Hidden Victims

Advocates say the health care sector should do more to recognize and help the thousands of people who have been bought and sold in the U.S.

By Gaby Galvin Staff  Writer June 15, 2018, at 7:00 a.m.

The Health Care Fight Against Human Trafficking

Polaris, which operates the National Human Trafficking Hotline, identified 10,615 victims of human trafficking last year, though that is likely only a fraction of the total victims in the U.S. (Getty Images)

A trip to the emergency room or local health clinic can present a path to freedom for a human trafficking victim – but only if the symptoms of their situation are seen.

Now, led by local community clinics and health organizations, a growing movement is seeking to bring victims of sex and labor trafficking out of the shadows by pushing for better awareness of who they are among health care workers.

“Doctors have been seeing these patients for a long time, but we just never had the terminology or awareness that this was human trafficking,” says Dr. Kimberly Chang, who works with minors trafficked for sex work at Oakland, California-based Asian Health Services.

Working in a clinic for underserved teenagers, Chang began to recognize a troubling pattern: Patients sometimes had bad bruises, were regularly intoxicated, came in repeatedly for sexually transmitted infections or were angry or shut down. She says she “just kind of treated their medical issues” for a while – until she realized some of these issues could indicate the teens were being exploited in what’s been referred to as modern-day slavery.

Trafficking victims live across the U.S. and all too often are hidden in plain sight: at grocery stores and movie theaters, or visiting dentists and doctors’ offices. Because spotting them is key to stopping the abuse, advocates say doctors, hospitals and clinics should screen and treat potential victims of trafficking the same way they would approach someone who may have been a victim of sexual abuse or domestic violence – though doing so can be difficult.

“There’s not a clear consolidation of scientific symptoms that says, ‘This person is being trafficked,’ unlike, say, something like an infectious disease,” says Chang, who also is a co-founder of the HEAL Trafficking network, which takes a public health approach to the issue.

That same ambiguity applies to trafficking at large, as exactly how many people are sold for sex or labor in the U.S. remains a mystery. Polaris, a nonprofit that operates the National Human Trafficking Hotline, tallied 8,759 cases and 10,615 individual victims of human trafficking last year. The majority of victims were female, of adult age and trafficked for sex.

Yet experts say such figures likely represent only a fraction of total trafficking victims in the U.S. Many aren’t captured by formal statistics, and even fewer see their day in court.

“They’re incredibly challenging cases to prosecute for a number of different reasons, and one of them is the trauma bond with the youth,” says Dr. Kimberly McGrath, who runs a program for exploited minors through Citrus Health Network, a mental and behavioral health provider in South Florida. “But we do work with them to help them heal so that they can testify. The majority I would say (don’t end up in court), but we have had some success.”

Although more victims identified by Polaris came into contact with law enforcement than health services in 2017, advocates say health care professionals have a greater opportunity to intervene because they interact with potential victims more frequently, perhaps as they’re being treated for an illness or injury.

According to statistics cited by the federal Health Resources and Services Administration, more than half of human trafficking victims visited an emergency department while they were being exploited, 44 percent came into contact with a primary care professional and more than a quarter saw a dentist.

Chang says all health care systems have a responsibility to address human trafficking, but community health centers – which serve about 27 million low-income or uninsured

Americans annually – play a unique role both in caring for the long-term mental and physical needs of those who have been trafficked in the past, and in preventing potential victims from ever reaching that point.

Some centers specialize in services for immigrants, seasonal farmworkers, homeless populations or those living in public housing. Because they see more marginalized groups that could be more likely to become victims, they have a special obligation to combat trafficking, Chang says.

“We’re a little bit different because we’re based on the ground in the community, in underserved communities,” she says. “We also have community health workers that are internal that help the patients navigate our system, and sometimes external, going out into the community. … As a system, I believe we’re much more integrated into the community and into the populations that we see.”

Still, many victims don’t identify themselves to health care professionals out of fear, shame or trauma. And while some providers have been striving to better recognize and serve human trafficking victims for more than a decade, most don’t know or are just now learning how to identify and care for them.

The challenge is compounded by the wide scope of trafficking victims, who can range from domestic workers whose passports have been confiscated to minors sold for sex.

“Who the victims of trauma are can be anybody,” says Jessica Sanchez, vice president of quality and operations for the Colorado Community Health Network, which represents 20 community health centers in the state. Since learning last year that Denver is a hub for human trafficking, her organization has been developing a framework to help clinic workers identify and treat victims.

