BY: JENNIFER COX AND RON CHAMBERS, MD, FAAFP
Illustration by Roy Scott
The victims of human trafficking — which encompasses forced labor and sex trafficking, include men, women and children in all 50 states as well as countries worldwide.1 Trafficking victims experience a range of acute and chronic physical and mental health issues resulting from their traumatic experiences, many of which have lifelong detrimental effects. Nearly every clinic and health care setting likely will see victims of human trafficking at some point,2 but there is an ongoing gap in the field of trauma-informed care, which supports a "safe clinical space" model of care.
Due to insufficient training for providers and limited implementation of survivor-oriented care, many people who have experienced trafficking characterize their interactions with health care providers as re-traumatizing, which deeply threatens their continued access to the services and support they need. The clinical experience or exam room often has not been seen as a safe space for victims and survivors. The Human Trafficking Medical Safe Haven at Mercy Family Health Center, part of Dignity Health Methodist Hospital of Sacramento, is working to change this for victims of labor and sex trafficking.
In 2014, San Francisco-based Dignity Health, in partnership with the Dignity Health Foundation, launched the Human Trafficking Response Program to better identify trafficked people in health care settings and to provide trauma-informed care and services to those who have experienced abuse, neglect or violence, including human trafficking. The health care system educates staff, physicians and other providers, volunteers, and contract employees about human trafficking. Dignity Health provides "Human Trafficking 101: Dispelling the Myths" training with basic education about human trafficking, including definitions, prevalence, common misconceptions and common red flags.3
In Sacramento, a Dignity Health family medicine residency training facility called the Mercy Family Health Center developed the Human Trafficking Medical Safe Haven to provide comprehensive, trauma-informed health services to people who have experienced trafficking.
The Human Trafficking Medical Safe Haven program offers comprehensive services at one location for patients of all ages, including primary and urgent care, X-rays, lab tests and access to hospital specialists. The medical safe haven clinic model is supported by the Dignity Health Foundation and the Sacramento, Calif.-based Mercy Foundation.
Jeanine (whose name has been changed to protect her identity) was only 15 when she first walked through the doors of the medical safe haven in 2016. She was referred by Sacramento County Child Protective Services staff; it was suspected that she was being exploited for commercial sex trafficking. Her provider saw a number of subtle signs that, in context with the patient's presenting concerns, were recognized as red flags for trafficking. She had her head down, with shoulders stooped and didn't make eye contact. She wore a revealing outfit, had a flat affect and an overall submissive demeanor. She was reluctant to discuss her situation, initially asking, "Why am I even here?"
The provider used survivor-informed practices and interview techniques to establish a sense of safety for Jeanine. The teen eventually disclosed she was being sold nightly on the internet for sex. She had been coerced into "the life" by a trafficker with whom she was still involved. Upon examining her, we determined that she was experiencing depression and anxiety. She lacked many of the support systems necessary to keep her safe and out of harm's way.
In a traditional health care setting, she might have been given medication for her conditions and sent on her way. But at the medical safe haven, instead of just treating her symptoms, we focused on her safety and healing, and provided or connected her to resources including therapy, medication management and a supportive advocate, who could help her regain control of her life and recover from her trauma.
A TRAUMA-INFORMED APPROACH
The strength of a trauma-informed approach within a medical clinic setting is that patients who may have in the past experienced re-traumatization through judgment, stigma, impatience and lack of empathy are now welcomed into a safe space where they are supported and cared for in a non-judgmental, empathetic way that focuses on their healing first and foremost.
The safe and healing clinical environment created within the medical safe haven was built upon the standards outlined in the Survivor-Informed Practice assessment tool, developed by fellows of the 2017 Human Trafficking Leadership Academy, organized through the National Human Trafficking Training and Technical Assistance Center and Coro Northern California.4 A team of six non-government service providers and six leaders who were trafficking survivors worked together to develop recommendations on how to enhance service provision to those at risk of human trafficking or trafficking survivors using trauma-informed practices and survivor-informed principles. The human trafficking medical safe haven meets a 30/30 rating on the survivor-informed best practices assessment tool, primarily because it engages and values the voices of survivors, those who have experiential knowledge in accessing health care while being trafficked and who can speak to what constitutes a safe and healing space.
Survivors have shared with the medical safe haven team their prior experiences in health care settings. One of the medical safe haven patients said, "When I went to an ER because my pimp beat me up, I felt judged, like I was just another drug addict." Unfortunately, at many clinics across the country, providers often lack the training, resources and institutional support to provide trauma-informed care. For the victims and survivors of human trafficking and other forms of violence and trauma who enter these clinics, their interactions with health care providers are frequently characterized as negative or harmful. Our patients have reported feeling rushed through previous appointments by an impatient provider who didn't take the time to ask any questions about how they got there. They've reported long wait times just to get in to see a physician in the first place. They've told us about the social worker who asked pointed questions and seemed to judge everything they said. They've told us how the staff allowed their abuser back into the room after expressly being asked not to. Most of all, they've told us they didn't feel safe.
