Psychiatrists’ Response to Human Trafficking: An Update

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This article is an update to "Psychiatrists’ Response to Human Trafficking."

Human trafficking is defined as using force, fraud, or coercion to compel a person into commercial sex acts or labor against their will.¹ Minors involved in commercial sex are always considered trafficked under US federal law. The Action-Means-Purpose (AMP) Model illustrates the definition of human trafficking (Table 1).² In 2020, the National Human Trafficking Hotline received more than 10,000 reports of trafficking in the US.³ From 2016 to 2021, the number of trafficked individuals worldwide rose by 12%, now numbering over 27.6 million individuals.⁴

Table 1. The Action-Means-Purpose (A-M-P) Model²

Traffickers utilize manipulation, grooming, deportation threats, debt, and emotional, financial, physical, and sexual abuse to control their victims, who often face threats against themselves or their families.⁵ Most individuals do not identify or recognize their situation as trafficking until they exit. It is therefore difficult for trafficked persons to “just leave” their situation.

Most recent data on human trafficking trends in the US, especially since the COVID-19 pandemic, reveal a significant increase in online recruitment and the proportion of individuals recruited by family members and intimate partners.³ While anyone can be trafficked, certain persons have heightened vulnerabilities to become trafficked, including those with disabilities, mental illness, substance use issues, unstable housing, financial instability, criminal record or history, and marginalized groups such as recent migrants, runaway youth, 2S-LGBTQIA+, and ethnic/racial minority communities.³

Trafficked persons endure psychological and medical consequences that are complex and long-lasting. Health care systems, including inpatient psychiatric units, can be vital for appropriate identification, intervention, and referral.⁶ Amongst those with lived trafficking experience, men, those with substance use disorders, and those discharged to temporary housing arrangements are more likely to have readmissions to inpatient psychiatry units.⁷ One study found that among persons with substance use disorders, alcohol and cannabis were frequently utilized, as well as polysubstance use, and recommended broad screening for substance use and a low threshold for referral to specialty services for trafficked individuals.⁸

Trauma-informed care involves appreciating the impact of the trauma sustained by the patient and understanding that it influences how persons with trafficking experience engage with service providers and authority figures.⁹ While looking for general indicators (ie, red flags) and utilizing objective assessment tools can help identify human trafficking, approaching the patient in a trauma-informed manner and listening to their story, provides a better understanding of their trafficking history. Providing unbiased training on human trafficking to mental health professionals, with accurate portrayals of trafficked individuals, can also improve prompt identification.⁶

A multidisciplinary approach, including psychiatric care, is pivotal in continuously assessing and treating trafficked individuals’ health and psychosocial needs. Validated assessment tools for health care settings exist for suspected minor victims of sex trafficking but not adults. The Rapid Appraisal for Trafficking (RAFT) tool, a 4-item questionnaire, has shown good sensitivity compared with long, existing, resource‐intensive assessment tools in the emergency department; however, additional multicenter studies are required (Table 2).¹⁰

Table 2. The RAFT 4-Item Assessment Tool¹⁰

The National Human Trafficking Hotline (NHTH) is available to physicians, health care providers, and patients to report confirmed or suspected trafficking, obtain guidance on the next steps of care, and access social and legal resources. It is available 24 hours, seven days a week, and can be reached by dialing 1-888-373-7888 or texting “HELP” or “INFO” to SMS 233733. Additionally, the National Human Trafficking Training and Technical Assistance Center (part of the Department of Health and Human Services)¹¹ provides training for health care providers through its SOAR online portal and access to publications, such as the 2021 Report: Core Competencies for Human Trafficking Response in Health Care and Behavioral Health Systems.¹²

Case Example

“Mr Lopez” is a 44-year-old man with a history of hypertension and diabetes mellitus type 2 who presented to the medical emergency room with headache, dizziness, nausea, dehydration, and weakness. Due to metabolic abnormalities secondary to dehydration and heat exhaustion, he was admitted to the inpatient medical floor.

On the second day of hospitalization, psychiatry was consulted after the primary team noticed Mr Lopez was dysphoric and tearful. On psychiatric evaluation, Mr Lopez was evasive, guarded, and unwilling to share personal information. Daily follow-up helped Mr Lopez to become more open and trusting towards the team. He reported anxiety, insomnia, anhedonia, decreased concentration, helplessness, hypervigilance, and nightmares that started around 6 months ago after he migrated to the US.

