BY: JENNIFER COX
Illustration by Kasia Bogdanska
A young woman who has endured sexual abuse since the age of 5. She is now grown up, but the abuse continues at the hands of more than 20 pimps.
A young boy whose mother sold him, at age 7, to a landlord for sex so she could make the rent payment and they would not end up homeless.
A woman who enters an emergency department, beaten once again by her pimp. She has a broken jaw and another sexually transmitted disease. She also has wounds buried so deeply in her mind that it will take years to help heal the memories of her suffering, if she chooses to try the challenging journey toward resiliency.
A young woman who enters a hospital labor and delivery department. Throughout her pregnancy, she was sold for sex and not allowed to visit a doctor or seek prenatal care. Now she is ready to deliver her baby and faces questions about her health and the pregnancy. She feels guilt, shame, fear and very alone.
These are glimpses into very real events in the lives of human trafficking victims.
THE PATH TO RESILIENCY
Human trafficking is mostly a hidden crime, and it often goes unnoticed unless you have the privilege of encountering survivors who have the courage to tell you about it.
Sawan Vaden is a program manager at Community Against Sexual Harm, a Sacramento, California-based agency providing survivor-led peer support and harm reduction services for commercially sexually exploited women. A peer mentor in the program, Vaden is a survivor of human trafficking. She was exploited at a young age and experienced years of trauma and abuse.
"The first memory of suffering I have is connected to being abandoned, at age 11, as I watched my father drive away, leaving our family of 12 to survive on our own," she said. "I was angry, and after a time, I could no longer stay in the sadness and poverty that surrounded me."
In a calm, steady voice, Vaden described how, at age 12, she ran away, only to find herself aimlessly wandering the streets. Eventually she met a woman who said she was pretty and lured her with promises of food, a place to live, nice clothes, having her makeup and nails done. The 12-year-old ended up on an airplane to Arizona, where she was to be taken in by a "new family." Soon she was taught that joining this "family" meant being traded from pimp to pimp in order to learn the tricks and trade of what they called "the life" — prostitution.
Vaden said she survived only by numbing herself, becoming disassociated from reality, which she now knows is a coping skill the mind uses during traumatic events. Every now and then, an unremarkable event — perhaps a whiff of something spoiled in the refrigerator — triggers memories of days she couldn't bathe, rest or receive normal care for her personal needs. She vividly recalls how she felt unhealthy and dirty to the point that to her, her own flesh smelled like it was rotting.
TRAFFICKING
According to the National Human Trafficking Hotline, there were 8,524 cases reported in 2017. When it was possible to collect demographic information, the hotline found that 5,278 of the reported cases were adults and 2,495 were minors; 7,067 were female and 1,124 were male; 1,947 were U.S. citizens and 1,510 were foreign nationals.1
Trafficking occurs around the world, but trafficked persons often go unnoticed, even though most receive medical or health services at one time or another in clinics, emergency rooms or physicians' offices. According to a 2014 study published in the Annals of Health Law, nearly 88 percent of the sex trafficking survivors who were surveyed reported that while they were being exploited, they came into some kind of contact with health care providers.2
Similarly, a 2017 survey report from the Coalition to Abolish Slavery & Trafficking found that more than half of labor- and sex-trafficking survivors surveyed had accessed health care at least once while being trafficked. Nearly 97 percent of them indicated they never had been provided with information or resources about human trafficking while visiting the health care provider. As these studies underscore, medical care providers too often are unprepared to identify and appropriately respond to trafficked persons. It is a challenge health care must address, so as to create opportunities for provider training in understanding red flags for human trafficking, trauma-informed care, and how to access referrals in supporting victims they encounter. This could potentially create a safety net for victims nationwide.
