable Care Act has changed the way
that people access health services, especially for
women and people with low to moderate
income levels, as they are more likely to have
health insurance. Some important changes that
may help victims of trafficking: are (1) domestic
violence screenings; (2) access to contraceptives;
(3) access to mental health care; (4) and
substance abuse treatment. The ACA mandates
that insurers cover the cost of domestic violence
screenings and brief counseling, at no cost to
the patient. Women have better access to long-
acting reversible contraceptives (LARCs) with
no co-pay, and victims of violence and trauma
can access mental health services and substance
abuse treatments that were previously
unaffordable to them.
Treatment and Patient Education
Nearly half of sexually exploited women report becoming pregnant, and 42% of those in the US give birth while in
exploitation;10 thus it is important to offer education and provide information about LARCs and other forms of birth control
that are less susceptible to sabotage.11 The high risk for STIs also makes it incredibly important to provide support, education
(including HPV vaccination as age-appropriate) and screening for STIs if abuse or sex work is suspected.
Screening and Referrals
The ACA requires that certain preventative services are provided to
insured patients with no cost-sharing. Screening for intimate partner
violence (IPV) is one such service and has been included since 2012.12
In recent years, screening rates for IPV by healthcare providers have
been reported to be around 7%.13 It is important to increase screening
rates, as this can improve detection of both IPV and human
trafficking. Evidence suggests that patients will not disclose abuse
unless asked, and 80% of victims of IPV will disclose when
screened.14 Multiple research studies have found that even the
addition of a single screening question administered during primary
care visits increases IPV detection rates from less than 0.5%15 to 7.5%-
11.6%.16,17,18
Recommendations
Use a screening tool to assess your patients’ safety. We have attached
one developed with local resources in mind, but if there is one that
you are already familiar with, use what is comfortable to you and
your patients.
Always screen in private. If there is a third party present to
translate or oversee, do anything you can to ensure privacy, and
wait to ask questions about exploitation or unexplained injuries/trauma until you are alone with the patient
Avoid mentioning law enforcement, as some may be less likely to disclose—especially victims who are undocumented or
have a history of arrests
If a patient discloses trafficking or you have a strong suspicion, call the human trafficking hotline—but never in the
patient’s presence
Ask permission before providing documents or information sheets that mention violence or trafficking—they can
compromise the safety of a victim if their abuser knows that someone else is aware of the situation
If the victim wants help, you can call other provider agencies in the area, but they will often want to talk to the victim
Clinical Signs and Symptoms
Unexplained, repeated injuries; signs of abuse or torture5
Patients with no documentation or who are not able to speak
for themselves [someone may insist on speaking for them]6
Chronic or untreated STIs, vaginal or rectal trauma; UTIs,
pelvic pain, infertility (may be due to untreated STIs or unsafe
abortions)7
Dental problems, cracked or broken teeth, head, neck, or
facial injuries
Disease or infections due to unsanitary conditions8
Substance use/abuse
Confusion about time/date/location due to frequent moves,
changing schedule (especially if involved in forced
prostitution)
Psychological trauma, PTSD, TBI, panic attacks9
“Branding” with tattoos; cigarette burns
ANY minor in the sex industry—they are unable to provide
legal consent](https://image.slidesharecdn.com/22cd4b5f-bb26-4b8d-94a0-631d7fb24e29-161007053348/85/HT-final-2-320.jpg)
HT final
- 1. Defining Trafficking Human Trafficking (HT), as defined by the United Nations Office on Drugs and Crime, is “the acquisition of people by improper means such as force, fraud or deception, with the aim of exploiting them.”1 Trafficking can present as labor trafficking or sex trafficking. Labor trafficking may happen in restaurants, nail salons, agricultural settings, travelling magazine crews, factories, construction sites, or domestic servitude (child care or housework). People trafficked for sex may be involved in prostitution, pornography, dancing, massage parlors (fronts for brothels) or “mail order brides.” No force, fraud or coercion is necessary to prove the trafficking of a minor. Risks Trauma is the most widely studied risk factor for domestic trafficking of minors (DMST), and childhood sexual abuse is the strongest correlate.2 Other risk factors include contact with the child welfare system or the juvenile justice system. Poverty and homelessness are additional risk factors that can make people vulnerable to trafficking, especially if they come from family environments that normalize transactional sex.3 Many of the victims we assist in the area have been trafficked by their partner—this is domestic violence with a financial motive—and something that is being observed by service providers with increasing frequency. The Role of Healthcare Providers It is important that healthcare providers recognize the role they can have in in responding to victims of HT and working to prevent further harm. Traffickers often use isolation as a tactic to further control their victims; preventing them from seeing family and friends, accessing needed services or completing tasks independently. However, it is estimated that 28-50% of people who experience trafficking will see a healthcare provider while still in captivity;4 it may be that a visit to a doctor is the victim’s first opportunity for services. Victims often have no health insurance, no access to preventative health care, and may present with many conditions as a result of being trafficked. Most of the victims we see in this area are adult women who have been victims of sex trafficking and as such, may present with signs specific to sexual exploitation. Human Trafficking: What is it, and What Can Healthcare Providers Do? A. Minturn March 2016
