A Chance to Help

TMA Looks at Raising Physicians' Awareness of Human Trafficking

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Public Health Feature — January 2016

Tex Med. 2016;112(1):53-57.

By Joey Berlin

They may present with suspicious bruises or distinctive tattoos. They may seem reluctant to say much, letting the older person who accompanies them do all of the talking.

Victims of human trafficking are walking into physicians' offices in Texas and elsewhere, entangling medicine in one of the most appalling and shadowy criminal realms. Their visits put doctors in a unique position to help them escape sexual and labor slavery.

But evidence suggests in many cases, physicians miss that chance. 

A report in the winter 2014 Annals of Health Law compiled responses from a series of focus groups of female sexual trafficking survivors. Of those survivors who answered questions about their health care, nearly 88 percent had contact with a health care practitioner while being trafficked. But the report said health care professionals are missing many of those opportunities for identification, "as even those … who recognized that victims might have been 'on the street' rarely understood that they had a pimp/trafficker." It said at least two prior studies had demonstrated that practitioners are "woefully unprepared" to identify victims of trafficking.

Texas is one prominent epicenter of the U.S. human trafficking trade, accounting for nearly one-tenth of the National Human Trafficking Resource Center's (NHTRC's) tip calls in 2014. The Texas Medical Association Council on Science and Public Health is studying a proposed TMA resolution to raise awareness about human trafficking and inform physicians about the resources they can use to help identify and aid victims.

"We know there's literature that shows that medical providers are some of the only professionals that victims of human trafficking come in contact with during their period of slavery," said obstetrician-gynecologist Melinda Lopez, MD, who founded and ran a clinic for sexual trafficking victims in Austin from 2013 to 2014. "So we are really a window of opportunity for these people who are seeking access to services and to escape their situation. When we're not able to pick up on some of those [signs] ourselves or even know what the risk factors are, or what to do with those after we do identify them, we're missing that opportunity."

No Stereotypical Victim

In 2014, the NHTRC hotline received reports of 1,876 suspected cases of human trafficking or compelling prostitution from Texas, representing nearly 10 percent of calls the center received in the United States. Only California had more, accounting for slightly less than 18 percent of all calls. NHTRC's 2014 data show 71.4 percent of the cases it evaluated were potential sex trafficking cases, 16.2 percent were potential labor trafficking cases, and 3.4 percent were both.

Through June 30 of this year, NHTRC had taken 833 calls referencing Texas in 2015 and recorded 214 cases of trafficking. (See "Trafficking in Texas.")

Data from two FBI task forces show 737 human trafficking-related incidents in Texas between Jan. 1, 2007, and Aug. 31, 2014, according to the Texas Human Trafficking Prevention Task Force's December 2014 report to the state legislature. Texas Department of Public Safety (DPS) data show 381 state arrests on human trafficking charges during that time frame, with 47 convictions for human trafficking, according to the report.

A 2008 state Office of the Attorney General report said nearly 20 percent of human trafficking victims found nationwide had been in Texas, with the Interstate 10 corridor serving as a major point of travel for the illegal trade. 

One notorious hub for trafficking is Houston, where Arlo Weltge, MD, vice speaker of TMA's House of Delegates, practices as an emergency physician. Dr. Weltge says identifying and helping the victims is a different, more complicated process than directing an abused spouse to help outside the hospital setting.

"This is a process of having to recognize the issue first and then being aware of the resources," he said. "So it is a much more complex [issue] and I think in many ways is being missed below the surface. I will tell you, just for me, that I'm probably missing a fair number of these that are just difficult to recognize."

Ted Held, MD, an assistant professor at The University of Texas at Austin and an obstetrician-gynecologist, says no one knows just how widespread human trafficking is. Dr. Held aided Dr. Lopez in founding the Hope Through Health clinic, which provided group therapy and meals for trafficking survivors and their families. The clinic, which Dr. Lopez founded through CommUnityCare Health Centers, closed after Dr. Lopez completed her residency and went to work at People's Community Clinic in Austin.

"Physicians in general aren't trained to screen patients to ascertain whether or not they're potential victims of sexual trafficking," Dr. Held said. "And because we don't screen for it well and we don't ask the right questions, we don't know the extent of it."

Texas' large border with Mexico makes the state an entry point for international trafficking victims, but young American citizens are also susceptible to recruitment and enslavement by traffickers. Angela Goodwin, director of investigations for Texas Child Protective Services, says when she worked as a prosecutor in federal courts in Houston in 2008 she had the opportunity to handle a human trafficking case. She asked her superior, a deputy criminal chief, what country the victims were from, assuming they weren't American citizens. But they were.

"I'd been prosecuting child sexual abuse cases for years. I had no idea of this whole underworld that was going on, of United States citizens, teenage girls, falling into the hands of these pimps," she said.

The Texas Department of State Health Services (DSHS) offers a domestic minor sex trafficking prevention program for staff and health care practitioners. David Gruber, assistant commissioner for regional and local health services at DSHS, says now that he's begun getting involved in trying to prevent trafficking, "it's hard to leave it. It's become a bit of a passion."

"Just picture or feel what it's like to have a child disappear off the street to begin with, and now know that child is being forced into doing things against their will, and horrible things," Mr. Gruber said. "It's just hard not to want to do something about that. I think the key thing is that every child is susceptible to being lured away. It's not [any] stereotypical type of kid."

Knowing the Signs

Human trafficking victims exhibit physical signs of abuse, and physicians can learn to glean clues from how the patient behaves. (See "Potential Signs of Trouble.")

