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Hidden in Plain Sight

Sex Trafficking photo showing a young female victim
Human traffickers employ a broad range of abuse – including forced drug use, food deprivation
and beatings – to terrorize their victimsinto compliance. Health Centers are one of the few places
where victims may seek help, one national expert says.

The child was in bad shape when she walked into Asian Health Services in Oakland, California: high fever, elevated heart rate, rashes all over her body, swollen joints. She had lost 30 pounds in the preceding three months.

She was 15 years old.

In the health center's teen clinic, Dr. Kimberly S.G. Chang was uneasy about the girl's symptoms and her skittishness about going to a hospital. Something was very wrong.

"I thought I had more of a responsibility than just treating her for her medical issues," Chang told a rapt audience at a recent gathering co-hosted by Sabrina Matoff-Stepp of HRSA's Office of Women's Health and Quyen Ngo-Metzger of the Agency for Healthcare Research and Quality. "That's why I am here today."

Many health providers treat victims of human trafficking without ever recognizing that the patient is in trouble, studies suggest. But more than half of victims surveyed report being treated in an emergency department at some point during their ordeal; more than two of every five are seen by a primary care practitioner; one in four, by a dentist.

It's likely then that federally qualified health centers are treating far more patients who are victims of human trafficking than they realize, Chang noted.

Photo of Dr. Kimberly Chang
Dr. Kimberly Chang has uncovered multiple cases of childhood sex trafficking in her Bay area health center practice.

Defined by law as "human trafficking" – which includes labor and sex trafficking – the full scope of the problem is unknown, said Chang. But it is widely believed to be the second most lucrative criminal enterprise after drug dealing. Authorities estimate that some 21 million people are victimized worldwide – and between 100,000 and 300,000 children are at risk of being forced into sexual servitude in the U.S alone.

Chang suspects the numbers are much higher. "That's just the tip of the iceberg," she said, noting that most estimates are obtained from criminal justice records that only represent a fraction of offenders.

What is clear is that victims intersect with health care systems everywhere. One study of survivors showed that almost 88 percent had encountered a health care provider during their ordeal.

Health care professionals whom trafficking victims encounter

Be a refuge: At right, time-tested assessment tools are readily available for adoption into routine practice. Source: National Human Trafficking Training and Technical Assistance Center (NHTTTAC).

It "affects patients across the board," Chang said. "It's hard to measure … it's such a hidden and underground problem."

Given their sheer number of patient encounters, Matoff-Stepp added, HRSA supported clinics – from health centers to Ryan White HIV/Aids Program providers – are obvious refuges for such patients.

Exacerbating conditions range from dangerous living and working conditions to social isolation, addiction, food deprivation and sexually transmitted infections, Chang said. Traumatic injuries are common, in addition to coerced drug use and a range of physical, emotional and sexual abuse.

"They are invisible, hidden from us, but sometimes, in plain sight," Chang added. "They can be cooks in our restaurants, people who grow our food; they staff our factories; and they are children on our streets. They are our community and our patients … and yet we don't see them."

Chang's patient in Oakland refused to go to the hospital for fear of becoming entangled in the justice system.

The following day, Chang and her staff at the health center marshalled their connections in the community to locate the battered teen, and a community health worker convinced her to go to an emergency room, and she was hospitalized for two months.

For Chang, the chance encounter in 2008 wasn't her last such case. She has since intersected with many more exploited children – often times further isolated by their inability to speak English. Her health center now offers services in 10 Asian languages.

The experience motivated her to co-found HEAL Trafficking HRSA Exit Disclaimer offers, a group of multidisciplinary professionals dedicated to ending human trafficking and supporting its survivors.

Chang recounted a conversation she had with a Colorado clinician who has a large patient base of migrant farm workers.

"I've been seeing these patients my whole career," the clinician told her. "I just never realized it."

View the archived presentation, the Intersection of Human Trafficking and Health Care HRSA Exit Disclaimer.

Suspect human trafficking HRSA Exit Disclaimer? Call 1-888-373-7888 (TTY: 711); Text 2337333

Date Last Reviewed:  April 2018