Human trafficking and exploitation: guidance for health workers

When you suspect someone has been trafficked

Trafficked persons may be unlikely to disclose their situation on their first contact with services due to their fears and lack of trust. Their recall of events may change due to this and the trauma they have experienced. Be aware that it could take someone a number of meetings before they feel safe to disclose their experiences.

Recognise that the defining features of trafficking – the lack of control and the unpredictability – make it important that they aren't further disempowered. Encourage them to participate in decisions.

The following approach is adapted from good practice recommendations^[10].

• Be trauma-informed in your approach. Be sensitive to possible indications of trauma e.g. hypervigilance, mistrust, anxiety, numbing, dissociative state. Respond non-judgementally and reassuringly.
• Do not rush the consultation. They may have some cognitive impairment as a consequence of the abuse and may find it difficult to remember details or make decisions.
• Be sensitive to possible fear of contact with statutory agencies – they may have been told that they will be deported
• Avoid calling authorities such as police or immigration services unless you have the informed consent of the patient or where the threat of danger to the patient or others is such that you need to do so

Broach the subject sensitively through gentle questioning around their health and living circumstances. Below are some examples that can be adapted depending on the individual's health condition:

• 'You look very pale. Can you tell me about your diet? What have you eaten over the last week? Last month?'
• 'You are coughing a lot. I need to know about your home situation. Can you tell me about your home and bedroom? Are you sharing with others?'
• 'Were you injured while working?' 'Can you tell me about your work and how you were injured?'
• 'Is this the first time or do you have other injuries?'
• 'Can you leave your job or situation if you want?' 'Have you been threatened or harmed in any way?'
• 'Is anyone forcing you to do anything you don't want to do?'

Assess the impact on the patient's health and ensure they receive appropriate treatment. Good practice guidelines recommend conducting a thorough physical examination given the multiple health problems experienced by victims. This includes:

• Full medical history
• Questions around head trauma, eyes/ears/nose and throat
• Respiratory, cardiovascular, gastro-intestinal, muscoskeletal and neurological history questions
• Dermatological and nutritional queries
• If possible, assess the mental health of the patient or refer for an assessment if you have concerns

For victims, or suspected victims, of sexual violence:

• Ask about any history of rape or other sexual trauma
• Treat any immediate physical or medical conditions and ascertain whether or not the patient wishes to report this to the police. Self-referral for a forensic medical examination without having to report to the police allows victims to have forensic evidence stored in case they wish to report at a later date. Currently, this is only available at Archway, which covers the West of Scotland, and in Dundee but there is ongoing work to develop a national self-referral service. Check with your Health Board to find out local arrangements.
• Limit invasive examination and assess the need for further testing e.g. for STIs, pregnancy (for further guidance refer to: What Health Workers Need to Know About Commercial Sexual Exploitation and What Health Workers Need to Know About Rape and Sexual Assault, NHS Scotland)

Assess safety:

• Is there an immediate or future safety risk? In cases of immediate danger – can you contact other agencies?
• Do they want you to contact the police? Does the level of threat require you to take action?

Discuss the options available with the patient and offer to contact a First Responder on their behalf if they wish. Advise of agencies that can help:

• TARA will help women in situations of commercial sexual exploitation and assist them to access other support services including access to safe accommodation
• Migrant Help will provide support to all other adult victims of trafficking and exploitation, including men who have been sexually exploited and all adult victims of slavery, servitude and forced or compulsory labour
• The Anchor Centre (Greater Glasgow and Clyde NHS, Glasgow Psychological Trauma Service) provides specialist mental health services to people who present with Complex Post-Traumatic Stress Disorder following complex traumatic events including human trafficking
• ARCHWAY rape and sexual assault service will support all victims of recent sexual violence in the Glasgow and Strathclyde area (further services are detailed in the Resources section)

Depending on the degree of freedom they have, it may not be possible to access these services on their own or to follow aspects of a safety plan. Discuss whether more assistance is needed to contact other agencies.

