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Physical and mental health symptoms in a trafficked person are often intertwined, in particular during the acute period during or immediately after the trafficking situation. Somatic symptoms without a clear organic cause are not uncommon but require thorough assessment to ensure that underlying organic causes are not missed. In trafficked persons, their many symptoms often intersect with – and are exacerbated by – post-traumatic reactions. Somatic and behavioural symptoms related to a history of trauma may include anorexia, chronic fatigue, chronic headaches, chronic pain, dizziness, emotional numbness, hostility, hyper-arousal, hyper-vigilance, irritability, lack of motivation, memory problems, poor concentration, reexperiencing traumatic events and sleep disorders. These post-traumatic symptoms contribute to the overall poor health status of trafficked persons (see action sheets 1 and 12).
Medical assessments of trafficked persons should be conducted based on the guiding principles (see chapter 3) and using the techniques described for trauma-informed and patient-centred care (see action sheets 1 and 2).
Confidentiality and privacy are of the utmost importance in cases involving trafficking. The history and exam should take place alone with the patient (i.e., with health provider and chaperone when necessary, but with no other accompanying persons). Note that in cases where a referral has been made from a support service to a medical clinic or where a clinic has ‘patient advocates’ or ‘cultural mediators24’ available, it is desirable to have these type of support persons at health encounters, particularly first encounters. As discussed, persons who have been trafficked are likely to mistrust others and find it difficult to express their concerns with new professionals. While some patients may state that they prefer their partner or family member to stay, it is crucial to have some private time with the patient, who may be scared to ask the accompanying party to leave the room. It may be necessary to state that it is the clinic’s policy to see all patients individually and in private at some point during the visit, in order to afford everyone the same kind of privacy.
Wolffers, I. et al., “Migration, human rights, and health”, The Lancet, vol. 362, no. 9400, 13 December 2003, pp. 2019-2020.
Hjermov, Birgit, Cultural Mediation at the Workplace – an Introduction, 2004.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSRequIRed ACTIonS Goals for the clinical encounter • Create a safe space for the patient where care is individualized, supportive, non-judgmental and integrated (see action sheets 1 and 2).
• Describe to the patient the reasons for the exam, how the exam will be conducted, how the results will be communicated and who will have access to the results.
• Conduct a comprehensive health assessment, because this clinical encounter may be the only contact the trafficked person has with the health care system (e.g., individual may return to the trafficking situation, may be in detention or in transit). This includes a thorough and systematic review of symptoms, a careful ‘head to toe’ exam and appropriate laboratory testing, recognizing that trafficked persons present with conditions that are co-morbid with other complex and chronic disorders (see action sheet 5 for specific considerations when examining children and adolescents).
• Focus the clinical encounter as much as possible on those medical problems identified by the patient. Questions that simply serve the curiosity of the provider are not appropriate.
• If possible, receive training in mental health assessment and/ or have access to a mental health provider to offer a detailed assessment necessary to identify specific mental health diagnoses and treatment needs. The impact of traumatic experiences on patients’ symptoms, adherence to treatment and outcomes cannot be overstated (see action sheets 1 and 12).
• Try to ensure that there is a consistent, certain and secure communications mechanism to inform patients of the results of any testing and a convenient means for patients to receive ongoing care, including preventive care.
• Confirm that patients are connected to resources and services to address multiple needs whenever possible, including food, shelter, legal advocacy, mental health support, education and job skills development, which are all crucial to the health, safety and well-being of trafficked persons (see action sheet 10).
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The thorough, systematic review of symptoms
While many vague somatic concerns, chronic pain and fatigue may not have an underlying organic cause, when conducting an initial medical assessment you must have a high degree of suspicion that organic conditions exist. Resist the urge for premature closure of the patient encounter. This means avoiding quick conclusions about the causes of a patient’s complaints without conducting a thorough evaluation of presenting symptoms. For example, a headache may be connected to distress or depression, or may be a result of a blow to the head.
You may become frustrated with patients who have been trafficked, because their reporting of events or symptoms seems vague. In the context of multiple traumatic experiences, poor recall of details is not uncommon.
Recognize that an unclear or inconsistent history does not mean that the patient is being obstructionist or difficult, but may instead reflect the patient’s reactions to abuse and violence.
In addition to the review of symptoms that is a standard of care among providers of Western medicine, the following outlines some additional
history questions to include in the assessment:
Poor oral health is a major co-morbid factor in poor general health and malnutrition.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS• Chronic diarrhoea? Constipation? Visible parasites in stool?
The first two symptoms may be related to mental health (see action sheet 12).
Genitourinary • Forced sex, or sexual trauma that includes foreign objects?
• Enuresis or encopresis (a potential result of sexual abuse)?
Musculoskeletal • Repetitive and non-repetitive work-related injuries?
• History of physical abuse such as burns? Contractures?
• Vitamin D deficiency?
neurological/behavioural • Seizure activity (may also need to consider pseudo-seizures)?
• Sleep disorders (inability to fall asleep, frequent awakenings, nightmares)?
• Any history of head trauma?
nutrition • Any nutritional deficiencies (food intake, content)?
• Disordered eating (e.g., anorexia or bulimic behaviour)?
dermatological • Scabies, lice, scant or fine hair (may indicate a nutritional deficiency)?
• Burns (e.g. cigarette burns, scalds from hot water)?
• Impetigo and fungal infections?
