A laborer worked 19 hours a day to repay an insurmountable debt to his employer. When he fell off a 10-foot platform on a construction job, he broke his back. Emergency physicians treated him with painkillers but overlooked the fact that he was chronically malnourished with signs and symptoms of tuberculosis.
A 17-year-old went to an emergency department (ED) with a gunshot wound to the leg. Her male companion told the provider it was the result of a drive-by shooting. No further questions were asked about the cause.
These are real-life stories of patients in this country who were treated but not identified by physicians as victims of human trafficking. There can be many overlooked signs, according to the human trafficking experts who provided these examples, including recurring sexually transmitted infections, suspicious burns, or even poor eye contact.
The U.S. Department of Homeland Security describes human trafficking as “modern-day slavery (that) involves the use of force, fraud, or coercion.” The involuntary acts may be of a sexual nature or related to labor. Many Americans assume that trafficking is a problem only on foreign soil, but this is not so.
Laura Lederer, JD, surveyed 125 survivors of trafficking for a 2014 study in the Annals of Health Law about their experiences with health care providers. Close to 90% of the victims, ages 14 to 60, sought medical care during their ordeals for symptoms including cardiovascular and respiratory problems, flashbacks, depression, anxiety, nightmares, and feelings of shame and guilt. Yet, more than half said their providers did not ask about their personal circumstances. “Health care providers were not trained about trafficking and not asking the right questions to identify victims,” Lederer concluded.
In the gunshot victim’s case, the girl’s pimp told the ED staff she was shot in a drive-by shooting. In reality, he shot her because she resisted doing something he ordered, Lederer said. Two years later, he shot her in the other leg, took her to the same ED, and again said it was a drive-by shooting. In neither case did health care providers question whether she was a trafficking victim.
“We can use our diagnostic skills from other forms of interpersonal violence to help us identify trafficking survivors.… Physicians should look for other ‘pattern recognition pieces’ beyond patients’ presenting signs or symptoms.”
Hanni Stoklosa, MD, MPH
Brigham and Women’s Hospital
Physicians typically “don’t have human trafficking on their radar,” said Hanni Stoklosa, MD, MPH, an emergency medicine physician at Brigham and Women’s Hospital and an instructor in emergency medicine at Harvard Medical School. But, she added, “Human trafficking doesn’t need to be siloed.” At Harvard, Stoklosa said she teaches her medical students that trafficking has many dimensions that can present in pediatrics, EDs, urgent care settings, orthopaedics, or infectious diseases.
Keith Horvath, MD, senior director of clinical transformation for Health Care Affairs at the AAMC, would add that it’s best practice to ask certain screening questions during any patient encounter, regardless of the circumstances. “Having physicians routinely ask questions like ‘Do you feel safe at home?’ will increase their awareness of trafficking-related injuries and illnesses,” he said.
“We can use our diagnostic skills from other forms of interpersonal violence to help us identify trafficking survivors,” said Stoklosa, also executive director of HEAL Trafficking, a network of health professionals who developed a toolkit to aid clinical staff on how to respond to suspected trafficking victims in health care settings.
Raising awareness through the medical curriculum
A 2014 report from the International Labour Organization estimated that 21 million men, women, and children worldwide are trafficking victims. Several academic medical institutions are taking steps to increase awareness about the problem and how physicians can identify and help victims.
Tonya Chaffee, MD, MPH, clinical professor of pediatrics at University of California, San Francisco, said that medical educators have become much better at recognizing the impact of social issues on health and in teaching medical students to “see the whole picture.” “We’ve learned from domestic violence. [Our response to human trafficking] is in its infancy and about 10 years behind domestic violence,” she added.
Some medical schools are integrating content about human trafficking into their classes. As part of the core curriculum at the University of Vermont Larner College of Medicine, for example, second-year students work with faculty physicians and nonprofit organizations on semester-long research projects that focus on identifying victims, barriers to health care for vulnerable populations, and an electronic screening tool for human trafficking.
Stanford School of Medicine created a set of educational resources to familiarize medical personnel with the scope of the issue.
The University of Miami Miller School of Medicine established an intradisciplinary victim services clinic seven years ago. A small grant to run a symposium about human trafficking ultimately led to a comprehensive program for survivors. “We built a medical home,” said JoNell Potter, PhD, professor of clinical obstetrics and gynecology. Students at the medical school learn about trafficking through participation in clinics and grand rounds at a local hospital where victims now obtain primary care, gynecological and other specialty care, and psychiatric services, she said.
Hilary Friedlander said she had no familiarity with trafficking as a first-year medical school student at Albert Einstein College of Medicine in 2015. Then, along with several fellow students, she attended a conference of the American Medical Women’s Association on the topic.
“We were blown away by what we heard.” Friedlander said. “We were not aware of the scope of the problem, and we didn’t realize that physicians could play such an important role [in helping victims].” The students believed their colleagues were probably as uninformed as they were, so they created a three-part model (lectures, small group meetings, and videos) to educate first- and second-year students. They took their model to Einstein faculty who were “really receptive,” Friedlander said.
Now a third-year student, Friedlander’s initial interest in trafficking victims has developed into a project that teaches Einstein medical students about signs of trafficking and how to respond.
What can physicians do?
At the national level, the U.S. Department of Health and Human Services (HHS) has taken steps to increase awareness about trafficking. It held a symposium in 2008 on victims’ health needs and committed to a federal strategic action plan for victims’ services. The Trafficking Awareness Training for Health Care Act was passed in 2015 as part of the Justice for Victims of Trafficking Act. And earlier this year, HHS created the Office on Trafficking in Persons (OTIP), which introduced SOAR (Stop. Observe. Ask. Respond.), a project to train health care professionals in human trafficking knowledge and skills.
“Physicians usually want to fix everything, but the goal is not to get disclosure. It’s to help the patient feel safe and confident enough to come back [for further care].”
Tonya Chaffee, MD, MPH
University of California, San Francisco
What can a clinician do when trafficking is suspected? “Providers need to have their radar out to identify and respond appropriately,” Lederer said. “They should separate victims from the suspected trafficker and question them to find out more about what happened.” Health care providers don’t take the place of law enforcement officers, but physicians can ask questions, she said, such as, “Can you leave your work if you want to? Have you ever been hurt or threatened? Do you know how to get help if you need it?”
Stoklosa noted that some victims may tell a physician they have been sexually assaulted, but the physician doesn’t recognize it as trafficking. “Physicians should look for other ‘pattern recognition pieces’ beyond patients’ presenting signs or symptoms. Those may include malnourishment, broken bones, fear, or anxiety.” Aggression and anger are common as well, stemming from feelings of shame, she said.
The list of possible physical signs Friedlander prepared for medical students at Einstein includes recurrent sexually transmitted infections, a number of pregnancies, bruises or burns, or addiction. Behavioral signs on the list are poor eye contact, relating a story that appears scripted or rehearsed, and a companion who seems to control the patient.
According to Chaffee, “Physicians usually want to fix everything, but the goal is not to get disclosure. It’s to help the patient feel safe and confident enough to come back [for further care].” Or as Friedlander has learned, “Patients need to play an active role in decision making. Avoid the rescue fantasy. Our goal is not to save but to assist.”