There is danger in past trauma. Studies have shown us time and again that trauma earlier in life, especially childhood traumas, can have extremely detrimental effects on future health and lifespan.5 Prior trauma greatly increases the risk for several chronic conditions and health-adverse behaviors including depression, alcohol and substance abuse, heart disease, liver disease, chronic obstructive pulmonary disease, risk of intimate partner violence, sexually transmitted diseases and infections, autoimmune disease, financial stress, suicide and self-harm, among others.
Trauma can be associated with a single life event that leaves damaging scars which often go unseen, or a person can experience multiple traumas. A single trauma is limited to one point in time, an incident such as a rape, a serious car accident, the sudden death of a loved one. Repeated traumas are defined as a series of traumatic events happening to the same person over time; they can include repeated sexual or physical assaults, exposure to frequent injury or abuse of others, or seemingly unrelated traumas. Repetitive exposure to traumas can have a cumulative effect over one's lifetime, but single traumas don't necessarily have less psychological impact than repeated traumas. Some repeated traumas are sustained or chronic. Sustained trauma experiences tend to wear down a person's resiliency and ability to adapt. Some examples include children who endure ongoing abuse, people who are in violent relationships and people who are victims of human trafficking.6
According to the Substance Abuse and Mental Health Services Administration's guiding principles of a trauma-informed approach, trauma can significantly affect how an individual engages in major aspects of their life, including ongoing health services. Health care systems and professionals are encouraged to apply trauma-informed care in all aspects of patient care and services, from registering a patient to providing clinical care, in order to more effectively treat patients. The core tenets of trauma-informed care include:7
- Safety: Throughout the organization, staff and patients should feel physically and psychologically safe.
- Trustworthiness and transparency: Organizational operations and decisions are conducted with transparency and with the goal of building and maintaining trust among staff, patients and family members.
- Peer support: Support from clinical peers is integral to the organizational and service delivery approach and is a key vehicle for building trust, and for establishing safety and empowerment.
- Collaboration and mutuality: There is a true sense of partnership between organizational leaders, staff and patients.
The ripple effect from training providers, resident physicians and others on trauma-informed care is that it creates a harm reduction model of care that extends to all patient populations served.
PROMOTING A SAFE ENVIRONMENT
The medical safe haven takes a number of steps tied to trauma-informed care. The practice works to promote a sense of security by bypassing the waiting room and bringing the patient to a private exam room immediately upon arrival. If a patient wishes, a medical staff member or patient advocate stays with the patient during the visit. Appointment times are longer than they may be for other patients, with 45 to 60 minutes for a visit. This allows time to build trust, to review the patient's history and needs, to allow the physician to thoroughly explain laboratory tests needed or results. The longer appointment times also allow for referrals to additional services and time for patient advocate support.
Sex trafficking survivors provided insight on how to create a clinical environment that is welcoming, safe and healing. They said they want to be heard during their visit and valued as decision makers in their care. They told providers to understand that as patients they have challenges remembering their history due to trauma. Survivors expressed the need for providers to be patient with them and not judge them when something may trigger an emotional or psychological reaction during an exam. They may not be able to control when they shut down or become agitated. And finally, they want to make choices. That said having the ability to choose where they sit during an exam, or whether or not they are ready to answer questions regarding their personal and medical history, makes a big difference. They said allowing choices can help them feel safe within the clinic room.
Billing practices also are designed to ensure patient safety and privacy. The medical safe haven sees patients regardless of their insurance coverage. It helps patients without insurance obtain Medicaid, and it directly bills insurance only. That's because billing a patient could put the person at risk, if they are living in an unsafe environment with someone who might harm them. Patients also do not receive a bill for any aspect of their visits, including required labs, medications, and identified behavioral health and mental health follow-up treatments. Most of the safe haven patients do not have the resources to pay for services.
The medical safe haven receives feedback from community agencies, which provide services to labor and sex trafficking victims, and which refer clients to our clinic. Staff at agencies have seen benefits to this care approach.
Sawan Vaden, the anti-trafficking program manager from the Community Against Sexual Harm organization in Sacramento, said, "The very first time I accompanied one of my clients to the medical safe haven, I felt a little nervous and skeptical, not knowing what to expect, but was completely amazed by the level of care that went into this first encounter. I had never experienced or even had an idea that something like this could be a reality for women like us. The doctors at Mercy Family Health Center Medical Safe Haven treat our clients with dignity and respect, never holding back their compassion that compels them to give the highest quality of care. The doctors show kindness without judgment. It is a whole new experience from the past health care they have received, where they did not feel safe enough to talk about the trauma in their life both current and past. This fear led to most of their medical and mental health needs being unnoticed and untreated. Other providers dismissed their stories with disgust or disbelief, but at the medical safe haven they are heard with empathy, (and receive) trauma-informed and survivor-informed care."