Mr. Gruber says traffickers will often brand their victims with a tattoo of a bar code. Bruising or evidence of trauma for which the patient can't provide a good explanation can also be a sign, as can a history of multiple unintended pregnancies or sexually transmitted infections.

The patients' interactions with health practitioners and any other people who might have accompanied them to the visit can provide insight into abuse. If the patient has a chaperone who seems to control what the patient is saying, it can be a troublesome sign. Dr. Held says he's encountered similar situations.

"Sometimes, we'll see patients come to labor and delivery who've had no prenatal care, and they're accompanied by a male who doesn't seem to be their romantic partner yet is very controlling," he said. "And that certainly raises red flags, and we've caught a couple of cases that way." 

Although a patient who's a trafficking victim can potentially tip off a physician by acting overly guarded, that lack of openness can also be one of the reasons practitioners don't realize they're seeing a victim. 

"They also might be very suspicious of any type of professional," Dr. Lopez said. "They might've been told by their trafficker that their family would be harmed if they talk to anybody or that they themselves would be harmed."

But Dr. Lopez says the biggest barrier for doctors in catching trafficking cases is simply time.

"We're limited on how long our encounters are, and a lot of these patients have very valid physical issues that we need to address," she said. "When it gets outside the realm of physical and more into the social realm, that can be overwhelming. And for us to stay on schedule and just get to our other patients, we sometimes have to limit what we discuss with the patient."

If a physician doesn't have enough time with the patient to dig deeper, Dr. Lopez says it's best to turn the case over to a social worker for further evaluation.

"[For] the social workers, hopefully, human trafficking should be on their radar, and there's some screening questionnaires out there that they can go over with the patient to see [if] they do identify a survivor or a victim of trafficking."

From there, if the social worker suspects the patient is the victim of a crime, he or she can take the case to law enforcement.

The Value of Education

Once physicians know what to look for, they'll begin to know when a potential trafficking victim shows up in their exam room, Ms. Goodwin says. She notes DPS troopers learned those signs through the department's Interdiction for the Protection of Children (IPC) program, with dramatic results.

In 2008, Texas had more than 57,000 reports of missing children, according to an FBI Law Enforcement Bulletin article on IPC in February 2015. But while DPS troopers made nearly 2.9 million traffic stops that year, the department's database showed troopers recovered no missing children during those stops. DPS developed the IPC program out of recognition it needed to train its troopers to identify suspicious behaviors associated with missing children and child abductions.

"This training teaches the troopers to pay extra attention to the children in the car and try to find out how they are connected with the adults in the car," Ms. Goodwin said. "And they'd even be [separating] the kids out a little bit and asking them a few questions to determine their safety."

DPS began training its troopers in 2009. Since 2010, according to the Law Enforcement Bulletin, the DPS database had recorded recovery of more than 139 missing or sexually exploited children and 47 resulting criminal investigations involving child pornography, child sexual assault, child enticement, child abduction, and human trafficking.

Like DPS troopers, Ms. Goodwin says physicians will know when to act once they've had the proper training.

"Of course it's [about] treating the medical condition of the child," she said. "But it's also stepping back and looking at the whole picture. I think they'll start picking up on signs, and even more cases will start to get referred to law enforcement."

Dr. Lopez, one of TMA's current representatives on the state's Human Trafficking Prevention Task Force, says education for anyone working in a medical care setting is the starting point. She says community education is important, as well, because human trafficking is everywhere.

"It's in rural areas; it's in urban areas; it's in every state in the country," she said. "So it's not something that's just isolated to bigger cities. We should be raising community awareness as well and reaching out to parts of the community that might not be aware that they're living right next door to people who are being trafficked, to let them know what their resources are and how they can report anything suspicious."

With traffickers often exerting tight control over their victims, Dr. Held says, the victims won't often walk in for primary and preventive care. 

"Really, the one place that physicians potentially interact with these patients is emergency rooms and urgent care centers," he said. "When there's an acute health problem not related to trafficking necessarily, they tend to present for care. So I do think that there's a need for education in the medical community, but I think that that education should really be targeted to the emergency room and to urgent care centers."

Dr. Weltge says a TMA resolution to raise physicians' awareness of trafficking would be a step in the right direction. The Council on Science and Public Health is preparing a report on the proposed resolution for TMA's 2016 Winter Conference, where it will finalize its recommendations on the resolution for House of Delegates' approval at TexMed 2016. TMA's Medical Student Section introduced the resolution.

Mr. Gruber says more physician involvement in identifying trafficking victims and taking subsequent action represents "an opportunity to intervene, to break the chain of events."

"I can compare it to being primed for Ebola or a highly contagious infectious disease or the doctor in Florida who identified the anthrax case way back in 2001," he said. "If you're attuned to something, you have a better chance of being able to recognize it. So if we can educate those in the medical community on signs and symptoms, much like we do for signs and symptoms of disease, then there's a chance to do some good."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


Potential Signs of Trouble

Signs physicians can look for when examining a potential victim of human trafficking:  


  • A history of unintended pregnancies or sexually transmitted diseases;
  • A pattern of bruises or evidence of trauma the patient can't adequately explain; 
  • A tattoo of a bar code or of a street name somewhere on the body, especially on the neck;
  • The presence of a chaperone or other person accompanying the patient who seems to control the patient's dialogue or around whom the patient seems especially guarded; and
  • Large amounts of cash on hand. 
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