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Human Sex Trafficking

The National Association of Nurse Practitioners in Women’s Health (NPWH) recognizes the critical role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for adolescent and adult females in terms of identifying, assessing, and responding to the needs of trafficked female individuals. Adolescent and young adult females comprise the majority of trafficked persons in the United States and globally, most specifically as victims of sex trafficking. NPs must be well prepared to identify, assess, and provide care for these individuals and have access to the resources to do so.

Many trafficked persons are seen in healthcare settings, yet they remain unidentified.2 Healthcare providers (HCPs) either are not aware of or do not respond to signs, when present, that a patient may be a victim of sex trafficking. A validated screening tool is not yet available. However, NPs can draw from existing evidence in related areas—especially intimate partner violence, sexual assault, homeless and runaway youth, child abuse and neglect, and individuals experiencing trauma in general—for clinical guidance. In addition, NPs can consider practice recommendations from colleagues in social service, advocacy, healthcare, and law enforcement who have expertise in human trafficking identification and intervention.

NPWH supports a comprehensive, coordinated, multidisciplinary approach to meet sex-trafficked individuals’ complex needs and help them address the challenges they face. To that end, NPWH supports research initiatives to develop a validated screening tool to better identify patients who are victims of sex trafficking, as well as to better understand the most effective manner in which to meet their emergency, short-term, and long-term healthcare needs.

Legislation and regulatory policies should focus on eliminating the demand for trafficked individuals in the first place, and on targeting persons and agencies that condone human trafficking. NPWH supports the development of legislation, regulatory policies, and advocacy efforts that protect the safety, rights, dignity, and cultural values of trafficked individuals.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct or support research in a concerted effort to increase knowledge and provide resources for NPs to identify, assess, and respond to the needs of trafficked female individuals.

Background

In 2000, the U.S. Trafficking Victims Protection Act (TVPA) updated post-Civil War slavery statutes to further guarantee freedom from slavery and involuntary servitude.3 For this purpose, sex trafficking was defined as the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex act.3 Severe forms of trafficking in persons was defined as sex trafficking in which the person induced to perform such act has not attained 18 years of age or sex trafficking for the purpose of subjection to involuntary services, servitude, peonage, debt bondage, or slavery.3 The TVPA was re-authorized most recently in 2013.4 Today, the terms modern slavery, trafficking in persons, and human trafficking are used as umbrella terms meeting the TVPA definition.

Accurate statistics for the incidence and prevalence of human trafficking are elusive because of the clandestine nature of the crime and trafficked individuals’ reluctance to identify themselves. Worldwide, it is estimated that 20.9 million persons are victims of trafficking and that among this group, 4.5 million (22%) are victims of forced sexual exploitation.5 Within the U.S., trafficked individuals may be transported across borders from other countries or they may already reside here. Data from a Bureau of Justice Statistics report for January 2008 through June 2010 identified 527 confirmed victims of trafficking, with 80% of these cases being classified as sex trafficking, 10% as labor trafficking, and 10% as undetermined.1 Eighty-three percent of the sex-trafficked individuals in this report were U.S. citizens, with 94% of them being female. The commercial sexual exploitation of minors comprised 64% of the cases. Of note, these data reflect only reported and investigated cases; the numbers may greatly under-represent the true extent of the problem. In 2015, the National Human Trafficking Resource Center (NHTRC) hotline received 21,957 calls across all states, with 4,314 calls reporting sex trafficking.6 

Females at high risk for being victims of sex trafficking include those who are young, live in extreme poverty, have limited education and work opportunities, engage in drug use, and/or have a history of instability or abuse in their families of origin. They may be more vulnerable if they have mental or physical disabilities. Adolescent females who are runaways and/or homeless are particularly vulnerable.2,7

Trafficked individuals face numerous barriers to disclosing their situation to HCPs. They may fear harm to themselves, family members, or friends; fear deportation if not legally in the U.S.; have language barriers; distrust authority figures; feel they do not have any options; be ashamed of their situation and the stigma they believe it carries; or have a criminal record. Traffickers may use monitoring devices to track these individuals’ every move to deter them from seeking help. In addition, some trafficked individuals may not under-stand the concept of coercion or that they are victims of an illegal activity.2

Patients who have been trafficked are at high risk for long-term physical and mental health con-sequences related to inflicted trauma and depriva-tion of their basic needs for survival. Health conse-quences may include unintended pregnancies; sexually transmitted infections (STIs), including HIV; poor dentition compounding malnutrition; depression; post-traumatic stress disorder (PTSD); and suicidal ideation. Commonly reported physi-cal symptoms include fatigue, headaches, back pain, and weight loss.8

