Hospitals train staff to spot victims of human trafficking

Dr. Aisha Mays, a family physician at the Native American Health Center in Oakland, Calif., uses a one-question survey—“Have you ever traded sex for money?”—to try to identify victims of commercial sexual exploitation.

She recalls a day last year when a nervous 16-year-old girl entered her clinic accompanied by a much older man whom she called her boyfriend. The girl complained of symptoms Mays thought likely indicated a sexually transmitted disease. After the man reluctantly left the exam room, Mays diagnosed the girl with gonorrhea, treated her with a shot of ceftriaxone and gave her a firm order: No sex for a week.

“When I said that, she looked at me like she'd seen a ghost,” Mays recalled. “She asked me if I was serious, and when I said yes, she asked me to write the order down on a prescription pad. When she left, I saw her show the note to her boyfriend.”

A few weeks later, the girl returned to the clinic alone. Mays asked her directly if someone was making her trade sex for money. “She said yes, and we were able to connect her with services that day,” Mays said.

Although human trafficking is often thought of as an issue faced by other countries, it's a growing problem in the U.S., affecting nearly every region, experts say. Hundreds of thousands of U.S. citizens, legal residents and foreigners brought to the U.S. are at risk of being trafficked for commercial sexual exploitation or forced labor each year, according to the Polaris Project, a Washington-based anti-trafficking group.

Experts who have studied human trafficking say a victim's most promising lifeline could be a healthcare provider—if that provider knows what to look for. That's why a number of hospitals and health systems around the country have launched training programs for their staff on how to identify and treat trafficking victims. Some states, including Florida and Michigan, now require healthcare workers to receive some type of human trafficking training as part of their regular licensing process. Michigan's law passed in January as part of a package of trafficking-related legislation.

In 2014, Wichita, Kan.-based Via Christi Health launched a training program aimed at teaching its physicians, nurses and other staff how to spot the telltale signs of trafficking, including patients who appear younger than their stated age and patients who report having an unusually high number of sexual partners. The program was developed with the help of Dr. Jeff Barrows, director of U.S. training at the anti-trafficking group Hope for Justice, based in Nashville.

The first training session drew 125 clinicians, and subsequent sessions have attracted several hundred each, said Skip Hidlay, Via Christi's senior administrator of communications. Hospital officials credit the program with helping clinicians identify and assist seven trafficking victims since the training began.

Massachusetts General Hospital launched its trafficking initiative in 2008. Since then, Dr. Wendy Macias-Konstantopoulos, medical director of the human trafficking initiative at the hospital, said she and her team have focused on healthcare worker training. They have presented webinars and provided other resources, and have led more than 80 trafficking-focused grand rounds across the country and abroad.

Physicians and nurses who attend such training sessions often realize to their chagrin that patients they've treated in the past may have been victims, said Dr. Holly Atkinson, director of the human rights program at the Icahn School of Medicine at Mount Sinai Hospital in New York. “I've led grand rounds where physicians have come up to me afterwards and told me about patients they saw multiple times whom they labeled as 'difficult,' ” Atkinson said. “After the training, it occurred to them these patients might have been trafficked.”

Nearly 88% of trafficking survivors reported having some kind of contact with the healthcare system while they were trafficked, according to a 2014 study in the Annals of Health Law. “No other sector plays a more critical role,” Barrows said. The bad news is most healthcare providers know little to nothing about trafficking and receive no training on how to identify and help victims. “The vast majority are absolutely clueless,” Barrows said. “Only a handful are looking at it seriously.”

Macias-Konstantopoulos acknowledged that few hospitals have comprehensive training and victim-assistance protocols in place.

But she said awareness and action among healthcare providers is steadily growing. “I've been doing this work since 2006, and when I started, it was very quiet,” she said. “Over the years, I've seen a big increase in interest on the topic. Hospitals and healthcare providers are starting to engage more than ever before.”

Others in the field agree that there's been an uptick in interest from healthcare providers. Natalie Garnett, assistant national director of UnBound, a faith-based anti-trafficking group with an office in Waco, Texas, said local hospitals are approaching her group to host training sessions, including one in May attended by staff from Baylor Scott & White Hillcrest Medical Center.

“Our ERs and clinics are seeing these victims,” Garnett said. “If our medical professionals are trained, they might be the ones who can help.” Last year, the National Human Trafficking Resource Center received reports of 5,042 potential trafficking cases in the U.S., nearly one-third of them involving victims under age 18. Among minors, most cases involved sexual exploitation while 9% involved labor.

