A dozen clinic staff walked into the training with skepticism.
“This is a waste of time,” they muttered. “Human trafficking isn’t a problem here.” An hour later, most walked out with a newfound awareness and zeal to confront the issue.
What prompted this change of heart: Was it the American Hospital Association statement that “human trafficking is an issue in nearly every corner of the country”? Was it the U.S. News article calling on the healthcare sector to do more to combat trafficking? Was it the research finding that 88% of trafficking survivors had seen a healthcare provider while being trafficked? All of these may have played a role, but the turning point came while discussing the signs of trafficking.
“Looking back, I knew something was wrong,” one physician reflected. Though she had cared for the patient years ago, she still remembers feeling unsettled afterward. “I wish I had seen the red flags.” One by one, the attendees realized that they’ve had patients resembling those described in the training. Some patients presented repeatedly with sexually transmitted infections. Others had signs of physical abuse and drug-related issues. Still others seemed fearful and submissive or scripted in their answers. While there’s no clear set of symptoms to diagnose trafficking, these are all potential indicators.
Dr. Kimberly Chang, co-founder of HEAL Trafficking, says that it’s common for physicians to have that lightbulb moment as they step into anti-trafficking efforts: “Doctors have been seeing these patients for a long time, but we just never had the terminology or awareness that this was human trafficking.” HEAL Trafficking brings together stakeholders to address human trafficking from a public health perspective. The nonprofit envisions “a world healed of trafficking” and educates clinicians on delivering trauma-informed care to survivors. HEAL’s website provides open access resources for healthcare organizations, including a human trafficking protocol toolkit.
Identifying Trafficked Patients
One question routinely comes up: How can providers ascertain whether a patient is trafficked? The toolkit offers guidance on interviewing suspected trafficking victims:
- Designate and train specific staff to perform the interviews. These might include social workers, forensic nurses, clinical psychologists specialized in trauma, or other professionals.
- Interact with patients in a trauma-informed manner. Many trafficking victims do not remember events clearly or linearly. They may omit information or lie out of fear or guilt, often to protect themselves, their traffickers, or their families (i.e., fearing retaliation from their traffickers). Providers should balance the need for complete information with sensitivity to the patient’s situation. For example, minimize retraumatization by only asking necessary questions.
- Recognize that trafficked persons may not realize or accept that they are victimized. What we consider labor or sexual exploitation in the US is often viewed as normal by foreign-born trafficking victims. In their countries of origin, these practices may be commonplace. Likewise, trafficked minors, like child abuse victims, may grow up accepting their mistreatment as normal.
- Should interpretation services be needed, select interpreters carefully. Patients may refuse to share their experiences through someone from their own culture. This is especially true when the local immigrant community is small or tight-knit. Screen interpreters for conflicts of interest and major political differences. These may not be apparent to the average US-born provider.
- Assess power dynamics between patients and those accompanying them. Interview the patient alone when controlling dynamics are present (e.g., the patient appears unable to speak freely). Reasons given for separation might include a test in another room or “clinic or hospital policy.” Another method is to ask the controlling individual to step outside to complete paperwork or schedule a follow-up. If the suspected trafficker refuses to leave, or the patient elects not to be separated, providers should decide on a case-by-case basis whether to push the issue. Raising suspicion may jeopardize the patient’s safety and our ability to care for them in the future.
Identifying trafficked patients is only the first step. Addressing the problem is even more complex.
Let’s discuss two core issues: First, while healthcare providers are instructed to document everything in the electronic health records, doing so may be harmful to the patient in court. For example, without the proper legal actions, sex trafficking victims may be charged with prostitution. Likewise, sex trafficking victims who contracted HIV may be criminalized for the transmission of HIV.
Secondly, some trafficked patients will decline assistance. They may not be ready to accept help or even believe that they need to be saved. The HEAL toolkit advises providers to “respect the decisions and self-determination of the patient.” This is a difficult situation to be in. But rushing a “rescue” may ruin your relationship with the patient and opportunity to help them in the future.
Anti-Trafficking In Action
While the HEAL toolkit is a wealth of best practices, what gets them adopted? Chang says that it’s you and me. It’s the passionate advocates at the local level. In addition to her advocacy work with HEAL Trafficking, Chang cares for sex trafficked minors at Asian Health Services in Oakland, California. Likewise, many healthcare professionals are making a difference in their own communities. I became involved in local efforts through the San Diego Human Trafficking Advisory Council. Though various stakeholders were represented on the Council—education, law enforcement, the DA’s office, survivor voices, community groups, and so on—healthcare had been conspicuously absent.
“It’s a no-brainer that healthcare should be at the table,” said Jamie Gates, Ph.D., professor of sociology at Point Loma Nazarene University and chair of the Council’s research and data committee. He invited me and others to convene a health services committee.
“Many health systems don’t have a protocol in place for how to identify or help people who are being trafficked,” said Amy Sharpe, medical librarian at Sharp Healthcare and an organizer of the new committee. The group works to raise awareness of trafficking, help providers see themselves as part of the solution, and equip them with the necessary resources.
For Sharpe, ending human trafficking is personal. “At the first meeting, Dr. Gates mentioned that foster kids are at high-risk of being trafficked,” she shared. “I’m a foster youth mentor with San Diego County, so hearing that struck me to the core.”
At the same time, trafficking is a community issue. Victims and survivors have needs beyond medical services. Knowing where to refer patients is critical for their recovery and social reintegration.
“Health also encompasses mental and social health, community inclusion, and self-independence,” said Karly Gersberg, victim advocate at La Maestra Community Health Centers. The clinic provides a host of services besides medical care including: trauma-informed counseling, housing placement, immigration services and legal advocacy, a food pantry, and classes on basic computer skills and financial literacy.
“We also have connections with family and criminal law attorneys, job placement organizations, and more,” Gersberg shared. “In addition, we help survivors enroll in public benefit programs such as Medi-Cal [California’s Medicaid] and CalFresh [food stamps] so that they have resources for independence.”
She concludes: “Our human trafficking program strives to meet all our clients’ needs with services in-house or to make strong community connections to provide services where we cannot.”
Healthcare professionals are well-positioned to intervene against human trafficking. It’s encouraging to see that, as they learn about the nature of the issue, many are ready and willing to take up the cause.
“Healthcare providers of all disciplines are solution-oriented,” said Sharpe. “As I talk with colleagues, many of them are already thinking of ways that they can contribute.”