Implications for women’s healthcare and WHNP practice

WHNPs and other NPs who provide women’s healthcare should be aware of indicators that raise suspicion that an individual presenting to a healthcare setting may be in an exploitative circumstance. Warning signs identified by anti-trafficking experts include:

Hypervigilant, fearful, or submissive demeanor; evidence of being controlled;

Provision of vague answers to questions or a script-like recitation of her history;

Delay between the onset of an injury or illness and the seeking of healthcare, in context with other indicators;

Discrepancies between an individual’s explained cause and the clinical presentation of her injuries;

Accompaniment by another person who answers questions for the individual and refuses to leave her alone during the visit;

Inability to produce identification documents;

Signs of physical abuse (e.g., cigarette burns, bruising), sexual abuse, medical neglect, torture, depression, PTSD, and/or alcohol or substance use disorder;

Tattoos or other markings indicating a claim of ownership by another;

Recurrent STIs;

Trauma to her genitals or rectum; and/or

History of repetitive abortions or miscarriages.2,7,9,10

WHNPs are particularly qualified through their educational preparation to recognize and provide needed healthcare services and referrals for adolescent and adult females who are victims of sexual, physical, and/or emotional abuse. Trauma-informed care for these patients places an emphasis on helping the individual feel safe and reclaim control of her life and decisions. Goals of a trauma-informed approach in care are to avoid re-traumatization, to emphasize the patient’s strengths and resilience, to support development of healthy short- and long-term coping mechanisms, and to promote healing and recovery.2

No official guidelines are available regarding the most effective manner in which to provide for the emergency, short-term, and long-term healthcare needs of trafficked patients. However, expert opinion supports these approaches:

Foster trust and relationship building, which includes an assurance of confidentiality.

Ensure privacy prior to discussing potential trafficking with the patient.

Recognize potential danger to the patient and/or her family members if she reports the crime.

Incorporate safety planning for both the patient and staff.

Use a trauma-informed approach in assessment and treatment.

Provide care for any immediate needs (e.g., treat STIs, diagnose a pregnancy).

Provide culturally appropriate services.

Mitigate language barriers; provide a professional interpreter when needed.

Establish a list of local resources for collaboration that provides wraparound services for the individual.

Contact the NHTRC hotline at 1-888-373-7888 for guidance on the next steps and referrals if needed.2,7,11

The NHTRC provides detailed information for HCPs concerning identification, assessment, and response to the needs of patients who have been trafficked.

Recommendations

WHNPs and other NPs who provide healthcare for adolescent and adult females should:

Be familiar with and educate staff about warning signs indicating that a patient may be a victim of sex trafficking;

Establish a plan in the healthcare setting for safety of both the patient and staff;

Establish partnerships with local social service providers, mental health providers, religious leaders, legal advocates, and law enforcement representatives for comprehensive services;

Serve as change agents in their communities through mentoring programs for at-risk youth, advocacy for policy changes to aid recovery of trafficked individuals, and engagement in activities that will promote greater cultural awareness of gender inequalities; and

Assess their own learning needs with regard to the unique and complex needs of trafficked individuals and seek continuing education as appropriate.

NPWH will provide leadership and resources to ensure that:

Educational programs for NP students with a population focus that includes adolescent and adult females impart evidence-based knowledge and skill building for the development of competencies to identify trafficked individuals and provide healthcare and appropriate referrals for them; and

Continuing education programs are available for NPs to obtain evidence-based knowledge and competencies to identify and provide healthcare and appropriate referrals for trafficked individuals.

References

1. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008-2010. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2011. 

2. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Waltham, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, and Committee on Violence Intervention and Preven-tion, Massachusetts Medical Society; 2014.

3. 106th U.S. Congress. Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386. 2000. 

4. U.S. Department of State. U.S. Laws on Trafficking in Persons. 2016. 

5. International Labor Organization. ILO 2012 Global Estimate of Forced Labor: Executive Summary. 2012. 

6. National Human Trafficking Resource Center. 2015 NHTRC Annual Report. 2016. 

7. Clawson H, Dutch N, Solomon A, Grace L. Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Planning and Evaluation; 2009. 

8. World Health Organization. Understanding and Addressing Violence Against Women: Human Trafficking. 2012. 

9. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human sex trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49. 

10. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. 2016. 

11. Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health. 2010;55(5):462-467. 

