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BackTable / OBGYN / Podcast / Transcript #71
Podcast Transcript: Human Trafficking: Red Flags & Clinical Guidance
with Dr. Julia Geynisman-Tan
Human trafficking is a complex health issue, with many providers unsure how best to detect, counsel, and care for victims and survivors of human trafficking. In this episode of the BackTable OBGYN Podcast, hosts Dr. Amy Park and Dr. Mark Hoffman are joined by Dr. Julia Geynisman-Tan, a urogynecologist at Northwestern, to discuss signs of human trafficking and resources for caring for this patient population. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Recognizing Signs & Combating Human Trafficking in Clinical Settings
(2) Common Health Concerns Among Trafficking Survivors
(3) Beyond the Stereotypes: Barriers Survivors Face to Leaving
(4) Immigration & Human Trafficking: Understanding the Overlap & Misconceptions
(5) Trauma-Informed Care: Restoring Control & Recognizing Trauma Responses
(6) Navigating Human Trafficking Resources, Laws & Provider Responsibilities
(7) Hospital Protocols for Identifying & Assisting Trafficking Survivors
(8) Guiding Principles for Clinicians: Responding to Suspected Trafficking
(9) Understanding Trauma’s Impact on Physical & Reproductive Health
(10) Long-Term Support for Survivors: Trust, Advocacy, & Ongoing Care
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[Dr. Amy Park]
Welcome to another episode of BackTable OBGYN. This is Amy Park, and I'm here with my co-host, Mark Hoffman. How are you, Mark?
[Dr. Mark Hoffman]
I'm good. How about you, Amy?
[Dr. Amy Park]
Good. I am so honored and privileged to introduce our next guest, who is Julia Geynisman-Tan. She's an assistant professor in the division of Urogynecology and Pelvic Reconstructive Surgery in the Department of OBGYN at Northwestern. She is the fellowship program director and the director of research for the division, and she's an investigator in three federally funded trials aimed at improving the care for women with urinary incontinence and has grant funding from two industry partners for surgical outcome trials.
Most pertinent to what we're going to be discussing today, she is very passionate about caring for survivors of gender-based violence and founded the Northwestern ERASE Clinic for Survivors of Human Trafficking and is an asylum evaluator for Physicians for Human Rights. Welcome to the program, Jules.
[Dr. Julia Geynisman-Tan]
Thank you
[Dr. Amy Park]
Thank you so much for coming to speak to us today about this super-important topic. I just wanted to hear from you because I think for me personally and just for our listeners, it'd be super interesting to hear a little bit about yourself and how you got involved in this work.
[Dr. Julia Geynisman-Tan]
Yes, absolutely. Thank you guys for having me. I first learned about human trafficking when I was in this gap year period between my undergrad years and going to medical school. I was actually doing a research fellowship abroad and trying to make some money on the side. A friend of mine was offering money to people who would translate documents for some legal case that she was involved in. I spoke the language that she needed translation in and I started looking over these documents just to help out and started reading these stories and understanding what was happening to the survivors who had been trafficked into this country.
Their experience, it uncovered this entire world for me of crime that I had not understood. I realized then how much it was happening in the United States as well. As soon as I started reading about it where I was, I came back, I started medical school, I started reading about what was happening in the US. Just seeing how especially in the Midwest where we're at an intersection of so many parts of the country and both nationally and internationally, an intersection of a lot of busy airports, busy highways, a lot of conventions happening here, a lot of migrant workers for all kinds of domestic labor. It was really a big problem where I was in medical school.
I started doing just some advocacy work there. Then when I went to residency, one of my goals was really to make sure that there was healthcare for this population because for so many of them, they end up going from one free clinic to the next, one emergency room to the next. There's no continuity of care. You can imagine the amount of stigma and trauma that might be associated with being a survivor of trafficking. For them to retell their story over and over or for them to be rediscovered or reinterviewed by people is really traumatic and keeps many of them from the healthcare setting.
I wanted to establish some form of continuity clinic. Actually, I was really lucky to get some ACOG funding to do that in New York and started my first clinic there and started getting involved with some national organizations that were groups of physicians from all different backgrounds working on this. It's become a small but very meaningful part of my career ever since. When I came here for fellowship to Chicago and stayed on as faculty, the ERASE Clinic is something that I really have enjoyed building and maintaining for the city of Chicago.
