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CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Special note regarding children: Care for children who have been abused or exploited requires special attention. Apply the above principles to children, including their right to participate in decisions that will affect them. If a decision is made on behalf of a child, the best interests of the child should be the overriding consideration, and appropriate procedures should be followed. UNICEF’s Reference Guide on Protecting the Rights of Child Victims of Trafficking in Europe provides some guidance on these issues and offers additional resources that can be consulted (see references section for more details).
These principles may serve as the basis for rights-based care strategies that recognize the vulnerability of individuals who are in or have emerged from Please see action sheet 16 for special considerations related to competence, capacity, and guardianship.
30 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERStrafficking situations. They are only fully beneficial if they are communicated to all health personnel who might come into contact with trafficked persons and if adherence to the principles is monitored on a regular basis.
Adapted from Zimmerman, C. and C. Watts, WHO Ethical and Safety Recommendations for Interviewing Trafficked Women, World Health Organization, Geneva 2003.
ACAction Sheet 1:
TION Trauma-informed care
RATIonAle Many individuals who have been trafficked will have experienced life-threatening or traumatic events prior to, during and sometimes after the trafficking experience. In addition to suffering from violence that is obvious because of physical injuries, trafficked persons may also sustain less evident health problems resulting from abuse.
This action sheet focuses on a central framework for the care of trafficked persons that acknowledges the impact of these traumatic experiences.
The goal in caring for trafficked persons is to ensure that all care is:
• adapted to the individual’s needs;
• supportive and avoids judgmental statements or actions;
• integrated and holistic, treating the trafficked person as a whole person, not just a list of clinical symptoms;
• empowering, ensuring that the patient’s rights to information, privacy, bodily integrity and participation in decision-making are respected;
• supportive of healing and recovery through a patient-centred treatment plan.
Trauma-informed care involves recognizing the impact of traumatic experiences (specifically, a range of violence that may include abuse prior to the actual trafficking experience) on an individual’s life and behaviour, and on their perceptions of themselves and their bodies.16 Trafficked persons often present with a constellation of symptoms and disease conditions (see Harris, M. and R.D. Fallot, “Envisioning a trauma-informed service system: a vital paradigm shift”, New Directions for Mental Health Services, vol. 89, Spring 2001, pp. 3-22 and Elliott, D. et al., “Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women “, Journal of Community Psychology, vol. 33, no. 4 (special issue on ‘Serving the needs of women with co-occurring disorders and a history of trauma’), July 2005, pp. 461-477.
34 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSaction sheets 4, 5, 11, 12, 13 and 15) that are influenced by these traumatic experiences. Hypervigilance around being examined, mistrust of health care providers, anxiety about sitting in a waiting room full of other people and fear of medical procedures may all be related to the abuses experienced while being trafficked. Providers of trauma-informed care incorporate into their routine clinical practice an appreciation of how traumatic experiences may affect their patients’ behaviours and perceptions of their bodies and health.
For providers who may only see these patients for brief clinical encounters (e.g., the individual is in transit), a non-judgmental, comforting approach helps to reinforce for the patient that no one deserves to be hurt, and that everyone deserves to be treated with respect. For those providers who have the opportunity to work for more extended periods with trafficked persons, the trauma-informed approach, which acknowledges exposure to violence, can serve to build trust with patients and may facilitate discussing abuse and the trafficking experience.17 Cultural norms, age, education, gender and personal histories influence how trafficked persons express reactions to traumatic experiences; such reactions may include anger, hostility, irritability, self-harm and withdrawal, as well as numbing or dissociative states (see action sheet 12). Notably, reactions to traumatic experiences, presenting symptoms in the clinical setting, and how patients talk about what has happened vary considerably.
This means that there is no simple ‘right way’ to approach all trafficked persons.
Yet, experience suggests that it is useful for providers to empower patients by encouraging their participation and offering information and support throughout the clinical encounter.18 Providers who recognize the intersection of physical and psychological problems in trafficked persons can address medical and mental health needs in an integrated way.
Related to trauma-informed care is the concept of patient-centred care, i.e., care that makes patients central to the decision-making process at all stages of the clinical encounter. The defining features of the trafficking experience are often unpredictability and lack of control over events – particularly abuse and neglect. The loss of personal control over one’s body and actions can have a significant influence on psychological health. It is Chang, J. C. et al., “Asking about intimate partner violence: advice from female survivors to health care providers”, Patient Education and Counseling, vol. 59, no. 2, November 2005, pp. 141-147.
Elliott, D. et al. (2005); Morrissey, J.P. et al., “Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders”, Psychiatric Services, vol. 56, no. 10, October 2005, pp. 1213-1222;
Huntington, N. et al., “Developing and implementing a comprehensive approach to serving women with cooccurring disorders and histories of trauma”, Journal of Community Psychology, vol. 33, no. 4 (special issue on ‘Serving the needs of women with co-occurring disorders and a history of trauma’), July 2005, pp. 395-410.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSimportant for health providers to restore decision-making power to each individual as quickly and supportively as possible. Encouraging patients to participate in decisions throughout the clinical encounter helps prevent disempowering or re-traumatizing individuals who have been trafficked.
