The darkness

As she was going off to sleep on the operating room table, we pulled up her hospital gown to expose her abdomen. Across her pelvis, in bold, cursive letters was a tattoo: “Property of…” and a man’s name.

“Did you see this before?” I asked my resident.

“Yes” he responded.

“And what did you think?” I probed.

“I don’t know,” he said. “I figured she was that kind of woman .”

“She’s just a prostitute,” the anesthesiologist added, and our medical student nodded agreeably.

They moved on to the procedure, unaware that our patient had been trafficked for 8 years by the pimp whose name she wore. Sex trafficking is an insidious and pervasive problem that we, too often, fail to recognize. The United Nations defines sex trafficking as the recruitment, transportation, transfer, or harboring of an individual by means of threat, force, coercion, or deception for the purpose of sexual exploitation. The underground nature of human trafficking makes the collection of reliable data on this issue limited. However, from the estimates collected by the United Nations, we believe that, in 2012, sex trafficking made up approximately 22% of all human trafficking and that 4.5 million persons were trapped in sexual exploitation worldwide. Although estimates are that 14,000–17,000 foreigners are trafficked into the United States each year, data from the National Human Trafficking Resource Center suggests that two-thirds of the cases of sex trafficking in the United States are of US citizens.

Girls are disproportionately affected. Poverty, homelessness, childhood sexual abuse, modeling of sexual exploitation by family members, substance abuse, gender nonconformity, mental illness, and developmental delay can put young women at risk of exploitation. In 1 study of 130 sex workers in San Francisco, 57% had been raped as children; in a second study of 222 sex workers in Chicago, 35% entered commercial sex before the age of 15 years. One in 3 homeless teens is approached within 24 hours of leaving home by a pimp, and teens who have been through the foster care system are at very high risk.

Although there are specific risk factors for entering the commercial sex industry, all young women should be considered “at-risk.” Traffickers are approaching children after school, in malls, and online. Thirteen percent of young internet users have received unwanted sexual solicitations, and in 27% of these incidents, solicitors asked these users for sexual photographs of themselves.

Historically, trafficking has been considered an issue of immigration and law enforcement. Sadly, this excluded physicians from getting involved in the solution. With growing data about the serious physical and psychologic health consequences of sex trafficking, it is time that we join the fight and recognize trafficking for the public health issue that it is.

The truth

The health consequences of sexual exploitation are systemic and prevalent. In a study of 107 survivors of trafficking who were 14–60 years old, Lederer and Wetzel found that 82% of the survivors reported memory problems, insomnia, and poor concentration, that 53% of them had headaches, and that 34% of them experienced dizziness. Sixty-eight percent of the survivors reported a cardiovascular or respiratory symptom. Sixty-seven percent of the survivors contracted a sexually transmitted disease, with Chlamydia being the most common. Seventy-one percent of them reported at least 1 pregnancy while being trafficked, and 21% of them reported ≥5 pregnancies. Fifty-five percent of the survivors reported at least 1 abortion, and 30% of them reported multiple abortions.

The study by Lederer and Wetzel was possible because trafficked women are accessing the health care system. Previous studies have reported that anywhere from 28–88% of sex-trafficked women see a health care provider. However, when these women present for health care, the experiences they have are often traumatic. They are retraumatized by being undressed and examined by multiple providers. Those brave enough to disclose their exploitation often feel stigmatized by health care workers. And for those who go unrecognized, our system of outpatient referral almost guarantees that we will never see them again. In discussions with case managers at antitrafficking organizations, we heard numerous stories of patients who seek medical attention but feel misunderstood, hurt, or lost.

In response to the lack of trauma-informed health care for survivors, we founded the Survivor Clinic at New York Presbyterian Hospital in 2013. This clinic provided free gynecologic and primary care to survivors of sex trafficking with a trauma-informed approach. Trauma-informed care involves the creation of an environment of safety, transparency, and choice. It encourages sensitivity to physical and emotional triggers, addresses distress, and does not punish patients for noncompliance. Clinics like the Survivor Clinic are operating throughout the United States (CARE in Massachusetts, Hope Through Health in Texas, Pacific Survivor Center in Hawaii) and are elevating the health care response to sex trafficking.

Through the Survivor Clinic, a total of 24 survivors of sex trafficking were seen over a 2-year period. Seventeen of the 24 women consented to completing surveys on their use and access to contraceptives, and all of the 24 women consented to having their charts reviewed to shed light on the health consequences of their exploitation. This research was approved by the Weill-Cornell Medical Center Institutional Review Board. One of the 24 women was a minor (16 years old). Seven of the women were American-born, and 17 were foreign ( Table ).

The women reported a contraceptive use rate of 94% over the last 5 years. Condoms were the most commonly used method (13 of 17 women) followed by oral contraceptive pills (7 of 17 women) and withdrawal method (6 of 17 women). The contraceptives were most often bought by the women themselves (8 women); 6 women reported that they received them from their exploiter, and another 6 women received them from a health care provider. None of the women used long-acting reversible contraception. Some patients reported that clients would pay more to have intercourse without a barrier and that clients lied about vasectomies to encourage this practice. There were 8 undesired pregnancies among the 17 women, of which 5 were terminated and 3 resulted in children.

Barriers to contraceptive access and lack of knowledge about effective use can play an important role in the cycle of trafficking. A pregnancy might increase the emotional bond a woman has for her exploiter, thus furthering the Stockholm syndrome on which sexual exploitation relies. Stockholm syndrome is a form of traumatic bonding in which the exploited person feels affection for the exploiter and helps to protect their innocence. This type of mental control over the victim is the ultimate goal of the trafficker and is achieved by “grooming” the victim through repetitive infliction of trauma; constant inducement of fear, unpredictable bursts of violence, threats to family, and convincing the victim that the perpetrator is omnipotent. It is not surprising, in light of this degree of mental and emotional abuse, that survivors often require ongoing mental health services.

A review of our patient’s medical histories supports the work of Lederer and Wetzel on the health consequences of trafficking. One of our patients was HIV positive. Three of them were noted to have genital herpes; 6 of them had abnormal Papanicolaou smear test results, and 2 women required excisional procedures for high-grade dysplasia. Three women had a history of ectopic pregnancies. Two women had a history of traumatic brain injury; 1 woman had permanent hearing loss from a beating that she sustained. Seven women had uncontrolled chronic diseases like diabetes mellitus, sickle cell disease, hypertension, and inflammatory bowel disease. There had been lapses in their diagnosis or follow up while they were being trafficked. Four women reported ongoing illicit drug use; 1 patient required multiple dental extractions because of methamphetamine use. Fifteen of the women reported a history of depression. There were stories of dish sponges shoved inside the vagina to collect menses during intercourse, stories of Emergency Department visits for foreign bodies, and stories of chronic and recurrent vaginitis that was treated with caustic chemicals. One patient reported multiple forced psychiatric admissions by a pimp who colluded with psychiatrists to have her hospitalized each time she threatened to leave. There were many missed opportunities for intervention in her story.