Every staffer who interacts with patients receives an annual two-hour training in the tenets of trauma-informed care. Resident physicians complete a 10-week curriculum, including a survivor perspective on health care experiences to help guide best practices. We also stress the importance of safety for our providers as well. Secondary trauma, or taking a patient's trauma internally and experiencing it yourself, is a real challenge for health care providers who work with victims of trafficking and violence. Part of creating our healing space means supporting providers' resiliency, so they can provide our patients with the best possible care and support and so they can look after their own well-being. Providers are not scheduled for initial appointments with patients back to back, giving them time to process any vicarious trauma triggers they encountered during an appointment. They are trained to debrief and decompress, and use grounding techniques, strategies to remain in the present and to try and minimize stress and anxiety.
The clinic also has a patient advocate to support those who have been trafficked. Patient advocate Tara Stowbunenko explained, "If a patient has an appointment scheduled, as a patient advocate, I will call to schedule transportation if needed. I will then speak with the patient to remind them of the appointment and confirm that they have transportation. I always remind them to call or text if there are any issues. The day of the appointment I may send a quick message, 'Hey, just a reminder that you'll be picked up at 12:15 p.m.' When the patient arrives at the clinic, the team is ready for him or her; the provider is often briefed prior to the appointment of any issues that need to be brought up. When the appointment is complete, the provider walks the patient back to the clinic coordinator and patient advocate to schedule future appointments, help make a plan to complete any follow-up lab work, and address any social issues mentioned by the provider and assist with a warm-hand linkage to community referrals." She said patients always have someone providing "a warm hand" to them, assisting with their needs so they are supported. "This helps patients feel safe, which makes it more likely that they'll come back," she said. Stowbunenko's role as a patient advocate is through a partnership of Dignity Health Methodist Hospital and WEAVE, Inc. WEAVE, based in Sacramento, provides services to assist survivors of domestic violence, sexual assault and sex trafficking.
Jeanine, our patient who came to us as a victim at 15, has been seeing us for almost three years now. We've been able to treat her depression and anxiety and enroll her in therapy and peer support groups. With the help of community organizations, we have provided or connected Jeanine and countless other patients to the resources needed to live the lives they want to live. Part of our healing space is creating a bridge of trust between the clinic and the organizations that provide services like housing, food, job training, counseling and financial assistance to victims. These organizations have long been a source of healing and safe spaces for victims of trafficking and violence. With their help, we can ensure comprehensive, collaborative, long-term care for victims both in and outside of the clinic and create a healing space for all who come through our doors.
Today, Jeanine is making great strides in her journey of healing. She last visited her physician at our clinic to discuss her upcoming college applications. Stories like Jeanine's show us just how powerful creating a healing space for victims and survivors of human trafficking and other forms of violence and abuse can be. While in the past, the health care community has not always understood or appreciated the extent of human trafficking, the need to identify its victims in the clinic, and the importance of trauma-informed therapeutic care, we are making progress to create clinical healing spaces for all victims and survivors.
JENNIFER COX is program director for Dignity Health's Human Trafficking Medical Safe Haven, located at Dignity Health Methodist Hospital in Sacramento, Calif. RON CHAMBERS is program director of the Dignity Health Methodist Family Medicine Residency Program and medical director for the Human Trafficking Medical Safe Haven. Dignity Health and Catholic Health Initiatives have merged into CommonSpirit Health.
- National Human Trafficking Hotline, hotline statistics, https:// human trafficking hotline.org/states.
- Laura J. Lederer, Christopher A. Wetzel, "The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities," Annals of Health Law 1, vol. 23, (2014): 61-91.
- More information about the Human Trafficking Response Program, a program that is both survivor-led and survivor-informed, is at www.dignityhealth.org/human-traffickingresponse.
- More information about the Human Trafficking Medical Safe Haven program, access to a shared learning manual and resources for residency programs, and the Survivor-Informed Practice Self-Guided Assessment Tool and other information is at www.dignityhealth.org/msh.
- Centers for Disease Control and Prevention, About the CDC-Kaiser ACE Study, https://www.cdc.gov/violenceprevention/acestudy/about.html.
- Substance Abuse and Mental Health Services Administration, "Trauma-Informed Care in Behavioral Health Services, Treatment Improvement Protocol," TIP-Series 57, (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014), www.integration.samhsa.gov/clinical-practice/SAMSA_TIP_Trauma.pdf.
- Substance Abuse and Mental Health Services Administration, SAMHSA News, "Guiding Principles of Trauma-Informed Care," 22, no. 2 (Spring 2014), www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/guiding_principles.html.
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