(1) Recognizing Signs & Combating Human Trafficking in Clinical Settings
[Dr. Amy Park]
That's amazing. It sounds like you've gotten a lot of support from obviously our national organization and then from the institutions that you're at. Then tell me in terms of your clinical work, how can we as OBGYNs, as physicians, or just in the healthcare setting, how can we find out or just have a spidey sense that a patient may be a victim of, or I don't know what the right word is, but just that human trafficking may be a part of the situation or the story?
[Dr. Julia Geynisman-Tan]
It's funny that you bring up what the right word is. I go myself back and forth between victim and survivor. I think when I'm talking with patients about it, I tend to use the word that they use. Oftentimes they use the word survivor because even if they are still in the life, they are surviving it. When they have left the life, they have survived it, but many of them bounce back and forth. That's really not uncommon for both sex and labor trafficking. Where people find themselves in situations where for a period of time, they might need to go back and forth.
In terms of the spidey sense, I think there are all kinds of risk factors and all kinds of historical things in their presentation that perk up my ears a little bit. Certainly, people who have moved around a lot to, they don't have continuity of care at your healthcare system, they are always in different clinics, emergency rooms, their records are from all over. People who present with a story that's a little disjointed or that changes with each person who asks them. Like the medical student goes and interviews them and they tell you a story and then the resident goes and sees them and the story is a little different. Then when you go in, it's a little bit different.
The nurse gives you some different aspect. Usually, that's because they either themselves are unsure of some of the details or they've revised the story in their heads to tell each person as they realize that actually maybe something that I said could get me in trouble or is unsafe or they're going to figure out what's happening and I need to revise things. That perks up my ears. I will say that one of the things that always makes me a little suspicious is somebody who's on their phone throughout the entire visit.
The history taking, the physical exam, they're just constantly texting with somebody to give them updates, particularly during the physical exam. If you can't put your phone down for a second to do all the things we typically do in a abdominal and pelvic gynecologic exam, it makes me a little concerned. Then a lot of it has to do with just their general demeanor. I always talk about this counter-transference that I think we all learned about in our psych rotations back in the day that our patients transfer energy back to us, their mood, their feelings in the room.
If you just took care of a patient that you've got this great rapport with, you felt like you were on your game, you had a great conversation, and then suddenly you walk into this room with this patient and you start feeling anxious and you're not really sure who's miscommunicating with who and why are they upset? Why am I suddenly upset? Why are we in a disagreement about this? That feeling of they are really anxious about something and it's making me anxious, I try to lean into that.
I know that I'm the professional there giving the best possible advice. I'm asking all the right questions, but if I'm feeling uneasy, it's probably because they're uneasy and I need to ask more about why that is. All of those are my spidey sense things. We're all taught this stuff about, ask about histories of domestic violence and sexual violence, to look for people with repetitive sexually transmitted infections, with poor pregnancy outcomes, with tattoos that have very explicit sexual messages or gang symbols or financial symbols. All those things are great to have in the back of your mind.
There are very few patients where you'll be like, "Ding, ding, ding, ding, ding, ding. It checks all those boxes." It's usually a lot more subtle.
[Dr. Amy Park]
By the way, I was just curious, how do these patients make their way to your clinic?
[Dr. Julia Geynisman-Tan]
A couple of different ways. I work with the emergency room and with our OBGYNs and primary care doctors a lot here, and they know that my clinic exists. When they see a patient that they think may have been a survivor of trafficking, they might just call me up for a curbside consult. "Hey, I'm seeing this. Does this sound weird to you? What resources should I provide them with?" Sometimes they want me to see them and take over their care. Then that's what I do.
Other times I'm seeing people who are not actually here at our health system yet, but they have already engaged with law enforcement or social work or with some community partner. That partner reaches out to me and says, "Hey, I have somebody that was brought in by law enforcement. I'm working with them on a T visa or on their housing placement or whatever it is. By the way, she needs some STI testing or she hasn't had a pap smear in five years or whatever it is, could her?" I get referrals from all over. Honestly, sometimes patients just call me up out of the blue. They find my website and they call.