Updated contraception resources from the CDC

The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 (MEC)1 and the U.S. Selected Practice Recommendations for Contraceptive Use, 2016 (SPR)2 were both released to the public on July 29, 2016. The MEC provides guidance to healthcare providers (HCPs) regarding safe use of contraceptive methods by individuals with certain personal characteristics (e.g., age, smoking status, postpartum status) or medical conditions (e.g., hypertension, diabetes, headaches). The SPR, a companion document to the MEC, provides guidance for common contraceptive management topics such as how to be reasonably certain that a woman is not pregnant, when to start contraception, which exams and tests are medically indicated prior to starting a contraceptive method, what type of follow-up is needed, and how problems should be managed.

The first edition of the MEC was published in 20103 and the first edition of the SPR, in 2013.4 The 2016 updates were made after a thorough review of the scientific evidence and consultation with national experts. A summary of the MEC changes since 2010 is provided in Appendix A of the 2016 edition and a summary of the SPR changes since 2013 appears on page 2 of the 2016 SPR.1, 2

MEC updates

The 2016 MEC provides more than 1,800 recommendations for more than 60 personal characteristics and medical conditions.1 As in the 2010 edition, the 2016 MEC continues to use four categories of medical eligibility to help HCPs assess the safety of a particular contraceptive method for persons with specific personal characteristics or medical conditions (Box). HCPs are reminded that although the MEC recommendations provide guidance, individual circumstances should always be considered in contraceptive method counseling and decisions. Take-home messages in the 2016 MEC remain the same as those in the 2010 edition:

Most women can safely use most contraceptives.

Women with medical conditions associated with an increased risk for adverse health events as a result of pregnancy need highly effective contraception for reproductive life planning.

Women, men, and couples should be informed of  the full range of methods to decide what will be best for them.

Use of the MEC can help HCPs decrease barriers to choosing safe and effective contraceptive methods.

New recommendations

New to the 2016 MEC are recommendations for women with multiple sclerosis (MS) or cystic fibrosis (CF) and for women taking selective serotonin reuptake inhibitors (SSRIs) or St. John’s wort. Ulipristal acetate (UPA) has been added to the recommendations on emergency contraception (EC).

Multiple sclerosis

HCPs should check the MS subsection of the Neurologic Conditions section of each appendix. In Appendix C, Classifications for Progestin-Only Contraceptives (POCs), depot medroxyprogesterone acetate (DMPA) is listed in category 2 for women with MS, with the comment that these women’s bone health may be compromised due to disease- related immobility and use of corticosteroids. Use of DMPA, which has been associated with small changes in BMD, might be of concern in this patient population. The other POCs, the subdermal implant and progestin-only pills (POPs), are listed in category 1 for women with MS. In Appendix D, Classifications for Combined Hormonal Contraceptives (CHCs), CHCs are listed in category 3 for women with MS who have prolonged immobility and in category 1 for women with MS who do not have prolonged immobility. Of note, although no data suggest an increased risk for venous thromboembolism (VTE) in women with MS using CHCs, these women are at overall higher risk than unaffected women for VTE.

Cystic fibrosis

HCPs should check the CF subsection of the Respiratory Conditions section of each appendix. CF is described as a condition associated with an increased risk for adverse health events as a result of pregnancy. Certain drugs used to treat CF (e.g., lumacaftor) might reduce the effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives. In Appendix C, Classifications for POCs, DMPA is listed in category 2 for women with CF, with the comment that these women have a higher prevalence of osteopenia, osteoporosis, and fragility fractures than the general population. Use of DMPA, which has been associated with small changes in BMD, might be of concern in this patient population. The other POCs in women with CF are listed in category 1.

Selective serotonin reuptake inhibitors 

HCPs should check the Drug Interactions section in each appendix for specific information about this drugclass. In Appendix A, SSRIs are listed in category 1 for all contraceptives. Available data, albeit limited, show no decrease in the effectiveness of hormonal contraceptives in SSRI users. Likewise, available data show no difference in the effectiveness or in the adverse effects of SSRIs in women using hormonal contraceptives versus those not using them. The comments sections of Appendix C and Appendix D note that drugs that are inhibitors of CYP3A4 or CYP2C9 have the potential, at least in theory, to raise levels of contraceptive steroids, which might increase adverse events. The SSRI fluvoxamine is known to be a moderate inhibitor of both CYP3A4 and CYP2C9; however, no clinical or pharmacokinetic studies were identified to explore these potential drug–drug interactions.