- 2. ACA and Trafficking The Affordable Care Act has changed the way that people access health services, especially for women and people with low to moderate income levels, as they are more likely to have health insurance. Some important changes that may help victims of trafficking: are (1) domestic violence screenings; (2) access to contraceptives; (3) access to mental health care; (4) and substance abuse treatment. The ACA mandates that insurers cover the cost of domestic violence screenings and brief counseling, at no cost to the patient. Women have better access to long- acting reversible contraceptives (LARCs) with no co-pay, and victims of violence and trauma can access mental health services and substance abuse treatments that were previously unaffordable to them. Treatment and Patient Education Nearly half of sexually exploited women report becoming pregnant, and 42% of those in the US give birth while in exploitation;10 thus it is important to offer education and provide information about LARCs and other forms of birth control that are less susceptible to sabotage.11 The high risk for STIs also makes it incredibly important to provide support, education (including HPV vaccination as age-appropriate) and screening for STIs if abuse or sex work is suspected. Screening and Referrals The ACA requires that certain preventative services are provided to insured patients with no cost-sharing. Screening for intimate partner violence (IPV) is one such service and has been included since 2012.12 In recent years, screening rates for IPV by healthcare providers have been reported to be around 7%.13 It is important to increase screening rates, as this can improve detection of both IPV and human trafficking. Evidence suggests that patients will not disclose abuse unless asked, and 80% of victims of IPV will disclose when screened.14 Multiple research studies have found that even the addition of a single screening question administered during primary care visits increases IPV detection rates from less than 0.5%15 to 7.5%- 11.6%.16,17,18 Recommendations Use a screening tool to assess your patients’ safety. We have attached one developed with local resources in mind, but if there is one that you are already familiar with, use what is comfortable to you and your patients. Always screen in private. If there is a third party present to translate or oversee, do anything you can to ensure privacy, and wait to ask questions about exploitation or unexplained injuries/trauma until you are alone with the patient Avoid mentioning law enforcement, as some may be less likely to disclose—especially victims who are undocumented or have a history of arrests If a patient discloses trafficking or you have a strong suspicion, call the human trafficking hotline—but never in the patient’s presence Ask permission before providing documents or information sheets that mention violence or trafficking—they can compromise the safety of a victim if their abuser knows that someone else is aware of the situation If the victim wants help, you can call other provider agencies in the area, but they will often want to talk to the victim Clinical Signs and Symptoms Unexplained, repeated injuries; signs of abuse or torture5 Patients with no documentation or who are not able to speak for themselves [someone may insist on speaking for them]6 Chronic or untreated STIs, vaginal or rectal trauma; UTIs, pelvic pain, infertility (may be due to untreated STIs or unsafe abortions)7 Dental problems, cracked or broken teeth, head, neck, or facial injuries Disease or infections due to unsanitary conditions8 Substance use/abuse Confusion about time/date/location due to frequent moves, changing schedule (especially if involved in forced prostitution) Psychological trauma, PTSD, TBI, panic attacks9 “Branding” with tattoos; cigarette burns ANY minor in the sex industry—they are unable to provide legal consent
- 3. NOTES AND ADDITIONAL RESOURCES 1 United Nations Office on Drugs and Crime. (2008). Toolkit to Combat Trafficking in Persons. p. 369. Retrieved from: http://www.ungift.org/doc/knowledgehub/resource-centre/UNODC_Toolkit_to_Combat_TIP_2008_En.pdf 2 Choi, K. R. (2015). Risk factors for domestic minor sex trafficking in the United States: a literature review. Journal of forensic nursing, 11(2), 66-76. DOI: 10.1097/JFN.0000000000000072 3 Ibid. 4 Dovydaitis, T. (2010). Human trafficking: the role of the health care provider. Journal of Midwifery & Women’s Health, 55(5), 462-467. DOI: 10.1016/j.jmwh.2009.12.017 5 Spear, D. L. (2004). Human trafficking. AWHONN Lifelines, 8(4), 314-321. DOI: 10.1177/1091592304269632 6 Ibid. 7 United Nations Office of Drugs and Crime (UNODC), op. cit. 8 Ibid. 9 Ibid. 10 Muftić, L. & Finn, M. (2013). Health outcomes among women trafficked for sex in the united states. Journal of Interpersonal Violence, 28(9), 1859- 1885. DOI:10.1177/0886260512469102 11 Greenbaum, J., Crawford-Jakubiak, J. E., Christian, C. W., Flaherty, E. G., Leventhal, J. M., Lukefahr, J. L., & Sege, R. D. (2015). Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics,135(3), 566-574. 12 U.S. Department of Health and Human Services, Family Violence Prevention and Services Program. (2013). The affordable care act & women’s health. Retrieved from: http://www.acf.hhs.gov/sites/default/files/fysb/aca_fvpsa_20131211.pdf 13 Oehme, K., & Stern, N. (2014). The case for mandatory training on screening for domestic violence in the wake of the affordable care act. U. Pa. JL & Soc. Change. 17, 1. Available at: http://scholarship.law.upenn.edu/jlasc/vol17/iss1/1 14 Todahl, J., & Walters, E. (2011). Universal screening for intimate partner violence: A systematic review. Journal of Marital and Family Therapy, 37(3), 355-69. 15 Freund, K. M., Bak, S. M., & Blackhall, L. (1996). Identifying domestic violence in primary care practice. Journal of General Internal Medicine, 11, 44-46. 16 Morrison, L. J., Allan, R., & Grunfeld, A. (2000). Improving the emergency department detection rate of domestic violence using direct questioning. Journal of Emergency Medicine, 19, 117-124. 17 Shattuck, S. R. (2002). A domestic violence screening program in a public health department. Journal of Community Health Nursing, 19(3), 121- 132. 18 Todahl & Walters (2011). op. cit. The CDC has a handbook of IPV screening tools available with reliability and validity measurements included for some of the tools. If you would like to learn more about these tools, the handbook can be accessed here: http://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf This issue brief was created by Annabelle Minturn, a BSW student at the University of Kansas and Human Trafficking Program Intern at the Willow Domestic Violence Center. Questions and comments may be directed to aminturn@wtcskansas.org