[Dr. Amy Park]
How can health professionals, specifically OBGYNs, but any health professional help in combating the human trafficking?
[Dr. Julia Geynisman-Tan]
I think the way I think about my clinic in this whole role is I would like to put myself out of business in the next five years. There shouldn't have to be a human trafficking clinic because my hope is that all of us, as we go through our medical training and our experience as clinicians, we should learn about these signs. We should learn about how to take care of these patients. We should learn about how to refer them to the right social work and law enforcement resources. There shouldn't have to be a clinic like this, but we should all be trauma-informed. We should all be advocating for our patients.
I sort think about this like there used to be special HIV clinics in the 1990s that we've more or less gotten rid of these days. Everybody is seen by their primary care doctor and most, OBGYNs and MFMs take care of patients with HIV all the time. They don't need a special clinic. There are no special LGBT clinics per se anymore. We all take care of patients who are in any gender identity or sexuality spectrum. There shouldn't have to be a special human trafficking clinic. This should just be part of all of our continuity.
(2) Common Health Concerns Among Trafficking Survivors
[Dr. Amy Park]
Then you alluded to this earlier in terms of STI testing or other things, but 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.
(3) Beyond the Stereotypes: Barriers Survivors Face to Leaving
[Dr. Mark Hoffman]
It's interesting. It's not something that I learned about specifically, certainly to the degree that you're talking about in training. I'm obviously certain that I've taken care of patients who are victims and/or survivors. You talk about the life, is a term that you've used, and also being able to willingly leave or not. I think whether it's TV or whatever resources most of us have to learn about this or at least have been exposed to, I won't say it's not that you don't have access to those resources. Many of us learn about this stuff as if it's like they're trapped and they can't get out.
I would imagine that the doctor's office is a place you would not want-- if you were someone trafficking another human being, you wouldn't want them around healthcare professionals. It sounds like maybe that's a more stereotypical or maybe not as accurate representation of the situation we're talking about. Can you talk a little bit more about the life as you described it in ways that might help some of us not just destigmatize, but help identify folks who are living this way?
[Dr. Julia Geynisman-Tan]
I think that that's a really important point. I agree that there's a lot of popular media about what it looks like to be trafficked. That people are abducted or somehow taken from familiar surroundings and brought to some other place and kept in an isolated area. That is not the typical case. Certainly, those cases exist and they make their high profile news, but for the most part, people are trapped in human trafficking because they have emotional bonds with their trafficker.
They don't need to be locked and chained because their heart is locked and chained or their dependence on food or illicit substances or childcare or housing or whatever is locked to that individual. In many cases, it's somebody who was a romantic partner, or it's somebody who was a friend or a parent or a-- I use this term, a partner in crime. Somebody who initially started out being your drug partner and then turned you out into trafficking or somebody who was part of your gang and then decided that you were going to be trafficked instead.
For many survivors, at least of sex trafficking, they have children with their trafficker. They worry about leaving because their children are caught in the middle of that. They are also sometimes tied because of criminal records. They've been carrying drugs or guns or other things, for their trafficker. They worry that if they're no longer under their protection, then their trafficker is going to expose these other crimes and that person's going to go to jail. Sometimes it's because they need the trafficker, frankly, for their drugs or their food.
It's not quite so simple for them to leave. I think the caveat to all this, and of course, we're talking about all of this in adult individuals where we don't have any obligation to take them out of the life. Certainly, if any of you are seeing people who are under the age of 18, there is 100% an obligation. Those are child victims. They are protected under all the child abuse mandatory reporting clauses. There, it's a completely different scenario. In the adult world, a lot of times all we can do really is support.
[Dr. Mark Hoffman]
No, thank you so much. It's extremely helpful.
(4) Immigration & Human Trafficking: Understanding the Overlap & Misconceptions
[Dr. Amy Park]
It's super interesting because, I just had an incident of domestic violence in an immigrant family, and where that line of domestic violence and immigration and feelings of being trapped, it's a very slippery slope where you start seeing what's happening. What would be your estimation or what are the statistics on the effect of immigration and visas and all of these social situations?