To accomplish this, it is necessary to train not only health care providers but also front-desk staff and medical assistants. They should be able to provide empathetic attention to patients’ needs; they should also engage patients as partners in the health care delivery process in an inclusive and respectful manner. When providers encourage patients to participate in the development of the treatment plan, patients are more likely to feel that they are actively participating in their health care and may more likely to adhere to the prescribed treatment.
RequIRed ACTIonSCreating a clinical ‘safe space’
• Aim to provide care in a rights-based environment:
o The clinical environment is welcoming (trained staff and literature available in multiple languages).
o Patients’ rights are communicated clearly, verbally and in writing.
o Patients’ rights are respected at all times (for example, by ensuring systems are in place for protecting the confidentiality of patient files and providing private spaces for taking histories and for the physical exam).
• In order to approach patients from a consistently supportive and empowering stance, staff and provider training should focus on describing the impact trauma may have on people’s behaviours, including ways in which patient’s post-trauma reactions may manifest as anger, irritability and belligerence, or withdrawal and avoidance.
• Every encounter – even with clerical or medical support staff – can have a positive or negative impact on a trafficked person’s health.
• Always strive to do no harm – inadvertent disclosures of trafficking history, breaches of confidentiality, judgmental comments or probing unnecessarily or in an insensitive manner about the patient’s abuse history may contribute to individuals’ mistrust and fear of health care settings. Providers can minimize the potential for re-traumatizing trafficked persons by having well-trained personnel and clear protocols
36 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Trauma-informed care relies on the above principles and actions, which aim to recognise and respond to the potential impact that patients’ past experiences of abuse may have on their health and on their interactions in a health care setting.
RefeRenCeS And ReSouRCeS Chang, J. C. et al.
2005 “Asking about intimate partner violence: advice from female survivors to health care providers”, Patient Education and Counseling, vol. 59, no. 2, November 2005, pp. 141–147.
Clark, H. and A. Power 2005 “Women, co-occurring disorders, and violence study: a case for trauma-informed care”, Journal of Substance Abuse Treatment, vol. 28, no. 2, March 2005, pp. 145–146.
Harris, M. and R.D. Fallot 2001 “Envisioning a trauma-informed service system: a vital paradigm shift”, New Directions for Mental Health Services, vol. 89, Spring 2001, pp. 3–22.
Morrissey, J.P. et al.
2005 “Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders”, Psychiatric Services, vol. 56, no. 10, October 2005, pp. 1213–1222.
38 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Action Sheet 2:
Culturally appropriate, individualized care RATIonAle Men, women and children who have been trafficked are likely to have highly diverse backgrounds, and many social, cultural, economic, ethnic, or linguistic differences. With trafficking occurring on a global scale, people may have been trafficked from various countries and distant regions from where they receive care. Having been isolated and dominated by traffickers, individuals may have little understanding of where they have been while they were exploited and, once in a clinical setting, they may still not know where they are.
Culturally responsive care (also called ‘cultural sensitivity’ or ‘cultural competence’) refers to the provision of care that is attentive to the various ways people from diverse backgrounds experience and express illness and how they respond to care. In addition to language and literacy barriers, styles of communication, levels of mistrust, differing expectations of the health care system, gender roles and traditions and spiritual beliefs all contribute to how a person experiences illness and responds to care.
This action sheet builds on action sheet 1 on trauma-informed care to highlight the particular importance of individualized care that recognises the potential cross-cultural differences in patients’ health and care needs. The guidance provided on culturally-sensitive care should also be considered together with action sheet 3, which focuses on the use of interpreters. Special approaches required for care of children and adolescents are described in action sheet 5.
People’s personal, cultural and socio-economic background, level of education and events that happened to them while in the trafficking situation are very likely to influence their experience of illness and health and their expectations for health care. Individuals who have been trafficked may, for
42 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSexample, have a profound fear of any formal setting, including the health care system. They may also have feelings of shame about being trafficked.
Ignorance about the health care system in the destination location – about their rights to health services and patient confidentiality – commonly compounds people’s fears and reluctance.
Language barriers and limited literacy levels are among the most difficult challenges of patient-provider communication. Language barriers, in particular must be quickly addressed through appropriate interpreting support, because misunderstandings and poor assumptions may contribute to misdiagnoses, poor adherence to treatment and poor outcomes overall (see action sheet 3). When there are significant differences in the backgrounds and knowledge levels of the patients and providers, it may be difficult for patients to relate their concerns and for providers to assess symptoms and needs. In particular, for women who might come from situations where abuse is ‘normalised’, the patient may tend to minimize the severity of her experiences.
Whenever possible, health care staff should receive training in traumainformed care (see action sheet 1) to be able to provide support that recognises that while people may have different expressions of illness and need, they each require care that is non-judgmental, holistic, and patient-centred. As part of this approach, providers – and the clinical settings in which they work – must also be able to provide culturally and linguistically responsive care.