Due to his status as an “undocumented” migrant, job opportunities were limited, and he found an employer who offered him payment, food, and housing on a fruit farm. The farm was secluded, and housing was unsanitary and crammed with multiple workers. He described his work duties as highly demanding and noted that he had not been paid despite months of work. When he raised this issue with the employer, Mr Lopez was threatened with deportation, physical violence, and longer work hours.

The psychiatry team educated Mr Lopez on human trafficking and referred him to a social worker and case manager for housing referral and a psychologist for psychotherapy. He followed up with outpatient psychiatry monthly to treat symptoms of posttraumatic stress disorder. As a result of his hospitalization, he benefited from mental health and medical services within a safe and multidisciplinary environment.

Future Directions

Health care professionals across different specialties, especially psychiatrists, need education and training on human trafficking, including the need for person-centered, culturally humble, trauma-informed care.¹³ Mental health clinicians are urged to utilize trauma-informed care to listen to their patients, build trust, address safety concerns, empower decision-making and agency, and eliminate biases when working with patients suspected of being trafficked. Developing partnerships between health care disciplines, community partners, and survivor advocates are essential to creating and maintaining a human trafficking response protocol while increasing outreach efforts.

Dr Alhajji is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. Dr Munoz is a PGY-4 Psychiatry Resident at the University of Miami Miller School of Medicine/Jackson Memorial Health System. Dr Padilla is a Consultation-Liaison Psychiatry Fellowship Program Director, and an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine. Dr Rovner is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine.

References

1. What is human trafficking? Homeland Security. Accessed January 11, 2023. https://www.dhs.gov/blue-campaign/what-human-trafficking

2. The Action Means Purpose “A-M-P” Model: Polaris Project. National Human Trafficking Hotline. 2012. Accessed January 11, 2023. https://humantraffickinghotline.org/sites/default/files/AMP%20Model.pdf

3. Analysis of 2020 National Human Trafficking Hotline Data. Polaris. Accessed January 11, 2023. https://polarisproject.org/2020-us-national-human-trafficking-hotline-statistics/

4. International Labour Organization; Walk Free; International Organization for Migration. Global estimates of modern slavery: forced labour and forced marriage. September 2022. Accessed January 11, 2023. https://www.ilo.org/wcmsp5/groups/public/@ed_norm/@ipec/documents/publication/wcms_854733.pdf

5. 2021 Trafficking in Persons Report. US Department of State. September 14, 2021. Accessed January 11, 2023. https://www.state.gov/reports/2021-trafficking-in-persons-report/

6. Babu J, Boland GM, Salami T. Accurate identification and prosocial behaviors towards human trafficking victims among psychology students. Journal of Human Trafficking. 2022;1-15.

7. White CN, Robichaux K. Factors related to psychiatric hospital readmission for survivors of human trafficking. Journal of Human Trafficking. 2022;1-12.

8. Koegler E, Wood CA, Johnson SD, Bahlinger L. Service providers’ perspectives on substance use and treatment needs among human trafficking survivors. J Subst Abuse Treat. 2022;143:108897.

9. Lanehurst A, Gordon M, Coverdale J, et al. Integrating trauma-informed care into clinical practice with trafficked persons. Bull Menninger Clin. 2022;86(Supplement A):44-55.

10. Chisolm‐Straker M, Singer E, Strong D, et al. Validation of a screening tool for labor and sex trafficking among emergency department patients. J Am Coll Emerg Physicians Open. 2021;2(5):e12558.

11. SOAR Online. National Human Trafficking Training and Technical Assistance Center. Accessed January 11, 2023. https://nhttac.acf.hhs.gov/soar/soar-for-individuals/soar-online

12. Report: Core Competencies for Human Trafficking Response in Health Care and Behavioral Health Systems. National Human Trafficking Training and Technical Assistance Center. Accessed January 11, 2023. https://nhttac.acf.hhs.gov/resource/report-core-competencies-human-trafficking-response-health-care-and-behavioral-health

13. Alhajji L, Hadjikyriakou M, Padilla V. Psychiatrists’ response to human trafficking. Psychiatric Times. 2021;38(12):67-70.