A 14-year-old girl, a repeat runaway, comes to the emergency department for abdominal pain. She states that she sleeps with her 28-year-old boyfriend’s friends for money. A 32-year-old male construction worker, who has never been paid, is seen in an urgent care for a puncture wound. He can’t leave his job due to physical violence by his superiors. A 16-year-old boy, who has a history of abuse, presents to the clinic for a wellness visit. He is homeless and exchanges sex for a place to live. A 40-year-old woman, an immigrant from Russia, presents to her family physician for joint pain. She sleeps at the beauty salon where she works and is not paid under threats of deportation.
These scenarios are all examples of human trafficking happening right here in America. Human trafficking exists all across the United States, from big cities to rural areas, and has been equated to modern-day slavery. As demonstrated, a trafficking victim could present to any healthcare setting for a variety of reasons.
It has been increasingly recognized that physicians have a very important role in identifying and assisting victims. A large percentage of trafficked individuals have had some contact with the healthcare system during their bondage, and a healthcare worker may be the only professional they encounter while trafficked.
Our role as physicians, therefore, involves not only identifying victims but also treating survivors in the long term. Research demonstrates that one severe adverse experience negatively affects the brain. But what about repeated traumatic events? This is complex trauma—the culmination of multiple adverse events over a period of time that have lasting, detrimental effects on a person’s development, psyche, and physical health. This form of trauma is what trafficking victims face from repeated exploitation and abuse.
The need for trauma informed care
Physicians can best care for patients of any population, but specifically those who have suffered from complex trauma, through the emerging field of trauma informed care. This is the care model that we, as pediatric residents, have been working to both raise awareness of and implement in our local community.
Trauma informed care recognizes the consequences ofcomplex trauma, specifically on individuals’ behavior as well as perceptions of themselves and others. As evidenced in the landmark CDC-Kaiser Permanente Adverse Childhood Experiences study, the vast majority of the general population has experienced at least one traumatic event, and many individuals have experienced several in their lifetime. Therefore, understanding the effects of trauma is important in building a therapeutic relationship with many patients.
- understanding the impact of trauma on development and coping strategies,
- providing privacy and safety,
- creating a respectful and empowering environment,
- incorporating shared decision-making, and
- actively promoting recovery from trauma as the ultimate goal.
According to research from the Journal of Community Psychology, the absence of understanding the impact of trauma is the equivalent of denying its significance. Taking a patient’s background and traumatic experiences into perspective should be common sense within healthcare settings. However, trauma informed care differs from patient-centered care and other current best practices that are already utilized.
The very nature of trauma informed care means that it would greatly benefit human trafficking survivors. Trauma informed care emphasizes how patients’ adverse experiences affect their interactions with physicians. Trafficking victims have a wide range of short- and long-term health consequences because of repeated abuse. Many also have a significant bond with their traffickers who may be their romantic partner, family member, or only source of support. These complex relationships can be explained by the principles of trauma bonding and Stockholm Syndrome. It also explains why traffickers strive to keep victims isolated and distrustful of others.
Physicians who learn about and practice trauma informed care gain a deeper understanding of the situations that victims have endured. These physicians can therefore provide more compassionate care for victims with mistrust of healthcare providers, anxiety about sitting in a waiting room full of other people, hypervigilance around being examined, or fear of medical procedures.
Read more: Human trafficking: What physicians need to know.
Implementing trauma informed care
To provide trauma informed services, all staff of an organization—from the receptionist to the healthcare providers to the board of directors—must understand how violence has impacted their patients, so that every interaction promotes recovery and reduces the possibility of re-traumatization. Though not directly involved in medical care, decisions made by upper management routinely affect provider workflow. Their support and commitment to integrate trauma informed care into the mission of the organization is necessary to ensure trauma informed principles, such as providing privacy and safety, are translated into tangible workplace policies and procedures.
Incorporating trauma informed care into medical practice entails anticipating discomfort around sensitive issues. Healthcare providers should also take extra steps to build trust and ensure a patient’s comfort. Something as simple as minimizing time spent in the waiting room, explaining the logistics of the appointment, asking permission to perform parts of the physical exam, or collaborating with a patient on the treatment plan can make all the difference to individuals who have been repeatedly victimized and unable to make their own choices for a long time.
Trauma informed care not only benefits the patient but also recognizes the effects of vicarious trauma, or the negative effects on the healthcare provider due to hearing and witnessing traumatic patient experiences over time. Trauma informed care promotes coping strategies for professionals as well as ways to recognize and process symptoms of vicarious trauma. For example, a medical practice may incorporate individualized action plans for providers who care for these populations. These action plans may include scheduling debriefing sessions with the team to address any secondary trauma among providers and making counseling and mindfulness resources readily available to manage this trauma. It’s imperative to care for providers’ wellness, so they can continue to treat and care for those who have experienced complex trauma.
As pediatric trainees in Cleveland, a city with a high prevalence of child sexual exploitation, we are actively implementing programs to educate our fellow residents and attendings on human trafficking and trauma informed care. Our hope is to establish a clinic to provide long-term trauma informed care to survivors—similar to a select few institutions around the country that are pioneering this model of care, including Dignity Health, the C.A.R.E. Clinic at Brigham and Women’s Hospital, and the Empower Clinic at NYC Health + Hospitals/Gouverneur.
In addition to benefiting human trafficking survivors, the principles of trauma informed care have a much wider application and would greatly benefit many of our patients, including survivors of child abuse, sexual and physical violence, and torture as well as other patients with significant adverse experiences. Organizations already implementing trauma informed care, such as the Henry J. Austin Health Center, are already seeing positive effects. They have documented a threefold increase in the number of patients receiving care for various mental health disorders and a twofold increase in patients with better control of their hypertension.
Our vision of the future of medicine is that all physicians will be knowledgeable about human trafficking and the benefits of trauma informed practices. Our hope is that trauma informed clinics will one day be obsolete because trauma sensitive procedures will become the standard of care.
Editor’s Note: Providers can educate themselves about trauma informed care by visiting The National Council on Behavioral Health.
Anjali Garg, MD, is a second year resident physician at Rainbow Babies and Children’s Hospital in Pediatrics. Her research focuses on the sex trafficking of domestic minors and the role of health care providers in providing trauma sensitive care. During medical school and her undergraduate years, Anjali worked as a medical and hotline advocate in the Michigan State University Sexual Assault program.
Preeti Panda, MD, is a resident physician at Rainbow Babies and Children’s Hospital in Cleveland, where she is currently training in pediatrics. Her research focuses on the sex trafficking of domestic minors and the role of health care providers. Prior to medical school she served as an AmeriCorps member at a charter high school working with at-risk youth, some of whom were survivors of human trafficking.