Doctors often unaware they are treating human trafficking victims

Jasmine was sold for sex in the Boston area for years. The primary care doctor she saw during that time had no clue that she was a virtual prisoner, a victim of human trafficking.

Every clinician fears the missed diagnosis. For this doctor, it was hiding in plain sight. Jasmine frequently came into the clinic to be checked for a sexually transmitted disease, worried that she had been infected even though she regularly used condoms and a bleach douche if the condom broke. More often than not she showed up with bruises and bumps. She struggled with addiction. And as a result of a head injury, she experienced chronic headaches.

To a clinician on the lookout for human trafficking, these were telltale signals that Jasmine was a victim of it. But trafficking wasn’t on Jasmine’s doctor’s radar, who missed critical opportunities to disrupt her cycle of violence.

Human trafficking means using women and men, girls and boys against their will in underpaid and under-regulated industries that include domestic work, restaurants, commercial sex, agriculture, construction, nail salons, and more. It happens to Americans and immigrants alike. In fact, Jasmine was born in the US in an Italian-American family.

Given its clandestine nature, no one knows the true scope of human trafficking. By one estimate, 21 million individuals are victims of this modern-day slavery.

At its core, trafficking is treating a human being as a commodity, exploiting him or her for profit. Victims become trapped through combinations of extreme psychological manipulation and shaming, financial bondage, rape, and physical abuse. Today, a growing number are bound to their traffickers by the perfect leash of a heroin or opioid addiction, with the trafficker maintaining control by manipulating their highs and lows. When victims are no longer profitable to a trafficker, they are discarded; some are left to die.

I didn’t have a single “aha” moment about the connection between human trafficking and health care. I heard about it in medical school, but it blended in with all the other things I was learning. When I heard about it again during my residency in emergency medicine, something clicked and I realized I had probably missed those telltale trafficking signs in many patients I had treated: the malnourished construction worker, the pregnant woman with unexplained bruises who could speak only Cantonese, the suicidal drug user, and more.

I still wonder how things would have been different for them had I known about trafficking and somehow tried to stop their exploitation. I dream that I could have been part of their journeys to freedom. Instead, unaware of the true diagnosis — trafficking — I just treated their medical problems and released them from the emergency department.

Once I began to look in earnest for signs of trafficking, I began to see them. The first patient I recall identifying as likely being trafficked was a 20-something woman hooked on heroin who came into the emergency department suicidal and asking for detox from her addiction.

The more I realized that human trafficking wasn’t a rarity, I wanted to awaken my colleagues to the plight of this vulnerable population that many of them are not truly seeing. So I cofounded HEAL Trafficking in the fall of 2013. Today, HEAL Trafficking unites more than 800 health professionals around the globe to combat trafficking from a public health perspective. My colleague, Dr. Makini Chisolm-Straker, and I recently published a book, “Human Trafficking Is a Public Health Issue,” to draw attention to the problem.

Why do we need an effort like HEAL Trafficking? Two-thirds or more of individuals who are being trafficked in the US seek health care during their exploitation. Yet most US doctors assume that trafficking is something that happens in European countries, as in the movie “Taken.”

Just as trafficking can take many different forms, so can its signs. Sometimes they are similar to the signs of domestic violence: bruises at multiple stages of healing, stories that don’t match up with illnesses or injuries, and possibly a controlling individual — female or male — who demands to be part of the health visit. Victims of trafficking may not know where they are or how they got to the clinic or emergency department. Many don’t have access to their identification documents. They may be malnourished, have late-stage cancer, or bear unusual tattoos or scars from being branded.

The health problems of trafficking victims tend to match what they have been exposed to as a result of their abuse. For a sex-trafficked American with a heroin addiction, it may be HIV and a heart infection; for a construction worker from Honduras, tuberculosis and a broken arm; for the Cantonese-speaking nail salon worker, it may be lung disease or other problems from long hours spent inhaling chemicals.

The mental health repercussions of trafficking are especially pernicious. Many survivors suffer from complex forms of post-traumatic stress disorder, struggle from addiction, or experience unexplained chronic pain. Some become suicidal. Many believe there is no way out. After an unsuccessful suicide attempt, a trafficked patient recently told me, “I wish it had worked. I wish I were dead.”

Doctors can play a special role in breaking the cycle of human trafficking. We meet people in moments of vulnerability. If we approach all of our patients with humanity and humility, they may entrust their deepest, darkest secrets, including being trafficked. It requires us to interrupt our rhythm of work, to look beyond the medical issues at hand and treat the whole person.

Responding to a patient’s disclosure of being trafficked must be victim-centered, multidisciplinary, trauma-informed, and culturally and gender sensitive. In other words, it isn’t something a clinician should make up on the spot when a patient discloses that she or he is being trafficked. That’s why HEAL Trafficking has designed a protocol toolkit to help health systems design their responses. The National Human Trafficking Hotline at 888-373-7888 is another source of information. My colleague, Dr. Makini Chisolm-Straker, and I recently published a book, “Human Trafficking Is a Public Health Issue,” to draw attention to the problem.

Jasmine was finally able to break free from her trafficker and is now running a ministry for trafficked women. But for every success story like hers, thousands of children and adults remain in captivity. Doctors can help some of them break free.

Hanni Stoklosa, MD, is an emergency department physician at Brigham and Women’s Hospital, an instructor in emergency medicine at Harvard Medical School, executive director of HEAL Trafficking, and co-editor of “Human Trafficking Is a Public Health Issue” (Springer, February 2017).

Revised to include updates from the author.