Conducting a patient-centred physical exam
Conduct a careful, complete physical exam from head to toe. All physical injuries must be documented, and when appropriate, through photo documentation. As is the case with all victims of violence and torture, describe the exam that will be conducted before a patient undresses and then explain each step of the exam as you carry it out, always giving the patient the option to refuse at any point. It is useful to warn the patient about procedures that may be invasive or potentially painful.
Patients may not always tell you all of their complaints or respond to questions honestly out of fear, mistrust or shame. Be vigilant to look for signs of other medical conditions that were not mentioned in the medical history.
In addition, be aware that the physical exam may trigger flashbacks in some patients. This may involve the patient ‘zoning out’ (appearing to be in a different place and not responding to questions), hyperventilation
62 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSand near-syncope. It may be helpful to explain before proceeding with the examination that it may cause the patient to recall prior victimization, and then to check regularly about the well-being of the patient throughout the exam. For example, some trafficked persons may have been exploited through pornography, so particular care should be taken if it is necessary to photograph lesions.
If the medical assessment might be used for prosecution, and in particular, if evidence collection is necessary to prove assault (particularly rape), a specially trained health provider should carry out a forensic exam.
Given the difficulties of good evidence collection and the challenges of avoiding re-traumatizing patients, a clinic with several providers may want to designate one provider to receive additional training in counselling and examining victims of sexual assault and collection of forensic evidence, depending on the procedures and laws of your country. In particular, providers examining children should have additional training in child abuse evaluations, including strategies for taking a child’s medical history and documentation (see action sheets 5 and 12). When appropriate, and according to local laws
and procedures, collect minimum forensic evidence:
Sexual trauma and reproductive health (see action sheet 13 for more details) While human trafficking does not always involve sexual exploitation, in many locations women and children, who are commonly subject to sexual violence when trafficked, make up a significant portion of trafficking cases.
• Where medically indicated, perform a thorough pelvic exam for women who have been trafficked and a genital (including anal) exam for men, if the patient consents. Offer patients the option of having a provider of the same sex if they prefer and of having a professional chaperone in the exam room. In some cases, the patient may never have received an internal exam and it is therefore especially important to explain procedures, step-by-step.
• Include detailed questions about reproductive and sexual health in the medical history.
• Follow up any external or internal evidence of trauma found during the physical exam with laboratory testing. Collect samples (urine, cervical, anal) to test for sexually transmitted infections.
• Offer testing for pregnancy as well as HIV and other sexually transmitted infections when laboratory capability allows.
Offer appropriate pre-test counselling and a specific followup plan for notifying and counselling patients about results.
This should include treatment planning and appropriate referrals if testing is positive. Offer presumptive treatment for sexually transmitted infections as indicated.
Trafficked individuals are often subject to severe restrictions in their movement and constraints in their access to food. Their access to fresh produce, intake of adequate protein and minerals and exposure to the sun (for vitamin D) may be severely limited, depending on the type of exploitation.
Histories of substance abuse, often co-occurring with other clinical problems, compound the problem of poor nutrition. It is therefore necessary to take a detailed history of nutritional intake as well as look for evidence of nutritional deficiencies (e.g., gum disease, tongue and skin changes) during the physical exam.
64 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSLaboratory testing should include at a minimum a complete blood cell count with mean corpuscular volume. When available, iron count, total iron binding capacity and vitamin B12, folic acid, calcium, phosphorous, and 25-hydroxyvitamin D (25-OH vitamin D) levels may help guide treatment.
Oral health Poor oral health (including caries, gingival disease and abscesses) is a common and often very painful co-morbid factor in the poor health of trafficked persons. Pharyngeal trauma from forced oral sex can further complicate this picture. Poor oral health can contribute to poor nutrition, chronic headaches, disturbed sleep and gastrointestinal problems.
Head injury Among the most common symptoms reported by individuals who have been trafficked are chronic headaches, with many patients describing multiple head traumas associated with loss of consciousness and relaying stories suggestive of concussion and post-concussion syndromes. With chronic headaches, the question of the need for neuro-imaging arises. If resources exist, and when history and exam suggest an intracranial process, head imaging is appropriate. However, a careful history which looks at migraine characteristics – aura, unilateral pain, nausea, photophobia, phono-phobia – and visual changes, seizure activity, loss of coordination and imbalance, as well as a thorough neurological exam are generally sufficient to rule out such significant underlying pathologies as chronic subdural haematomas.
Seizure disorders, pseudo-seizures and dissociation In addition to non-specific symptoms of headaches and dizziness, trafficked persons also report experiences of falling, passing out and not remembering things. In light of the traumatic head injuries that some patients may have experienced, a thorough history and neurological examination are crucial. Specifically, asymmetries in exam, ataxia (e.g., loss of balance or disordered gait) and proprioceptive dysfunction may indicate a serious underlying cause. More often, however, the overall neurologic examination is normal, without evidence of deficits, but the patient continues to have near-syncope or actual falling, sometimes with what appears to be seizure activity (see action sheet 12). Apparent dissociative states and pseudoseizures should first be evaluated for organic causes before assuming that these are post-traumatic reactions.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSOccupational health Trafficked persons may have been exploited for labour in a variety of industries, such as garment factories, meat processing plants, construction, agriculture and domestic servitude.
• Document the types of work performed to help guide diagnosis of injuries.