Treating Trafficked Patients: Focus on Trauma-Informed Care

[Dr. Amy Park]
What are some of the common health problems that these patients may face, especially in relation to reproductive health, but just generally speaking?

[Dr. Julia Geynisman-Tan]
Yes, of course. I think the first thing to remember is they are normal people and normal patients with every other kind of health condition in the world. The most common things that they have are common things amongst the entire population. Hypertension and diabetes and depression and headaches and all of that. Most often when they present into healthcare, it's for all those things. The hard part is figuring out who that patient with diabetes and hypertension is who is not taking their medications because their trafficker is taking them away from them or won't give them the money to pay for them or won't let them come see the doctor to get the new prescription.

I think specifically when we think about sex trafficking, for sex trafficking, there are additional reproductive health risks. Of course, those are things like unplanned pregnancies or poor pregnancy outcomes due to violence and trauma during the pregnancy or due to poor food access or drug use during pregnancy. There's definitely a higher risk of STIs. There's a higher risk of cervical cancer and all kinds of HPV-related diseases. I think that all of the things that you would think about with individuals who have high-risk sexual encounters.

[Dr. Mark Hoffman]
For the clinic that you're talking about, that's mostly patients who are no longer in a situation of being sexually trafficked or exploited as opposed to the ones who are currently in that situation at the time they see you.

[Dr. Julia Geynisman-Tan]
It could be both. I definitely see patients who are still in the life. They come and see me because they found me online and they want to come and get their healthcare from somebody who understands. My job is not to extract people from that life. People leave when they're ready and they leave in spite of whatever efforts we've made. More than anything, I try to keep the door open and try to provide them the best healthcare that they can have and let them know of whatever resources are available. If they are not interested in talking about it or not ready to leave, that's not the focus of my visit.

[Dr. Amy Park]
What do you think are ways that OBGYNs can provide trauma-informed care for patients who are in this situation?

[Dr. Julia Geynisman-Tan]
I think the first aspect for trauma-informed care is to think about the way that our hospital environment rips people of their control. Everything that we do is all about us having processes that we have designed and that we control. Then we impose those processes on patients, whether it's the way that we register them, the way that we bring them into the exam room, the line of questioning we do, how we don't disclose the cost of their visit until they get a bill months later. All of these things that really strip people of control.

For somebody who has already lost so much control in their life, the healthcare system is really traumatizing. I think recognizing that and trying as best as we can to explain why we have the processes we have and giving people choice in those processes as much as we can. If you are going to bring somebody into an exam room, where do you want to sit? Not like this is the patient chair, the one that is exposed so that anybody walking into the room inadvertently can see your pelvic exam, but where do you want to sit? Who do you want to have in the room with you to hear this conversation? How do you want me to document the thing you just told me?

All of these things that we can do to restore some amount of control. How do you want me to contact you after the visit? Do you want me to call? Do you want me to send a text? Maybe it's safer for you if I call you at these hours of the day where you're not with the person who brings you so much stress and anxiety. All of those things are important. I think also just having some good techniques for what to do when a person is really triggered by our questioning or by our exam. How to recognize that and then backpedal and bring them back to the reality of the moment that they're in and what your role is as their safe person, as their advocate.

I think it's so important that we recognize when somebody is dissociating and have tips to say, "Okay, I'm going to stop. This moment is over. I'm going to stop this exam. I'm going to stop this line of questioning. Let's talk about where you are. Remember, you are here at this hospital with me in this room. I want you to count backwards from 10 slowly, take deep breaths, tell me about something you did this morning." Bringing back that conscious memory and presence, and then try again if need be. There's all these techniques you can look up online of how to reground somebody who's dissociating, but I think that that's a really helpful technique to have for your patients.

[Dr. Amy Park]
Oh, can you tell me about this dissociating? I do think that I can recognize it at this point, but for our listeners, people who are freaking out, but people who are spacing out, what are the signs just to elaborate?

[Dr. Julia Geynisman-Tan]
I think that people who've experienced trauma tend to respond in healthcare encounters in one of two different ways, and they're polar opposites. One way is the kind that typically leads to dissociation, which is people who become numb and absent, almost abstracted out of the visit. They let you talk for a long time, and then they might provide a one-word answer. They don't make eye contact. They would just really love to be done with this entire encounter, and they will say whatever little things you need them to say to hopefully move them out of the room, and it's because they've shut down. They're numb.

Then when you go to do the exam, oftentimes it seems like they're just not present there with you. You give some cues as to what you're going to be doing next, they don't respond, or they're gripping the sides of the exam table, but otherwise not physically present there. That is a person who their brain is elsewhere, and they're thinking about the next place that they might be at the end of this exam. That's a moment, I think, to stop and say, "Okay, you know what, go ahead and sit up. I want to make sure that we talk about this again. Let's try the exam a different way, or let's figure out whether we really need to do one right now." That's one category.

Then there are the people who actually respond by being really abrasive, really controlling, or even belligerent in their encounters with you. You can imagine the typical person in the emergency room who is coming off of a drug of some sort, and their response to being controlled is to lash out. I see that sometimes in survivors of human trafficking where this might actually be the one place in their life where maybe they can exert some control without fear of physical punishment. They know that you're not going to hit them, and so they are taking this moment to lash out. That to me is also a sign of trauma and abuse history.