Screening and Documenting Cases of Human Trafficking Are Important, But Carry Risks
By Melinda Young
Human trafficking is a critical issue from a public health perspective. It has lasting psychological and physical effects on victims. There is too little information about how prevalent human trafficking is in the United States and how often the victims are seen in healthcare settings.
Case managers, hospitals, and ambulatory providers could improve the data by documenting suspected or confirmed human trafficking cases via Z codes. But new evidence, based on the Nationwide Emergency Department Sample (NEDS) of 2019, suggests this rarely happens.1
“In public health, you need to know the size and scope of the problem, and that’s been elusive,” says Erica Koegler, PhD, MSW, study co-author and an assistant professor at the University of Missouri — St. Louis School of Social Work. “When we knew ICD-10 codes were capturing human trafficking, we were curious.”
NEDS is a national data set that contains close to 1,000 EDs in the United States, says Nathaniel Dell, PhD, LCSW, lead study author and an assistant professor of psychiatry at Washington University School of Medicine in St. Louis.
“I was excited to use this data set,” Dell says. “It’s a really good representative cross-section of emergency departments in the U.S., and it’s useful for looking at regular phenomena.”
Victims Are Hard to Reach
People experiencing trafficking often are a hidden and hard-to-reach population. “We don’t know the true population size,” Dell says. “This study is the first incremental step in getting a sense of how these codes are being used in the emergency department setting.”
It is one of the first studies to use a large sample of ED visits to see how ICD-10 Z codes are applied to identify suspected cases of trafficking. “Because there are a lot of reasons why trafficking might not get coded, we knew whatever we found would be an underestimate,” Dell explains. “Nonetheless, we thought these ICD-10 codes could be useful for what’s occurring in different healthcare settings.”
Dell, Koegler, and colleagues studied both Z codes and T codes, which are the external causes of morbidity, including trafficking as a cause of morbidity. “Z codes look at personal history and health issues,” Koegler says.
They studied these four Z codes:
- Z04.81: Encounter for examination and observation of victim following forced sexual exploitation;
- Z04.82: Encounter for examination and observation of victim following forced labor exploitation;
- Z62.813: Personal history of forced labor or sexual exploitation in childhood;
- Z91.42: Personal history of forced labor or sexual exploitation.
The researchers also studied eight T codes related to child and adult sexual or labor exploitation, both suspected and confirmed.
“People who are trafficked are often called hidden, but they’re not hidden,” Koegler says. “They seek medical care, largely in the emergency department, but also elsewhere.”
When victims of trafficking appear in the ED, it is an opportunity for healthcare professionals to support them and to help them if they are ready. The signs might not be visible to the public, but healthcare professionals can identify risk factors, such as injuries and a controlling partner or guardian accompanying them.
“The trafficker might be with them in the ED to influence what is said and what is not said,” Koegler says. “Separate them from anyone else who might be presenting so the victim or survivor might be more honest.”
The key is to use a victim-centered approach. This allows the individual, if an adult, autonomy. If the victim is a child, then healthcare providers are mandated to intervene.
“For adults, they know their situation best and have the autonomy to make their own choices about whether they get help, call the police, or receive the services,” Koegler says. “You don’t want to miss [identifying] them at the healthcare facility because it could potentially be one of the few opportunities to support them.”
This means everyone who works in a healthcare facility should be trained in how to identify and help a suspected victim of trafficking. Without training, providers could bring harm through actions that alert the trafficker to what is going on.
Each healthcare organization should put a protocol in place for what to do when a victim of trafficking is identified. Advocacy organizations, like HEAL Trafficking, make such protocols available online for health systems.2
The person who suspects a patient is a trafficking victim could be the ED receptionist, a janitor, a nurse, a case manager, or someone else. They can contact a social worker, provider, or another point person who has received more extensive training in dealing with this population.
“The point person is more trained to walk the survivor through the process of the protocol for human trafficking,” Koegler says.
Another risk in identifying victims involves privacy and stigma. If this is coded or included in their patient charts, there is a risk they will experience stigma in healthcare settings.
“If we’re going to document trafficking in greater detail in medical reports, we need to do it in a way that does not inadvertently result in more harm to people having these experiences,” Dell says. “This is a huge problem for healthcare settings, and my interest is in how we can build systems of care where clinicians do not stigmatize people who have these experiences.”
- Dell N, Koegler E, Holzer KJ, et al. ICD-10-CM codes infrequently used to document human trafficking in 2019 Nationwide Emergency Department Sample. Am J Emerg Med 2023;64:37-42.
- HEAL Trafficking. HEAL Trafficking and Hope for Justice’s Protocol Toolkit. 2023.
Human trafficking is a critical issue from a public health perspective. It has lasting psychological and physical effects on victims. There is too little information about how prevalent human trafficking is in the United States and how often the victims are seen in healthcare settings. Case managers, hospitals, and ambulatory providers could improve the data by documenting suspected or confirmed human trafficking cases via Z codes.
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