St. John’s wort

HCPs should check the Drug Interactions section in each appendix for information about this herbal product. In Appendix A, St. John’s wort is listed in category 1 for intrauterine devices (IUDs) and DMPA, and in category 2 for the implant, POPs, and CHCs. With regard to the implant, POPs, and CHCs, as noted in Appendix C and Appendix D, limited available data raise concern that St. John’s wort might decrease the effectiveness of hormonal contraceptives by increasing the metabolism of estrogen and progestins. Interactions may be dependent on the dose of St. John’s wort. Also, the concentration of active ingredients in St. John’s wort products may vary. Any potential impact of this herbal product on the contraceptive effectiveness of DMPA is less likely than with the other POCs because of the higher dose of progestin.

Ulipristal acetate

HCPs should check Appendix J, Classifications for  Emergency Contraception, for more information about UPA, which has been added to the EC appendix. Like levonorgestrel (LNG) and combined oral contraceptives (COCs) used for EC, UPA is listed in category 2 for women with a history of severe cardiovascular disease, severe liver disease, or obesity, and in those who use a CYP3A4 inducer (e.g., bosentan, carbamazepine, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s wort, topiramate, efavirenz, lumacaftor). Of note, for women who are obese or who use strong CYP3A4 inducers, UPA, LNG, and COCs used for EC are listed in category 2 because of possibly reduced effectiveness. There are no personal characteristics or medical conditions that place UPA, LNG, or COCs used for EC in category 3 or 4.

Women who are breastfeeding and have taken UPA are advised to express and discard breast milk for 24 hours after taking the medication. This recommendation has been made because UPA is excreted in breast milk, with highest concentrations in the first 24 hours.

Other MEC revisions

Revisions to recommendations have been made for postpartum and breastfeeding women, as well as for several medical conditions. The revisions to recommendations for postpartum and breastfeeding women include those presented in the 2011 CDC revised recommendations for these populations related to use of the IUD, POCs, and CHCs.5 Appendix B, Classifications for IUDs, includes changes for women with gestational trophoblastic disease, HIV infection, and certain factors related to sexually transmitted infections. Appendix D, Classifications for CHCs, includes changes for women with migraines, superficial venous disease, or known dyslipidemias, and for women on antiretroviral therapy.

SPR updates

As in the 2013 edition, the 2016 SPR provides information organized by contraceptive method.2 Charts and algorithms are included in appendices that summarize guidance across all methods for when to start, examinations and tests that are needed, routine followup, and management of bleeding irregularities. SPR updates are consistent with changes in the 2016 MEC. Take-home messages in the 2016 SPR remain the same as in the 2013 edition:

Most women can start most methods anytime.

Few, if any, exams or tests are needed.

Routine follow-up is generally not required.

Regular contraception should be started after emergency contraception.

Anticipatory counseling for potential contraceptive-related bleeding changes and proper management are important.

Use of the SPR can help HCPs decrease medical barriers to accessing and using contraception.

New recommendation: use of medications to ease IUD insertion

Misoprostol is not recommended for routine use before IUD insertion but might be helpful in some circumstances—for example, in a woman with a recent failed insertion. A paracervical block with lidocaine might reduce pain during IUD insertion.

Updated recommendation: when to start regular contraception after taking UPA

Under ideal circumstances, women should start or resume a hormonal contraceptive method no sooner than 5 days after taking UPA because of a risk that hormonal contraceptives might decrease the effectiveness of UPA. However, if the chosen hormonal method would require an additional visit to an HCP (e.g., DMPA, implant, IUD), the risk of reduced effectiveness needs to be weighed against the risk that a regular contraceptive method might not be started. Women who have taken UPA should abstain from sexual intercourse or use a barrier method for 7 days after starting or resuming regular contraception or until the next menses, whichever comes first. Any nonhormonal contraceptive method can be started immediately after taking UPA.

Useful tools for HCPs

The CDC provides a variety of useful tools and aids to facilitate use of the MEC and SPR in clinical practice. The summary MEC chart has been updated, as has the MEC and SPR Smartphone app. Printable PDF versions of When to Start Contraceptive Methods and Routine Follow-up and What to Do If Late, Missed, or Delayed CHC are available. 

Beth Kelsey is Assistant Professor and DNP Program Director at the School of Nursing, Ball State University, in Muncie, Indiana. She is editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs and Publication Coordinator for NPWH. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. July 29, 2016.

2. CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. July 29, 2016.

3. CDC. U.S. medical eligibility criteria for contraceptive use, 2010. June 18, 2010.

4. CDC. U.S. selected practice recommendations for contraceptive use, 2013. MMWR. 2013;62(RR-5):1-46.

5. CDC. Update to CDC’s U.S. medical eligibility criteria for the use of contraceptive methods, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR. 2011;60(26):878-883.