CHICAGO (FRONTLINE MEDICAL NEWS)Physicians can play a leading role in identifying patients who are human trafficking victims by knowing the signs to watch for during visits and taking immediate steps to address their suspicions, according to Dr. Holly G. Atkinson.

Key indicators include discrepancies between history and clinical presentation, multiple sexually transmitted diseases, and the accompaniment of a controlling third-party who is not a guardian, said Dr. Atkinson, director of the human rights program at Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai in New York City.

“This is an underground problem,” Dr. Atkinson said. “We have a number of issues that we need to address in the medical profession. Health care providers are missing the opportunity to intervene.”

The prevalence of U.S. citizens being trafficked is higher than some people may think, Dr. Atkinson said at the annual meeting of the American Medical Women’s Association. In 2014, the National Human Trafficking Resource Center, operated by the antislavery organization Polaris, received 3,598 reports of sex-trafficking cases inside the United States. And Homeland Security Investigations of the U.S. Immigration and Customs Enforcement in fiscal 2013 opened 1,025 investigations involving possible human trafficking, an increase from 894 from 2012.

Meanwhile, the National Center for Missing & Exploited Children estimates that between 100,000 and 300,000 U.S. children are at risk of being sexually trafficked each year. The average age of entry into the commercial sex trade for girls is between 12 and 14 and for boys between ages 11 and 13, Dr. Atkinson said. Factors that contribute to a higher risk for human trafficking include childhood sexual abuse, involvement in the foster care system, and poverty. Runaway and minority youth also are at higher risk.

Research and personal accounts show human trafficking victims regularly come in contact with health providers during the course of their exploitation. In a 2014 survey of domestic sex-trafficking victims, 88% said they encountered one or more health professions during the period in which they were being trafficked, yet none was identified as a victim by physicians during the visits.

In another 2014 survey of survivors, 39% of victims reported having contact with emergency departments; 29%, with primary care physicians; 17%, with ob.gyns.; 17%, with dentists; and 3%, with pediatricians, according to data cited in Dr. Atkinson’s presentation.

“This really points out that we all need to pay attention to it across the entire span of the health care system,” Dr. Atkinson said during the meeting.

Physicians should pay close attention to physical signs that could denote the possibility of patients being trafficked, she added. This includes visible tattoos with “daddy,” “property of,” or a trafficker’s street name. Perpetrators often brand their victims so that they are easily recognizable and can be returned if they escape, Dr. Atkinson explained.

Dehydration, malnutrition, multiple sexually transmitted infections, and multiple pregnancies or abortions could also be clues. Doctors should watch for a history of discrepancies and confusion in how patients answer questions, for example, the inability to provide an address, confusion about their current location, an appearance younger than the stated age, and answers that sound scripted.

Signs of human trafficking may also be apparent in the relationship between patients and third-party visitors, Dr. Atkinson said. A controlling third party who does not let the patient answer questions or who interrupts or corrects the patient is a red flag. Other indicators include a patient who appears fearful or avoids eye contact.

“Understand that there is a lot of fear and distrust,” Dr. Atkinson said.

Several health care centers and medical systems have started developing protocols for health providers to follow to address possible human-trafficking victims.

The Via Christi Health system in Wichita, Kan., recently published guidance for clinicians on how to proceed if they suspect a patient is a victim of human trafficking. Steps include following child abuse or domestic violence protocols; separating the patient from the controlling third party; providing the patient a comfortable, safe area; and ensuring a patient interview is performed by a trauma-informed social worker or nurse.

Some questions physicians may want to ask patients include: Have you ever exchanged sex for money, food, or shelter? Have you been forced to have sex against your will? Have you been asked to have sex with multiple partners? If the patient answers yes, physicians should follow child abuse protocols and mandatory reporting requirements. If the patient is aged 18 or older, doctors should obtain the patient’s permission to call law enforcement or assist the patient in calling 911.

More efforts are underway on the state and federal levels to fight human trafficking, Dr. Atkinson said.

All states have criminal laws that address human trafficking, and 14 states now have educational laws specifically about trafficking. In late April, the U.S. Senate passed a measure that would increase penalties on human trafficking.

In addition, AMWA recently launched Physicians Against the Trafficking of Humans (PATH) to help educate health providers about trafficking in their communities. The PATH website includes resources for physicians and an online video about trafficking that doctors can share with their practices and colleagues.

“As physicians, we are trained to act, and we’re trained to solve problems,” AMWA Immediate Past Resident President Kanani Titchen said in the video. “It’s important in these situations to remember that we are not going to fix this person’s life in one visit. Many of these patients have been in their situations for years, and many times the path to recovery is a long one, and we are one stepping stone in that path. It’s important to listen to our patients, to provide the information that they need, the resources that they need, and it’s important for us as physicians, to know what those resources are.”

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