[Dr. Julia Geynisman-Tan]
Great question. I guess the first point I want to make about immigration is when we think about immigration and human trafficking, a lot of people tend to conflate crossing a border and trafficking, and those are separate. Crossing a border is just smuggling. That crime is smuggling. Trafficking is exploiting that individual's labor or their body or sexual favors for financial gain or personal gain and doing that by force, fraud, or coercion. In order to be trafficked, you don't have to move any boundaries. You could be trafficked out of your own home. Smuggling does not necessarily mean that that person then will be trafficked.
They could be smuggled into the country and then go get gainful employment that they are fully in control of. Those are two separate things. That being said, when somebody is an immigrant, obviously there's barriers in terms of language. There are barriers in terms of visa status. There are issues with access to jobs and all of that makes people very fearful and makes them very susceptible to coercion or fraud. As much as all of us probably get all kinds of scam texts and emails and calls every day, you can imagine how much more manipulative those things can be in somebody who isn't aware of our laws here or isn't a fluent English speaker.
For people who are immigrants, they're so much more susceptible. I was just the other day reading something about immigrants and migrants basically here in the US being targeted to go help in the cleanup efforts after the hurricanes in North Carolina. Essentially all of these scams where people are being bused and shuttled and brought to work and supposedly to help the cleanup efforts, but it's very unclear who is paying them and how much, and is that the amount of money that they will receive once they get there?
Do they actually have, work status and legal protection, essentially, if they're exploited during their work? In situations like that, it's very easy to have these blurred lines between immigration status, legal rights for employment here. Of course, people are worried about crossing any line inadvertently and being deported. It's so much easier to manipulate somebody who doesn't feel that they have the protection of the law here.
(5) Trauma-Informed Care: Restoring Control & Recognizing Trauma Responses
[Dr. Amy Park]
Absolutely. 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.
(6) Navigating Human Trafficking Resources, Laws & Provider Responsibilities
[Dr. Amy Park]
How can people identify resources or training that can better identify and assist people in this situation? I think listening to this podcast obviously is one answer, but I'm sure there's resources online and organizations. Can you just elaborate on what they are?
[Dr. Julia Geynisman-Tan]
Yes, of course. Probably the best organization, which is the National Human Trafficking Hotline, or Polaris is the official name of the organization, but they run the National Human Trafficking Hotline. They are the central source of truth for all of the newest research on human trafficking. They provide all of the national statistics that are updated every year, and they run the hotline where anybody, whether it's physicians or your friend or neighbor can call in and provide tips.
The patients, the survivors themselves can also call that hotline to get help and to get connected with local resources in any city or state that they're in. That's probably the main organization to know, and then from there, you can find resources in your own community. Most major metropolitan centers have a number of organizations that are working on this. Some of them are typically through either the Salvation Army or other religious or faith-based organizations. Those do tend to run a lot of them. In some cities, the county or criminal justice unit of the county also runs some of these organizations, but that tends to be a little bit more sporadic.
[Dr. Mark Hoffman]
You mentioned local organizations. It's also important to understand different states' laws too. As a resident of Kentucky, you mentioned there are standard laws, I think, in probably every state about mandatory reporting for minors. In Kentucky, at least it was, and I have to remember it, it may have gone away, but we had the highest rates of domestic violence in the country, so they made it mandatory, which actually was potentially dangerous for victims in some ways. I think that's one thing, again, knowing your local laws, knowing it can vary state by state. That's where it is important for providers to know what their responsibilities are where they are.
[Dr. Julia Geynisman-Tan]
Yes, absolutely. Certainly, across all states, reporting for minors is mandatory. In terms of specific laws for adults, most of them have more to do with the laws in place for the survivors, for their ability to get back the wages that they made for their trafficker or their ability to get rid of any criminal charges that they have. That really varies from state to state. There's also a really big difference in terms of the burden of proof needed in order to prove human trafficking in different states, and whether things like pornography or other kinds of businesses, if they are not in-person things, but online escort services or pornography, if those count as human trafficking.
