Family physician Ronald Chambers has spent hours searching the website Backpage to see if he might recognize former patients among the dozens of girls posing and smiling in sex ads. He wonders if their layers of makeup hide bruises or if he might have missed the telltale signs of sex trafficking in patients at his south Sacramento clinic.
Chambers, like a growing number of health care providers across the country, has waded into the disturbing world of human trafficking to learn how to better recognize and treat its victims. Although the illicit trade has become a media buzzword in recent years and a cause célèbre for public health campaigns, medical professionals have, until recently, remained largely in the dark about their role in helping fight the crime.
“We just don’t look for it,” Chambers said. “We’re some of the few people in society who actually see these victims while they’re being trafficked. We’re just now recognizing them – and that’s a huge piece of the puzzle.”
Trafficking refers to the use of force, fraud or coercion to engage victims in sex or labor services against their will, and often involves transporting them across state or international borders. More than 100,000 minors are trafficked at any given time in the United States, according to FBI data. California law enforcement agencies arrested more than 1,200 children on prostitution charges between 2010 and 2014.
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While much of the trade takes place on illicit websites and in out-of-the-way hotels, experts estimate that more than 30 percent of trafficked youths see a medical professional at some point while they’re being exploited.
They show up in clinics, offices and emergency rooms, sometimes accompanied by a pimp posing as a family member. Some might have unwanted pregnancies or physical injuries such as broken bones and gashes. They may avoid eye contact and dodge questions about where they’ve been in recent days. Without training, a doctor might unknowingly send them back to their exploiters instead of connecting them to the medical and therapeutic care many will need after years of trauma, Chambers said.
“It’s easy to get flabbergasted when a patient doesn’t know their medical history, or won’t tell you what happened because they’re afraid of the consequences,” said Dr. Sarah Chaffin, a resident working with Chambers at the Mercy Family Health Center. “It’s this terrible pass-on-both-sides situation where you show up hoping to get a solution and both parties end up frustrated and confused.”
Part of the answer, experts say, is to build a workforce of health professionals trained to recognize trafficking victims so that they can guide them to safety, often with assistance from law enforcement and aid groups. Physicians throughout California are working to better identify victims, while also developing targeted therapies for the psychological scars that victims carry with them years after they leave the situation.
“Ideally, it standardizes some practices and it’s not reliant on a great nurse or a great doctor or a great social worker,” said Kate Walker Brown, director of child trafficking at the National Center for Youth Law, an Oakland nonprofit group. “Everybody in medical settings has the ability to identify and help these kids, so we’re not letting them fall through the cracks.”
Know the signs
Dr. Kimberly Chang, a family practice physician at Asian Health Services in Oakland, said she started researching sex-trafficking after noticing patterns in young female patients, often runaways, who showed up at her practice. Chang helped write identification protocols for the California Department of Health and Human Services and the American Professional Society on the Abuse of Children.
A history of sexually transmitted infections or multiple abortions could be a warning sign that a patient is a victim, as could substance addiction. Someone who gives information that appears to be recited, has tattoos of gang insignia, wears expensive clothing or carries hotel room keys also could need special attention, according to the guidelines.
“Trafficking isn’t a medical diagnosis,” Chang said. “It’s not a separate entity or a separate box. It’s interrelated with child abuse, sexual partner violence, exploitation. It’s about knowing what the definitions are, observing how your patients may be, asking questions in a trauma-informed way, and knowing how to respond.”
Josie Feemster, a Carmichael resident who says she was sold for sex in several states between the ages of 18 and 25, said she was wary of getting treatment at clinics and hospitals while she was being exploited by her pimps. A jagged line on her right cheek, which she covers with makeup, is what’s left of a gaping bite mark from one of her traffickers, she said. The wound bled and swelled at the time but she never got it looked at, afraid the doctors would judge her or that her pimp would find out and hurt her or her family, she said.
Still, she said she managed to visit a Planned Parenthood clinic every month to get herself checked for sexually transmitted diseases. Feemster now works as an advocate for the Sacramento nonprofit WEAVE, running group sessions for sex-trafficking victims.