Offer a further appointment. A health appointment may be one of the few occasions where they are allowed some freedom of movement. This may provide the opportunity to access further help.

It is vital that the trafficked person decides what course of action to take.

Where you are concerned that they won't come back

• Maximise your encounter with the patient
• Offer as much information as possible about their health condition and treatment. Ensure they know they can access health services freely
• Provide information on support services. Ensure this is discreet and safe e.g. provide helpline numbers on paper that can be hidden in clothing
• If applicable and possible, provide a complete regimen of prescribed medication in that single encounter – assuming they will not return for follow-up treatment and assessment

Documenting and recording

Keep accurate and detailed records.

Record the following:

• Nature of health problem, with details of any injuries and symptoms and any concerns you may have
• What the patient says and not what you think, although it is important to note any concerns or suspicions
• Outcome of risk assessment
• Any action taken or advised

Sharing information

You may need to share information about a particular case. It may be required by law or it may be necessary to share information with support agencies to make sure that a trafficked person is safe and properly supported. This is not automatic, however, and there may be a risk of deterring such people from seeking medical attention if their request for confidentiality is not respected. Reporting information may also endanger their safety if traffickers can trace it back to them.

It may be the case that there are local arrangements for providing intelligence on crimes such as human trafficking which allow for anonymised information to be shared with the police, for example, alerting them to the possibility of forced labour in certain areas. It is crucial, however, that in passing on this intelligence the safety of the individual is maintained.

There are circumstances where information may be shared without a patient's consent. For example, if there is a threat of imminent danger to them or others, or if doing so may prevent or support the investigation of a serious crime. Balancing responsibility for patient confidentiality against disclosure in the public interest requires careful consideration. The decision to share information without consent needs to be considered on an individual case basis with regard both to the law and the particular circumstances of the case. Discussion with a senior colleague or line manager is of paramount importance in this instance.

Case study

A young woman attended ER accompanied by an older woman. She could not speak English and presented as poorly nourished, withdrawn and nervous. The older woman was well dressed and wanted to accompany her throughout the consultation. The attending registrar was concerned about her but the young woman denied anything was wrong when the registrar asked. The registrar noted her concerns in the case notes and highlighted her suspicions about the safety and welfare of the young woman. Some months later, the young woman became pregnant and was referred to a specialist midwifery service. Alerted by the registrar's notes, the service asked the young woman about her situation and she disclosed that she was a victim of trafficking. The service referred her to TARA and continued to provide care throughout her pregnancy. She and the child are now safe and supported.

You must, of course, make sure that you comply with all your legal requirements.

It is good practice to:

• Get the patient's permission before you pass on information and seek advice if you are in any doubt
• Ensure that the information shared is proportionate and limited to the relevant details
• Make the patient aware, if possible, of the need to share information when they do not wish you to do so
• Avoid divulging confidential information by accident, for example, if you are approached by someone saying they are a relative or support person of the individual
• Be guided by your professional code of conduct on confidentiality and information sharing, and your organisation's protocols
• Seek guidance from senior colleagues identified by your Board who can advise on the appropriateness of sharing information with the police in accordance with national directives^[26]
• Record a clear account of the decision making process involved when sharing information

There may be a local multi-agency protocol on trafficking in your Board area which will provide further guidance on information sharing.

Duty to notify

When a potential adult victim of trafficking does not wish to be referred to the NRM, the Human Trafficking and Exploitation (Scotland) Act 2015 provides for a duty on specified Scottish public authorities to notify Police Scotland about anyone they suspect may be a victim of trafficking. This is to aid intelligence gathering and information relating to the adult should be anonymised unless they have consented to sharing personal information. As of October 2019, the NHS has yet to be confirmed as a specified public authority. In the event the NHS does have a duty to notify, there will be arrangements put in place to guide you on this. In all cases you should discuss any concerns with your line manager and Board Lead for Human Trafficking.

Follow-up

Your intervention will depend on the setting you work in. You may only see the person once, for example, in an emergency setting. If possible, it is helpful to offer a follow-up appointment. Always consider their safety and how any approach you make might affect this.