“These patients are probably already coming to our health centers, so (we are) just trying to figure out how to identify them and then start to make partnerships in the community to refer them for housing and food and mental health care,” she says.

Doctors involved in anti-trafficking efforts say they need federal and state support, and that social services organizations and community groups also should be involved in developing a holistic approach to caring for trafficking victims, whose needs will vary. Someone being actively exploited may need legal services, housing or help dealing with substance abuse, while someone with trafficking in their past may struggle with depression or other mental health issues.

In January of 2017, the U.S. Department of Health and Human Services launched the National Human Trafficking Training and Technical Assistance Center as a resource for health care, behavioral health and social service workers. It seeks to improve care for victims as well as reduce the risk of being trafficked for those who may be particularly vulnerable to exploitation, such as the chronically homeless, someone who’s been in an abusive relationship or a teen with an unstable home life.

To ensure fewer victims slip through the cracks in the criminal justice system, it’s vital that health professionals step up to connect them with services, says Dr. Anita Ravi, founder and medical director of the PurpLE Clinic at The Institute for Family Health, one of the largest community health centers in New York.

“In medical school … you learn that heart attacks kill people and what else kills people, but we’re not taught … that humans kill people,” Ravi says. “And I think in the situations that I’m facing, it’s very often that the worst-case scenarios are not, ‘Oh, she’s going to go back to the ER, or hospitalization.’ It’s death, incarceration or deportation.”

Ravi operates the PurpLE Clinic out of a health center in lower Manhattan several days a week for victims of trafficking, violence and human rights abuses. Patients initially came to the clinic after other health organizations identified and referred them to her, but about a year and a half ago, they started coming in on their own, Ravi says.

She stresses the importance of understanding how patients’ social needs are tied to health outcomes. The five topics she always asks about – food, housing, employment, legal services and transportation – have helped her identify patients who may have been trafficked in the past or are at risk of becoming victims.

“I may have thought it was a domestic violence referral, and maybe it is now, but they had a history of trafficking, or their ex-trafficker is harassing them from jail and they’re waiting for them to get out,” Ravi says. “It has those kinds of complexities, so one form of trauma sometimes lends itself to identifying others, depending on where people are.”

Identifying victims can be half the challenge. Traffickers often manipulate their victims to keep them under control, so doctors should insist on seeing patients while they’re alone, even if that means calling a translator by phone if they speak another language, Chang says. And anyone vulnerable to trafficking should be screened for victimization, especially if they appear physically injured or abused.

Medical providers should look for a combination of factors to identify potential victims, including an inconsistent or seemingly scripted backstory, a lack of control over their money or time, or frightened or nervous behavior, according to a guide from the National Human Trafficking Resource Center, which is operated by Polaris. Health professionals then can connect them with other services in a sensitive and patient-centric way.

“I have had people who are in active trafficking situations, similar to domestic violence, where if someone is ready to leave the situation, we’re able to connect them to right services – lawyers, housing, community-based organizations,” Ravi says. “Sometimes if they’re not sure, at least they know how to get ahold of us and know they can always come to see the doctor.”

Teenagers especially are hesitant to identify themselves as victims of trafficking, McGrath says. Her clinic works with 12- to 18-year-olds in Miami-Dade County, which she says is a hotbed for trafficking due to “a lot of factors: the travel and tourism, South Beach, the weather, the music industry.”

To identify potential victims of trafficking, McGrath’s clinic looks for signs like whether a teen has frequently run away from home or has returned home with expensive items they can’t explain. Tattoos and other markers, as well as multiple instances of sexually transmitted infections or pregnancies, also can be indicators.

“This is a public health issue, so we need health care providers to not only be trained in identification, but then linkage and follow-up and support for this population,” McGrath says.

Having a close eye on the community also is key to identifying victims and removing them from dangerous situations, advocates say. But health care’s role doesn’t end with recognizing someone is being or has been exploited.

“The health care system right now, understandably so, is very focused on identification of survivors,” Ravi says. “What I think my role in this movement is, ‘OK, you’ve identified someone. What does long-term care look like for this population?’ There’s no data out there on what a sixth visit looks like, or lifespan or quality of life, or what the mental health issues long-term are.”

Gaby Galvin, Staff Writer

Gaby Galvin is a staff writer at U.S. News & World Report. You can follow her on Twitter and email her at ggalvin@usnews.com.