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Documenting encounters when you suspect trafficking

The ICD-10 was the first edition to publish diagnostic codes for suspected and known human trafficking, including commercial sexual exploitation. On December 5, 2019, HEAL Trafficking and the International Center for Missing and Exploited Children convened national experts to develop draft guidelines and training requirements to inform the safe and ethical implementation of ICD-10 codes for human trafficking. AAD/A Task Force member Abigail Judge, Ph.D. participated in this 2019 meeting and co-chaired the Survivor Advisory Workgroup.

Dermatologists should consult emerging guidance on the safe and ethical implementation of these codes. Above all, dermatologists are encouraged to speak directly and frankly with patients to engage in shared decision making as to when, whether and how suspected trafficking is documented in the EMR. Scripts for shared decision making are available in the January 2021 guidelines below.

When deciding on the approach to patient confidentiality in use of ICD codes and inclusion of sensitive information in the medical record, dermatologists should consider three basic tenets of trauma-informed care:

  1. Safety of the patient from harm by those gaining access to information in the record. Failure to document may also pose a risk to patient safety in that future clinicians may lack important information to guide treatment and referrals.

  2. Respect for the patient’s autonomy, as well as their concerns and wishes regarding confidentiality, in the context of their culture and history of trauma.

  3. Informed consent: patients need counseling on how their health information is created, protected, handled, maintained, and accessed. Patients need to be empowered to participate in making decisions about documentation (under the limits of relevant laws/policies). This counseling also provides further opportunity to build trust between the patient and practitioner and may encourage the patient to continue to access necessary care and resources.

Important considerations and affirmative need for including sensitive information in the EHR:

  • Patient factors: Documentation of relevant sensitive information helps to ensure continuity and optimization of the patient’s care with future clinicians. It may assist clinicians in obtaining relevant resources for the patient now and in the future, as patient needs change. Appropriate documentation may help keep the patient (as well as staff and visitors) safe in the hospital if there are concerns that the trafficker/abuser will come to find them. Finally, it helps health care professionals to recognize the prevalence of human trafficking, which can help decrease bias and stigmatization, especially among disenfranchised populations (e.g., transgender).

  • Criminal justice factors: Documentation of information may help with an investigation, especially if the trafficked/abused person chooses to seek criminal justice in the future. The depth of conversation about documentation needs to be feasible, relevant, and appropriate to the patient and context.

  • Resources: Tracking patients who have been trafficked or abused helps to ensure that the local community has data to support requesting the resources they need to serve these populations. The government needs to know where trafficking and other types of violence occur in order to direct resources appropriately.

  • Epidemiology: Research and epidemiology will lead to improved access to, and quality of care for, populations that are disenfranchised/under-recognized.

Key concerns regarding inclusion of sensitive information in the EHR:

  • Patient factors: If information appears in the patient portal, a proxy (typically the guardian) or trafficker/abuser may obtain access to the information and may harm the patient.

  • Staff reading sensitive information may exhibit bias/discrimination in their treatment of the patient.

  • A patient may feel shame or other negative emotions regarding the information. This may be exacerbated if a health care professional mentions some sensitive information to the patient in a manner that seems abrupt, unexpected, or out of context.

  • Ability for the information to be used against a patient in a legal proceeding (e.g., child custody hearing, criminal case, immigration proceeding.)

  • Information may be used by the trafficker to blackmail, threaten, or otherwise manipulate the patient.

In some situations, it may be possible to convey necessary information to future clinicians using text that is less specific and worrisome to the patient. Some examples include:

  • Use of an abbreviation (preferably one known to coders and other clinicians): HT: human trafficking; CST: child sex trafficking; CSEC: commercial sexual exploitation of child, CSA-child sexual abuse; DV/IPV-domestic violence/intimate partner violence.

    Given the lack of consensus about language to describe trafficking and commercial sexual exploitation, it is unlikely that established abbreviations are available to most dermatologists.

  • “There are multiple vulnerabilities for labor/sex HT, high level of concern”

  • “Risk factors for exploitation discussed and resources offered; recommend f/u with further discussion and resources in future”

  • “Administered HEADSS screen and discussed positive components (underlined), with resources provided.”

Documentation of sensitive information is only one aspect of the comprehensive care needed to support these patients. The information in this document should be linked to response protocols and resources to support clinicians’ understanding and familiarity with processes to recognize and to respond to suspected trafficking/exploitation/violence using a trauma-informed approach.

  • Prioritize patient safety first. If a clinician decides to document information about trafficking/exploitation/other violence in the record, they need to make sure there is a proactive documentation plan in place that maximizes patient safety, including security and confidentiality protocols. Patient input and shared decision making in this process should be at the center of any response protocol.

  • If the clinician is mandated to report suspected trafficking or abuse but does not know much about what will happen after police or child/adult protective services are notified, they should consult staff members with relevant expertise (e.g., social workers), who are familiar with interdisciplinary collaboration in child/adult protection situations. Consultation with social workers is extremely helpful even if reporting is not mandated, given the knowledge and experience of these professionals in working with outside agencies and organizations.

Clinicians should be familiar with antitrafficking laws in their jurisdiction regarding mandated reporting when commercial sexual exploitation of children and child sex trafficking is suspected. Scripts for navigating this encounter are available in the 2020 guidelines below.

Downloadable resources for dermatologists and patients

  • The resources described here are primarily national and may not be immediately relevant to where you practice.

  • Dermatologists are therefore encouraged to develop relationships with multidisciplinary providers that specialize in HT/CSE in your community. Given this population’s legitimate mistrust of healthcare and history of severe trauma, offering a “warm hand-off” to a patient with potential or known HT is much more effective than providing a business card or hotline number. Trust is paramount with victims and survivors and being able to vouch for the resource or organization can make a tremendous difference.

  • Building such relationships is challenging and time consuming but has the greatest chance of linking patients with the kind of tailored and longitudinal care most victims and survivors require.

  • Take care to assess whether it is safe to provide written resources to a patient.

    • When patients remain in situations of ongoing exploitation it may not be safe or advisable to distribute material a trafficker might discover or which the patient doesn’t understand or identify with.

    • When considering whether to offer a resource, engage in shared decision making with the patient and regard the patient as an expert in his/her/their own safety. When a specific resource can’t be shared this may lead the provider to feel helpless or like they have not sufficiently helped. Remember that it is more important to provide the patient with a safe and non-traumatizing interaction than the perfect potential resource. The goal is to maintain safety and reduce re-traumatization such that the person feels comfortable and secure returning to see you or another healthcare provider.

For trainings, tutorials, and comprehensive resources on the topic of human trafficking:

More resources: