Special Edition: Intimate Partner Violence and Human Trafficking

HRSA BPHC Primary Health Care Digest

October 10, 2018

Special Edition: Intimate Partner Violence and Human Trafficking


October is Domestic Violence Awareness Month. In recognition, this special edition focuses on intimate partner violence (IPV) and human trafficking (HT). Both IPV and HT are forms of trauma, which can have long-term impacts on both physical and mental health. Following are vetted resources and promising practices to help you provide the necessary care and services for victims of IPV and HT. 

IPV, also referred to as domestic violence, is widespread, affecting one in four women and one in seven men.[1] IPV disproportionately affects populations served by health centers, including pregnant women, adolescents, racial/ethnic minorities, the LGBTQ community, people with disabilities, people living with HIV/AIDS, and individuals with substance use disorders.

HT is a public health issue that impacts individuals, families, and communities. In 2017, the National Human Trafficking Hotline received over 26,000 calls with over 8,500 cases reported. Traffickers disproportionately target at-risk populations, including individuals who have experienced or have been exposed to other forms of violence and individuals disconnected from stable support networks, like runaways and homeless youth.[2] Not only does HT splinter families, it can have severe effects on the physical and mental health of its victims.

How health centers can address these issues

  • Employ a trauma-informed care model, which assumes patients have experienced trauma. This model includes organizational change that promotes resilience in patients and staff, engages individuals in care, prevents re-traumatization, and incorporates knowledge about trauma in policies, procedures, practices, and settings.
  • Partner with local domestic violence advocacy programs to support bidirectional supportive referrals for both IPV and HT.
  • Offer universal education using Safety Cards (see sidebar) to open the conversation and follow with screening and counseling.
  • Share Safety Cards with patients to take home, if it is safe to do so.
  • Offer a safe, confidential environment: See each patient alone for a portion of every visit.
  • Recognize HT warning signs and red flags.
  • Consider IPV and HT in the differential diagnosis.
  • Visit the National Human Trafficking Resource Center hotline to speak with advocates and view a local referral directory.
  • Provide access to a private phone or meeting location within your health center for patients to connect with a local domestic violence advocate or the National Domestic Violence Hotline for safety planning.

Current IPV Initiative: Project Catalyst
HRSA is implementing an agency-wide initiative to address IPV in HRSA’s key programs. As part of this initiative, HRSA and the Administration for Children and Families (ACF) are implementing an initiative that builds upon promising approaches included in the IPV Health Partners Toolkit. Project Catalyst: Statewide Transformation on Health and IPV convenes state leadership teams (Arkansas, Connecticut, Idaho, and Iowa) consisting of the state Primary Care Association, Domestic Violence Coalition, and Department of Health. Leadership teams are implementing state-level policies and practices that support health providers and train health centers on addressing IPV and HT. Project Catalyst will spread to additional states in the coming year.

HRSA’s Office of Women’s Health and the Health Center Program collaborated to produce this special edition. If you have any feedback on this issue, or suggestions for future topics, please contact the Health Center Program Chief Medical Officer.

[1] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

[2] U.S. Department of Health and Human Services, Office of the Administration for Children and Families

Screening Tools

Intimate Partner Violence (IPV) 
In addition to universal education, U.S. Preventive Services Task Force recommends these screening tools.

Human Trafficking (HT)

Promising Practices

Health centers are increasingly using innovative approaches to help their communities address these often hidden social issues. Here are a few examples of the many promising practices implemented by health centers. Thank you to all of the organizations that shared their models. Please reach out to the contacts below to get more information. 

Asian Health Services, Oakland, CA

  • Provides a multi-pronged approach to addressing commercial sexually exploited children and domestic minor sex trafficking. This includes a youth program, a teen clinic, a HT-specific program for youth (developed in collaboration with community-based organizations), and a school-based health center.
  • The teen clinic routinely and universally screens for sexual exploitation and has implemented a reporting and referral protocol for any youth identified with suspected or disclosed commercial sexual exploitation.
  • Conducts research, provides trainings, and is engaged in policy development.

    Contact: Dr. Kimberly Chang, Family Physician, Human Trafficking and Healthcare Policy Fellow

    Brockton Neighborhood Health Center, Brockton, MA

    • Trained staff on universal education; Safety Cards are placed in waiting and exam rooms and distributed by providers, patient navigators, and case managers.
    • Warm handoffs are made to an embedded behavioral health clinician.
    • Navigators and case managers make referrals to community resources including the housing department, department of transitional assistance, and local domestic violence counseling and resources center.
    • Police Department provides an officer at the health center one day a week who is available for referrals.
    • Implementing a social determinants of health questionnaire that includes questions about IPV.

      Contact: Maria Cancel, Adult Behavioral Health Integration Program Manager

      CommuniCare Health Centers, Woodland, CA

      • Maintains a strong collaboration with a local IPV treatment provider.
      • Screens all new patients for trauma, including all new clients entering services for behavioral health. For children accessing specialty mental health, a tool is used to identify commercially sexually exploited children. (This health center piloted and helped to validate the tool’s effectiveness.)
      • Trained health center leadership in trauma-informed care and includes trauma-informed care in new hire orientation curriculum.
      • Implemented a “Healer’s Arts” program to support resiliency and address secondary trauma for providers. The program includes a safe learning environment to explore values of service, healing relationship, reverence for life, and compassionate care.

        Contact: Sara Gavin, Director of Behavioral Health for CommuniCare Health Centers

        FamilyCare Health Centers, Scott Depot, WV
        This center observed a large increase in IPV disclosures after implementing these practices.

        • All medical providers are trained in providing universal education using informational Safety Cards from Futures Without Violence (please see Safety Card link above).
        • Individuals disclosing abuse are offered immediate assistance with on-site integrated behavioral health team, including therapists and social workers, who refer and collaborate with local domestic violence shelters.

          Contact: Kathryn Adams, PsyD, Head of Behavioral Health Department, Licensed Psychologist

          Institute for Family Health, New York, NY

          • Implemented The PurpLE (Purpose: Listen and Engage) Clinic, which offers a safe and sensitive primary care home for people who have experienced sexual trauma, including HT.
          • Clinic runs several days a week with extended hours, staffed by a family medicine physician. It offers comprehensive health services that mirror health center services and utilizes extended visit lengths to develop trust.
          • Clinic was informed by collaborations with community-based organizations, including local anti-trafficking, domestic violence, immigrant, and LGBT-focused organizations, and with input from incarcerated sex trafficking survivors.

            Contact: Dr. Anita Ravi, Founder, Medical Director of the PurpLE Clinic, The Institute for Family Health

            La Clinica del Pueblo, Washington, DC

            • Training entire staff on universal education regarding gender-based violence and trauma-informed approach to managing all clinical conditions.
            • Uses an integrated care team that includes provider, medical assistant, behavioral health clinician, and health educator; making warm handoffs; and communicates through EHR.
            • Health Center Community Health Action Department provides health education, navigation to community-based resources including, a peer-led, Community Gender-Based Violence Prevention program, legal services, and behavioral health care; also provides care coordination.
            • Provides patient education materials and a weekend women’s group.

              Contact: Suyanna Linhales Barker, Senior Director of Health Equity and Community Action

              La Maestra Community Health Centers, San Diego, CA

              • Legal Advocacy and Social Services department (LMLASS) provides education, assistance, and support to people who face rights violations or who are survivors of crime, the majority of whom are victims of domestic violence and trafficking.
              • All clinic personnel at the health centers are trained by LMLASS to recognize signs of domestic violence and trafficking, maintain confidentiality and safety, and make sensitive, warm handoffs to the LMLASS staff.
              • Developed La Maestra Circle of Care™ services to provide comprehensive, holistic, and patient-centered services addressing social determinants of health.

              Contact: Carmen G. Kcomt, Director of the Legal Advocacy and Social Services Department, International Human Trafficking program


              Intimate partner violence (IPV): physical, sexual, or psychological harm by a current or former partner or spouse.

              Human trafficking (HT): modern-day slavery and involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act.

              Sex trafficking: the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age.

              Labor trafficking: the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

              Trauma-Informed Care Model: According to SAMHSA, “A program, organization, or system that is trauma-informed:

              • Realizes the widespread impact of trauma and understands potential paths for recovery;
              • Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
              • Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
              • Seeks to actively resist re-traumatization."



              Please consider patient privacy and safety considerations when coding for IPV or HT.

              Example ICD-10 Codes for IPV:

              • T74.11X   Adult physical abuse
              • T74.31X   Adult emotional/psychological abuse
              • T74.21X   Adult sexual abuse
              • Z13.89     Encounter for screening for other disorder

              Futures Without Violence has more information on IPV codes.

              ICD-10 Codes for HT:
              New ICD-10 Codes for Human Trafficking for FY 2019 includes T codes to report for cases of suspected and confirmed forced labor and sexual exploitation and Z codes for the examination and observation of HT victimization. 



              Substance Use, Trauma and Domestic Violence: Critical Issues, Promising Approaches
              Hosted by National Center on Domestic Violence, Trauma & Mental Health
              Tuesday, October 23
              3:00-4:00 p.m. ET
              Register here

              Intimate Partner Violence

              Intimate Partner Violence Health Center Toolkit

              • Includes a step-by-step guide to implementing an evidence-based intervention, Confidentiality, Universal Education and Empowerment, Support (CUES), for addressing IPV at health centers.
              • Provides guides for partnering with domestic violence advocacy organizations. 
              • A product of the HRSA and ACF-supported Improving Health Outcomes through Violence Prevention Pilot Project (2014-2016), which engaged health centers and partnering domestic violence organizations

              Improving Health Outcomes through Violence Prevention: Model Partnerships between Community Health Centers and Domestic and Sexual Violence Programs 
              The webinar and slides provide guidance on implementing CUES and highlight a successful partnership between a health center and a domestic violence/sexual assault program.

              Futures Without Violence Webpage and Health Resource Center 

              State & U.S. Territory Domestic Violence Coalitions
              Directory of state domestic violence coalitions to identify locations of local shelters and supportive services to refer patients.

              National Domestic Violence Hotline
              Resources and support for anyone affected by domestic violence. Providers can call this hotline for treatment guidance as well. Free | 24/7 | Confidential call/chat | 800-799-7233 | 800-787-3224 (TTY) | Spanish chat 1:00-7:00 p.m. ET

              Human Trafficking

              HHS Office on Trafficking in Persons
              Multiple resources including training, partnerships, victim assistance, grants, research, and policy.

              National Human Trafficking Training and Technical Assistance Center
              Training and technical assistance for health care providers on how to identify, treat, and respond appropriately to potential victims of human trafficking.

              SOAR Online Training  
              A series of free CE/CME training modules from the NHTTAC based on the approach, “Stop, Observe, Ask and Respond.” Trains health care providers, social workers, public health professionals, and behavioral health professionals to identify, treat, and respond to individuals who are at-risk or who have been trafficked.

              HEAL Trafficking, Inc.  

              • Includes access to a Protocol Toolkit for health care providers’ response to victims of human trafficking.
              • A multidisciplinary group of public health professionals dedicated to ending HT and supporting its survivors. Dr. Kimberly Chang, a family physician at Asian Health Services in Oakland, California, is a co-founder.

              National Human Trafficking Hotline
              Resources and support for anyone affected by HT. Free | 24/7 | Confidential | 888-373-7888 or text 233733 (BEFREE) or use TTY: 711.

              National Human Trafficking Referral Directory 
              Provides access to critical emergency, transitional, and long-term social services for victims and survivors of human trafficking. 

              Trauma-Informed Care

              SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach

              • Introduces the concept of trauma and offers a framework for how an organization, system, or service sector can become trauma-informed.
              • Includes definitions of trauma and a trauma-informed approach, six key principles, and 10 implementation domains. 

              SAMHSA's TIP on Trauma-Informed Care in Behavioral Health Services
              Provides a guide (suitable for primary care settings) for implementing trauma-informed care and building a trauma-informed workforce.