An unspoken chief complaint

Family physicians are at the forefront of our communities’ health. We rise to confront public health challenges and advocate diligently for our patients. I have known this to be true since medical school but now as a community medicine fellow, I realize there are unseen public health concerns that I am well positioned to address but not well equipped to—one being the impact of trauma on health.

Providing care in community and academic settings has increased my awareness of the value of recognizing trauma in the health care of my patients. I observe how adverse childhood experiences, exposure to crime, unsafe neighborhoods, and violence have affected a patient’s physical or mental health. I think about how these problems can be a barrier to seeking necessary care by members of my community.

Among multiple types of trauma, human trafficking has been an issue I have focused on during my fellowship. The United Nations Office of Drugs and Crime defines human trafficking as “the acquisition of people by improper means such as force, fraud, or deception, with the aim of exploiting them.” The most common forms are sex and labor trafficking. It is extremely complex and challenging to address due to its hidden and criminal nature. Human trafficking is an issue in Texas. The National Human Trafficking Hotline reports Texas is number two in the nation in number of calls received.

There are limitations that can prevent physicians from recognizing trafficked victims. These include knowledge, training, time, and resources. Learning more about human trafficking has made me certain that I have interacted with victims in my clinic, during my OB-GYN rotations or in the emergency room. I just did not realize it then because I wasn’t looking for red flags. Multiple studies report that about 30-80% of survivors were seen by a health care provider while being trafficked.1 Health care sites thus provide an opportunity for intervention.

Conversely, there are limitations that prevent victims from seeking help when in health care settings. A few of these limitations include fear, lack of trust, threats from their trafficker, language barriers, and lack of awareness of legal protections.

I recall a 17-year-old Caucasian female during my OB-GYN rotation who presented in labor and her much older male friend was the only one who would come by the hospital, often at odd times. There was also the elderly Hispanic female who offered to help a family member with her children and ended up being held against her will to provide domestic help. Mandated reporting and legal concerns thankfully could guide our response in these situations.

However, I always think of the 20-year-old African American female who would come to the emergency room every other night during my rotation believing she had an STD. There was a certain level of discomfort in our interaction and in retrospect, asking the right questions may have helped identify if she was a possible victim.

I have learned that an important step in providing care for victims of human trafficking is that I learn the signs, respond with a multidisciplinary approach and know how to incorporate trauma-informed care into my practice, focusing on resisting re-traumatization. The Substance Abuse and Mental Health Services Administration, or SAMHSA, provides six principles of a trauma-informed approach.

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration
• Empowerment and choice
• Cultural, historical and gender issues

I am also fortunate to have behavioral health integrated in our teaching site, which offers expanded services to patients who have been victims. Also social work support has helped with community resources. Some patients or their families are more willing to disclose certain issues when they know resources are available.

Some tools I have found useful—recommended by the AAFP—when addressing human trafficking include SOAR, the Stop Observe Ask Respond to Human Trafficking modules provided by a partnership with the U.S. Department of Health and Human Services. The Health, Education, Advocacy, Linkage (HEAL) trafficking network also provides tools to guide practices on training and implementing multidisciplinary procedures and protocols. Additionally, it has been helpful to know which organizations in my community are serving victims and survivors of human trafficking to ensure appropriate referrals are made.

It is probable that we will meet a victim of trafficking in our health care setting and it is critical that we can identify red flags while being aware of helpful resources. I encourage you to start the discussion on including training opportunities at your practice site. As with many public health challenges we stand up to every day, family medicine physicians are well positioned to be part of the anti-trafficking efforts in our communities.

Resources

SOAR for Health Care

Health, Education, Advocacy, Linkage

Substance Abuse and Mental Health Services Administration trauma and violence resources

The National Human Trafficking Hotline: (888) 373-7888 (TTY:711) | Text 233733

1. Schwarz C, Unruh E, Cronin K, Evans-Simpson S, Britton H, Ramaswamy M. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health Hum Rights. 2016;18(1):181–192

Victoria Udezi, MD, is a community medicine fellow and assistant instructor at the UT Southwestern Department of Family and Community Medicine.