In the U.S., for example, 16 juveniles were rescued in a two-week FBI crackdown on sex trafficking in the New York-New Jersey area leading up to the 2014 Super Bowl game. The minors were ages 13 to 17 and included high school students and children reported missing by their families. In 2010, a federal grand jury indicted labor contractors on charges that they forced about 400 Thai guest workers to toil on farms in Hawaii and Washington state to pay off debts in Thailand. Globally, human trafficking is estimated to be a $32 billion industry with 2.5 million victims, according to United Nations data.

The red flags are there if healthcare staffers know how to spot them, experts say. Trafficking victims may not know what city they are in. They may have a fearful, submissive demeanor or have tattoos bearing someone's name. A victim may be accompanied by a controlling companion who insists on answering providers' questions. There may be signs of physical abuse and trauma. And for labor-trafficking victims, red flags can also include hearing, vision, cardiovascular or respiratory problems from working in unsafe conditions.

Provider training typically focuses not only on red flags, but also on strategies for intervention, such as interviewing techniques and tips for working collaboratively with law enforcement and other local agencies. Hope for Justice's Barrows said hospitals and clinics should proactively reach out to law enforcement and other groups so they have solid relationships in place when they identify a victim.

Experts say children's hospitals are, in many cases, ahead of the curve when it comes to educating their staff about trafficking. At Children's Healthcare of Atlanta, for instance, all new clinical staff undergo training, and current staff are encouraged to participate. The hospital also has a six-module webinar series on human trafficking.

Demand for those webinars “skyrocketed” in the last half of 2014, said Angie Boy, program manager at the hospital's Stephanie Blank Center for Healthy Children. “We used to see demand from healthcare professionals in Georgia but now we have much more of a national audience,” she said.

Macias-Konstantopoulos serves on a technical working group for an HHS pilot project that trains healthcare workers to identify trafficking victims. Through the program, known as the SOAR—Stop, Observe, Ask and Respond—to Health and Wellness Pilot, HHS hosted training sessions in six cities last September. Attendees were required to take a survey before the training, another immediately afterward, and a third follow-up survey three months later to see how well they retained the information.

HHS is analyzing data from the SOAR pilot and may scale the program up if the results are promising, she said.

In March, Macias-Konstantopoulos spoke at a daylong trafficking training session in Berkeley, Calif., attended by more than 100 healthcare providers. “We had a few physicians who traveled all the way from Texas,” she said.

Even with high-quality training, providers still have to look at all of the signs together and trust their instincts. “There's an array of red flags, and no single one is specific and indicative of trafficking,” Macias-Konstantopoulos said. “We always say you need to put your thinking caps on and put the pieces of the puzzle together.”

It would also help to have a validated and easy-to-use screening tool, especially in a busy emergency department, said Dr. Alan Janssen, director of the emergency medicine residency at Genesys Regional Medical Center, in Clio, Mich. He and his staff are starting to use a six-question tool developed by Dr. Jordan Greenbaum at Children's Healthcare of Atlanta.

It consists of quick and straightforward questions, such as “Have you ever run away from home?” and “Have you had more than five sexual partners?” Those questions successfully detected 92% of trafficking victims in a study, Greenbaum said. The results are encouraging, but the sample size was small and results were from only one site. “We're now trying to pilot and validate the tool in EDs and clinics across the country,” she said.

Michigan State Sen. Rebekah Warren, who sponsored her state's legislation requiring healthcare workers to receive training, said she was drawn to the issue after speaking with one of her constituents, a foster mother of three sons who were trafficked from the African country of Togo to the U.S. as forced laborers. A dentist who treated the three boys recognized that their paperwork did not match their ages and medical histories. He notified authorities and the boys were rescued from their trafficker and placed in the woman's care. “For me, it shined a light on the fact that healthcare professionals can really help if they know the signs,” Warren said.

Some say there's a need for national action to increase healthcare workers' awareness of the problem. In April, U.S. Sen. Gary Peters (D-Mich.) announced he was co-sponsoring the Trafficking Awareness Training for Health Care Act of 2015. The bill would provide federal funding for a medical or nursing school to develop a healthcare professionals training program. That grantee would then select 10 sites to pilot the training program.

The best approach remains to be seen, said Macias-Konstantopoulos, who cautioned that government-mandated training could spark resistance among healthcare providers. But greater awareness can save victims' lives. “As easily as they come through our doors, they walk right back out again,” she said. “We have a window of opportunity that so far we haven't been able to take advantage of. That needs to change.”