SURVIVORS AND HEALTH CARE
"First time I went to the ER, it was because I got beat up. I was questioned a lot, the police were brought in, and people started taking pictures. No one told me what was going on, I was freaked out and uncomfortable. I was coming to the ER for help, with confidential information about my situation, but so many people just kept coming in and out of the room. I told staff I didn't want them to tell anyone I was there, but when I woke up — I was so scared, he was now sitting next to me. Hospital staff don't know how it is, but I know my pimp doesn't care how many black eyes I have, if he thinks I said something to you, that is how it goes."
A human trafficking survivor told this to Tara Stowbunenko, a patient advocate with Dignity Health and WEAVE Inc., a crisis intervention nonprofit in Sacramento. Stowbunenko supports human trafficking survivors within the medical safe haven at Mercy Family Health Center – Dignity Health in Sacramento.
Researchers Elizabeth Hopper, PhD, and Laura Gonzalez, MA, described human trafficking as "a form of interpersonal trauma that has significant mental health impacts on survivors."3 Their study of psychological symptoms in 131 survivors of sex and labor trafficking identified high rates of depression (71 percent) and post-traumatic stress disorder (61 percent). Two-thirds of the survivors also met criteria for multiple categories of Complex PTSD.
Health care providers noticed that patients with these kinds of symptoms were turning up in Dignity Health hospital emergency departments. In the fall of 2014, Page West, Dignity Health's senior vice president of patient care services and system chief nurse executive, and Bernita McTernan, Dignity's former executive vice president for sponsorship, mission integration and philanthropy, launched a systemwide program in partnership with Dignity Health Foundation to ensure that trafficked persons are identified in the health care setting and that they are assisted with victim-centered, trauma-informed care and services.4
Sacramento-based physician Ron Chambers is director of the family medicine residency program at Dignity Health's Mercy Family Health Center, and he is the physician adviser for Dignity Health's human trafficking response program. Chambers became aware of human trafficking during system-led training, and he realized there was no education for medical residents that focused on human trafficking and trauma-informed, victim-centered care.
He saw to it that all residents and clinic staff received training, then took it a step further by championing the creation of a safe-haven medical clinic where a team of specially trained physicians would provide health care and coordinated resource referrals for trafficking survivors.
Mercy Family Health Center's model gives survivors access to care geared for their complex needs. Survivors often are emotionally shut down and disassociated from their experiences, so their appointments are scheduled with extra time for the medical team to build trust and to slowly, gently uncover layers of abuse and trauma as the medical history emerges. In caring for those who have experienced severe suffering, it is crucial to employ patience and trauma-informed listening and, as Chambers emphasizes, "above all else, have empathy."
For patients, a visit looks very much like this: A young woman (we will call her Janise) walks into the Mercy Family Health Center and is greeted warmly by the receptionist. Everyone on staff is ready to engage his or her trauma-informed training and skills to ensure each patient benefits from a seamless and supportive environment.
Patients who have been trafficked are not openly identified as such. During clinic hours for human trafficking survivors, physicians and staff make a point of giving a smile or nod to any patient passing by in the hallway — a respectful acknowledgment of the patient's presence.
Janise is escorted to an exam room, and a patient advocate comes in to greet her and anyone she may have brought for support. It is important for survivors to know they can be accompanied during their appointment if they wish.
The protocol for human trafficking clinic hours is to make individual appointments flexible in terms of time. It may take up to an hour or more in order to build a patient's sense of safety and trust. Clinic staff are careful to communicate respect to the patients; Janise is encouraged to choose where she wants to sit in the exam room; she is assured that whatever questions the physician asks, she is free to answer to any extent she is comfortable, and she can take her time — this is not a hurried appointment.
Resident physicians who provide care for human trafficking patients at Mercy Family Health Clinic develop their own perspective on working with this patient population. Some say they are reminded of what brought them to choose practicing medicine in the first place.
One resident physician (unnamed by request,) said, "Here, in our medical safe haven, I feel a huge sense of purpose and gratitude to work with victims of human trafficking, who often have no voice. As providers it is our duty to give them a voice. I feel that their struggles are beyond the scope of my understanding and many others in society who have not undergone the psychological, emotional and physical torment they have. However, I feel it is my duty as a physician to ask deep questions, to uncover truths, and to provide patients with avenues to seek support towards their journey of recovery."