That really does vary state by state. The other part of it that really varies is medical training for it. There are some states where you are required to post signs about human trafficking in every healthcare facility. Illinois is one of them. Every clinic, every private practice office, every hospital everywhere has signs about human trafficking and numbers to call, but that is not equivalent state by state. Then Illinois is a state where there's mandatory human trafficking training for every healthcare professional. Of course, that's not true everywhere. Those things are trickling through state by state, but you should know what your local laws are.
(7) Hospital Protocols for Identifying & Assisting Trafficking Survivors
[Dr. Amy Park]
That's super interesting because I was going to ask you, how can healthcare systems better support healthcare providers in identifying and assisting people who are in this situation of human trafficking, but it's also you are alluding to a lot of the state laws and a legal framework for it as well and social networks. It sounds like it's a very multidisciplinary process here to galvanize and support people where they're at.
[Dr. Julia Geynisman-Tan]
Absolutely. Our hospital has a human trafficking protocol that I wrote together with some other colleagues here at the hospital. Many hospitals have a protocol like that that probably your social workers and emergency room providers know best. There are examples of protocols like this through the HEAL website. HEAL is the Health Education Advocacy Linkage Group. It's a whole bunch of healthcare professionals who work on this nationally. There are example protocols that you can use and modify for your hospital.
We have a protocol that, goes through screening questions, that goes through response, which might include calling me or some other colleagues of mine here, and then where to reach out for resources outside of the hospital.
[Dr. Amy Park]
Since you're a subject matter expert in this arena, tell me what this protocol says.
[Dr. Julia Geynisman-Tan]
Yes, sure. The protocol first starts with identifying risk factors and who to be screening. We don't recommend that you screen every single person coming into the healthcare setting with these questions. The burden is too high. Luckily, the incidence of this is low enough that we don't need to screen everyone. If you do see a number of risk factors, which are laid out in the protocol, then we do some screening questions. A lot of them have to do with where did you sleep the last three nights. Is it the same place? Do you have control of the documents that you carry? Your ID card or passport or work visa, whatever it is, do you have control of that?
We ask about physical safety and whether anybody has asked you to carry a weapon for them or if you choose to carry a weapon to protect yourself against anyone. We have a whole screening questionnaire. We have a protocol around where to do this. Probably all of our emergency rooms have beds in the hallway and stretchers all over the place and things, and that is not the appropriate place to be screening. The protocol talks about how to create these safe spaces and making sure that you tell the patient that you're going to be asking these kinds of questions and that they feel that they're in a safe space.
That the trafficker is not on the phone with them on FaceTime. That the trafficker has not made their way into the other side of this curtain and is listening in. We talk about how to get these safe spaces. Then the protocol goes through what to do if there is a disclosure and who to call. Here in Chicago, that involves calling the local Chicago Police Department, but also the FBI trafficking agent on call. There is a human trafficking FBI agent stationed here in Chicago who will come and evaluate these cases. We have a elaborate protocol that may not fit every particular hospital, but it's a place to start.
(8) Guiding Principles for Clinicians: Responding to Suspected Trafficking
[Dr. Amy Park]
That's amazing. As an individual OBGYN or urogynecologist or any person taking care of patients, what steps should we be taking if we suspect that our patient is in this situation of human trafficking?
[Dr. Julia Geynisman-Tan]
I think the first thing is to not act like you are shocked and appalled because that will make it worse.
[Dr. Amy Park]
We got to work on our poker face.
[Dr. Julia Geynisman-Tan]
Yes, you kind of do.
[Dr. Mark Hoffman] Don't shame them. Don't scold them.
[Dr. Julia Geynisman-Tan]
This would not be a moment to be like, "Oh, my God, how did that happen to you?"
[Dr. Mark Hoffman]
No, but truthfully though, I have a lot of patients who've got pain or all sorts of diagnoses who say they can't talk to their doctors about certain things because they've been shamed about certain behaviors. It's just the judgment from clinicians, sadly, it's not an uncommon thing. This is for all sorts of things that, are, again, I don't want to use the word normal because I don't want to impress upon anyone my version of what I perceive to be normal or abnormal. These women say, "I was told this is my fault." It's unbelievable what patients will tell me that they're been told by the providers.