“I remember feeling like, ‘I wish I could say something,’ ” Feemster said. “But the fear of ‘What if she doesn’t believe me? What if she thinks I want to do what I’m doing?’ And the judgment. It’s your own guilt and shame. I didn’t want them to look at me like I’m this bad person or this dirty person.”
The Mercy clinic where Chambers works aims to provide a haven for exploited women. Its walls are painted an unassuming beige, and earthy, tranquil artwork hangs on the walls. The clinic has seen about 60 women who identified themselves as current or former sex-trafficking victims since it began getting the word out about its services last summer, Chambers said.
Trafficking victims always get an appointment at Mercy within 24 hours and never sit long in the waiting room, where they might become anxious around other patients, Chambers said. The patients can make their appointments through a special hotline with a receptionist who is trained not to pry or condescend. Everyone from nurses to lab technicians are trained in what they call “trauma-informed care.”
Community Against Sexual Harm, in Oak Park, is one of a handful of local nonprofit groups that have been referring patients to Chambers in recent months.
Until six months ago, director Terri Galvan might struggle to find a clinic or hospital that would take the girls, who typically are uninsured. That meant the agency, which provides housing and employment assistance to victims of sex trafficking, often would wait days for an appointment, Galvan said.
“The girls in the life were being told there’s no help, and for a long time that was the truth,” Galvan said. “The medical piece was the missing link.”
A safe space
At Mercy, appointments can last up to two hours – longer than a typical visit – because it can take physicians that long to break the ice with patients. Patients can receive counseling, reproductive health care, lab work and other services including pediatric care if they have children, which Chambers said can reduce the anxiety of having to visit multiple locations.
Dignity Health shoulders the cost of the treatment through its community benefit program. The staff training and protocols are part of a $1 million systemwide initiative to combat human trafficking, launched in 2014.
“The first initial visits, it’s just about building trust, and letting them know that I’m not afraid of what they’ve been through,” Chaffin said. “It’s stuff that, as hard as it is to hear, I try to keep a flat face and move on from there. If I make too much of a commotion about it, it’s probably a more emotional burden than they can handle at that point.”
Once a relationship is established with a patient, physicians can lay out available medical services and community resources. If the victim is a minor and still being exploited, staff members are required to report the situation to the authorities. An adult patient, however, may choose to return to their trafficker, a decision that can be especially hard for doctors to accept, Chambers said.
“Part of victim-centered care is allowing that choice,” Chambers said. “If they know this is a safe place, they might come back tomorrow or next year and be ready for that intervention, but they might not be ready for it now.”
Feemster said she thought often about leaving her pimp, but each time he would convince her that no one else wanted her and that she wouldn’t make it on her own. She served jail time after being convicted of attempting to traffick a minor under age 16 – an activity she says she also was forced into by her pimp.
“People think that people are really being chained to a room or chained to a bed, when it has nothing to do with that,” she said. “They’re mental chains, because exploiters get into your mind and your heart and take advantage of your vulnerabilities.”
Those experiences, repeated for months or years, alter the brain’s reaction to stimuli, said Yvette MacDonald, a social worker at the West Coast Children’s Clinic in Oakland, which runs a mental health program for trafficked youths. Victims might seem depressed and withdrawn, and then suddenly yell and thrash at a painful memory.
“It’s adaptive,” MacDonald said. “A lot of times when you’re in a dangerous situation, there’s a fight or flight response. When the girls get triggered, they may not know what’s triggering them, but they want to fight or get out.”
Feemster, who was diagnosed with post-traumatic stress disorder after she left her situation eight years ago, said she still gets flashbacks when someone unexpectedly touches her or when she passes by Bay Area hotels where she remembers being trafficked.
Seeing a therapist and visiting the Mercy center has helped her find ways to control those reactions, she said.
“It really can be like someone is stepping on you, or sitting on you, and you can’t breathe,” Feemster said. “This journey, this healing journey, is a lifelong one.”