Patients in your exam room may be experiencing one of a number of forms of abuse—domestic violence, human trafficking or other violence—and identifying those being abused can sometimes be tough.

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An article published in the AMA Journal of Ethics® outlined the challenges and identified ways for physicians to better spot and help trafficking victims. The authors noted that a 2014 study found that 88 percent of victims had contact with a health professional while being trafficked, but none were identified or offered help in getting out of their situation during the medical encounter.

Family physician Anita Ravi, MD, MPH, MSHP, discovered that she has had to rethink the way she approaches patients to best help those facing abuse or violence. The founder and medical director of the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health in New York City offers a health home for those who have been victims of human trafficking and other trauma.

Dr. Ravi said her experience, including a study that involved interviewing 30 sex-trafficking survivors about their interactions with the health care system, has taught her that patients experiencing violence or abuse can be of any gender, age, documentation status or background and they may be encountering a range of medical issues. It may be a patient who has never encountered the health care system before because traffickers deny their access to care or the person seeking care was never able to leave their abuser long enough to seek medical care.

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Patients have told her there were times when they have left a medical setting because they felt they were being judged.

“We need to think differently about people we deem “frequent flyers”,” Dr. Ravi said. For example, a patient may be coming in for frequent sexually transmitted disease testing because they are being forced to have unprotected sex.

She said physicians need to be nonjudgmental and let people know that mental health, housing, legal and social services are available. While a patient may not open up to what is really going on during a first or even second visit, those interactions can lay the groundwork that the physician’s office or an emergency department is a safe place.

Dr. Ravi said it is also important to establish a policy—even putting it in writing in the exam and waiting rooms—that says a patient needs to be seen one-on-one for part of the visit. Often, trafficked patients will come in with a man or woman who is trafficking them; sometimes that person could even be a relative.

The AMA Code of Medical Ethics offers physicians guidance on their obligation to take appropriate action to help patients avert harms that violence and abuse cause.

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In Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse,” the Codeexplains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient’s health or ability to adhere to medical recommendations. Physicians, in light of their obligation to promote the well-being of patients, have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse.

The Code says to protect patients’ well-being, physicians individually should become familiar with:

  • How to detect violence or abuse, including cultural variations in response to abuse.
  • Community and health resources available to abused or vulnerable persons.
  • Public health measures that are effective in preventing violence and abuse.
  • Legal requirements for reporting violence or abuse.

Physicians also should:

  • Consider abuse as a possible factor in the presentation of medical complaints.
  • Routinely inquire about physical, sexual, and psychological abuse as part of the medical history.
  • Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.
  • Treat the immediate symptoms and sequelae of violence and abuse and provide ongoing care for patients to address long-term consequences that may arise from being exposed to violence and abuse.
  • Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources.
  • Report suspected violence and abuse in keeping with applicable requirements.

Before reporting suspected violence or abuse, the Code says physicians should:

  • Inform patients about requirements to report.
  • Obtain the patient’s informed consent when reporting is not required by law. Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision.

Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.

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