[Dr. Julia Geynisman-Tan]
Yes, absolutely. I think that you'd be surprised what patients hear us saying outside of their exam room also to other nurses, physicians, staff. That even if you have a great poker face when you're in the room with the patient and then you leave and they hear you retelling their story as if it's this crazy salacious thing behind the curtain, that encounter is done. You have lost their trust.
[Dr. Mark Hoffman]
That's a good point. Those walls are thin, those doors are not soundproof. We have to remind teams all the time. Even if you're laughing about something else, someone's just trying to be a pro at work and Amy can vouch for this. I can certainly laugh and have fun, but at work, I'm super boring and very clinical because you don't want people to think we're making light of anything that's going on. No, it's such a good point that I wanted to highlight. I appreciate that because there's just people have in front of the hallway and someone's really shared something really personal and like, "Oh, my God, are they laughing at my story?"
We don't think of it, but that's such a great point you bring up.
[Dr. Julia Geynisman-Tan]
I think once you have heard some disclosure like that, then the next thing really is to say, "What do you need? What things do you need first today?" You might think that what that person needs is immediately a safe space to go to, they need to call the police. We got to get this investigation rolling and rip them out of whatever situation, but that may absolutely not be what they need.
They may say to you, "What I need is to have my pain treated so that I actually have the emotional capacity to figure out what I want to do with my life and with this person who's in my life. I don't need you to do anything for me related to the trafficking. I need you to treat the pain that I came here for. Then I will be able to take care of my situation."
[Dr. Mark Hoffman]
Their medical problem may be part of their dependence on this other person. That's interesting.
[Dr. Julia Geynisman-Tan]
I think figuring out what it is that they need. I will say, I have done a lot of social admissions for patients like this, where they may say, "I don't really even know what I need because I don't know where I've been this last week. I just need some time to think and a safe place and a hot shower and a meal. I want to call my mom." In those cases, I make up all kinds of reasons to admit them to the hospital for their pelvic pain or UTI or whatever it is. Then they sleep in the hospital for a few nights. In two days I have social work come and talk with them and we figure out what it is that they want to do next.
Inevitably this always happens on a Friday. They have a couple of days before all of the shelters open and all of the social work and community partner groups open. Then we figure out where they're going to go.
(9) Understanding Trauma’s Impact on Physical & Reproductive Health
[Dr. Amy Park]
That's incredible work. There's all these psychosomatic effects that we know happen in people's health, just generally speaking, but what have you noticed in your work in this space? I know it overlaps with trauma. It overlaps with other reproductive conditions, but you're seeing this on the regular. What are the patterns you've noticed?
[Dr. Julia Geynisman-Tan]
You're absolutely right. Trauma affects our entire central nervous system and our autonomic system. Individuals who've survived trauma have all kinds of conditions. Whether it's abdominal pain, it's headaches, it's chronic musculoskeletal pain, pelvic floor dysfunction. I see a tremendous amount of all of that. I think it's important to recognize that when we treat those patients, that we have to talk about the fact that this may be stemming from their trauma. Oftentimes the only way to treat those conditions is some combined physical treatment of the problem, but also a central somatization component of this.
I think to not even mention that there might be a relationship really does them a disservice. Of course, a lot of these patients have depression, anxiety, and PTSD, and getting them into mental health care is one of the hardest parts of this work because there are so few mental health resources to begin with in this country. Particularly, it's hard when the patient maybe doesn't speak English, it's hard when what they're looking for is specifically PTSD work. We know that EMDR therapy works really well for survivors, and it's just hard to get EMDR care in most places.
[Dr. Amy Park]
Wait, what is EMDR?
[Dr. Julia Geynisman-Tan]
Oh, it's rapid eye movement desensitization. It's a form of PTSD brain retraining like hypnosis, but getting people into essentially a REM sleep state where they can form new neural pathways. That type of therapy works really well for this condition, but it's really hard to do and certainly can't be done over telehealth. It just requires having excellent trauma-informed gender-based in gender congruent services and language-based services. I think, again, in urban centers, it's a little bit easier to come by that. In other places, not so much. That is a big part of it.