RESOURCES FOR HEALING
City of Refuge is a human trafficking response agency located in a Sacramento urban neighborhood. Co-founder Rachelle Ditmore walks daily with the broken: victims of sex trafficking, as well as young boys who are being groomed by friends and family to become the next-generation pimp. Ditmore works to provide clients with stability, hope and tools to build self-worth and strength needed to withstand the lure of sex trafficking.
She has linked clients to the medical safe haven in order to provide them resources for stabilization and healing.
"A woman and her daughter (we will use the names Sheena and Alisha) needed our help …immediately!" Ditmore said. "Sheena was belligerent, so filled with pain, and needed shelter and intervention. Sheena's child, Alisha, age 6, was now in the care of [child protective services] due to neglect, drug addiction and abandonment that tragically left the child exposed to familial molestation."
Ditmore describes how clients' stories may differ in texture, but they carry the same threads of violence, abuse, exploitation, sorrow, neglect and trauma. Such suffering can be generational. Sheena herself had been a child left on her own whenever a pimp drove her mom away to work. The child would run after them, crying. Sheena's mom also was addicted to drugs, resulting in Sheena being moved in and out of foster care, taken to a variety of family members' homes and, tragically, exposed to familial molestation at the age of 6. Just as Alisha has been.
"Identities are fractured by exploitation and suffering, and when you have a blank slate of identity, there is an evil world waiting to define you," Ditmore said. "When you come from a poor family, or no family, you don't want to struggle, and [you] have a will to do whatever it takes to make it. Girls in this situation are vulnerable to the accessibility of nice things that a pimp will provide; clothes, hair and nails done, going out to eat, and the knowledge that you can make $1,000 a day, even though you don't keep the money yourself. Then the abuse starts when you want it to stop. The pimp won't let you make a choice like that."
Chambers frequently provides human trafficking training and information about creating a medical safe haven for survivors. He speaks to physicians at local and national symposia and conferences in order to bring awareness to the scope and prevalence of human trafficking and discuss how to create access for survivors within a health care setting.
"You can't open up many medical textbooks that have any information about human trafficking in them," he said. "How do we know what labs to order? How do we know what medications are appropriate? It's heavy-duty PTSD that we're dealing with."
Chambers and his team have begun to expand the medical safe haven model throughout the nine Dignity Health physician residency programs. He notes, "This is a start. There are 537 residency programs within the U.S. By incorporating human trafficking training into residency programs, we are training the physicians of tomorrow who will be able to more effectively identify victims and provide trauma-informed and victim-centered care."
"Seeing these patients, hearing their stories and playing a role in their care has brought me back to the roots of why I wanted to be a physician," he said. "The trauma many of the victims and survivors have endured is enormous, and their road to recovery may be long. It will take them time to heal. I am constantly humbled by the privilege to walk it with them."
We can all do our part in responding to the suffering of those who have experienced human trafficking. Awareness is the first step, and then staying vigilant to perceive those who might be silently suffering and in need of support.
JENNIFER COX is the family medicine residency program manager for human trafficking, Mercy Family Health Center, Dignity Health. She also is a steering committee member for Dignity Health's human trafficking response program. She has served as a nonprofit leader, speaker and community-based collaboration specialist for more than 25 years in Sacramento, California.
NOTES
- National Human Trafficking Hotline, "Hotline Statistics," website. https://humantraffickinghotline.org/states.
- Laura J. Lederer and Christopher A. Wetzel, "The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities," Annals of Health Law, 23, no. 1, (2014).
- Elizabeth Hopper and Laura Gonzalez, "A Comparison of Psychological Symptoms in Survivors of Sex and Labor Trafficking," Behavioral Medicine, March 2018.
- Dignity Health, Human Trafficking Response Program — Shared Learnings Manual, "Background of Human Trafficking Response Program." www.dignityhealth.org/humantrafficking.