Then for labor trafficking, which I feel like we gloss over so much when we think about human trafficking, especially in the OBGYN world, because we're so used to talking about sex. Labor trafficking happens more often than sex trafficking in this country. They are oftentimes intertwined. People who are actually in labor trafficking might be exploited for sex as well and vice versa. That somebody who is initially maybe trafficked for sex maybe ages out of it and is exploited for their labor or something of that nature.
They intersect a bit. For labor trafficking, there are absolutely these tension points of what is psychosomatic and what is the physical degradation of the body from really hard manual labor. When somebody comes in with chronic back pain, and they've been a manual laborer doing agricultural work or housekeeping work, or whatever, for 20 years, people are like, "Of course, you slipped a disc in your back, and that's why you have low back pain." I think to not recognize that there might be this component of trauma involved too, and their interpretation of their pain and that central somatization of pain that's a result of abuse is really important to take into account.
[Dr. Amy Park]
I know this is not your or my area of expertise or Mark's, but how has it affected pregnancy and prenatal care? Do you happen to have any insight into that?
[Dr. Julia Geynisman-Tan]
We know pregnancy is a very vulnerable time for women in general if they're in a violent situation. Human trafficking, even more so puts them into that vulnerable situation, because the violence doesn't stop during pregnancy. Traffickers are trying to recoup as much money as they can from their "investment", and they feel no shame about exposing the person to whatever in order to get the money that they can. I've seen horrific things.
People who have been asked to put dish sponges in their vaginas during their menstrual cycle to still be able to have intercourse, people who put shaving cream caps in because nobody will give them a diaphragm or a tampon or something that is silicone and meant for the vagina. I think that traffickers oftentimes will exact punishment when somebody is pregnant or unexpectedly got pregnant, but at the same time, they don't want to pay for contraception. They oftentimes don't want people to use condoms because they will allow whatever the John, which is the colloquial term for the person buying, whatever that person wants.
If they are going to pay more to not use a condom, then they will have the woman not use a condom. The risks in pregnancy are huge. Just things like a normal UTI that can turn into pyelo or all kinds of just physical trauma to the body.
(10) Long-Term Support for Survivors: Trust, Advocacy, & Ongoing Care
[Dr. Amy Park]
That's super depressing. What can we do to help survivors rebuild their lives?
[Dr. Julia Geynisman-Tan]
Man, I think that's a tough question. There's so much I think that we can do in helping the social organizations that do this more long term. Just because we are physicians here doesn't mean that we have to stop caring about this when we leave our office door. We are also human beings who can take part in all of the organizations that work on this more long term. Many survivors end up either in some sort of residential program where they go through a long-term rehabilitation. That might mean job training, it might mean intensive therapy, it might mean just communal social activities with other people who have been through what they've been through.
That's certainly one way to get involved. I think for labor trafficking, all of us probably live in areas where there are large migrant populations right now. Just being involved in refugee and migrant programs and helping those people to get resettled in a way that doesn't put them at risk. Helping them to find work that is safe and protected is really important. I think the other thing we can be thinking about is if you are seeing adult patients who are themselves, survivors of domestic violence or all kinds of challenging social situations, you have to think about the children of those adult patients and the risk that those children are in.
People don't suddenly become a 25-year-old who is trafficked. They were at one time a six-year-old who experienced sexual violence in the home or who was a runaway or a throwaway kid who end up on the street at some point. They may have been in a foster care situation. When we as OBGYNs are delivering the babies of adults who are in these difficult situations, I think one thing to be thinking about is how do I make sure that this kid's life is different. What can I do to support this parent so that the child is not later in a human trafficking situation because of being primed from a young age to abuse, violence, a difficult social situation at home?
I think there are so many ways that we can help, but one-on-one with your patient, it's just being there and listening and taking note when they are clearly in distress and asking them what they need.
[Dr. Mark Hoffman]
You're a large academic medical center. I imagine these are not straightforward visits. Do you have students with you? Do you have residents with you in this clinic? It sounds like as much as we want to teach in complex, I think we likely all deal with this to some degree in our specialties based on the intimate nature of their issues that is challenging in general, but this seems to me like another level in some ways. I was trying to imagine how there would be a way to incorporate learners, and I just couldn't think of a way where it would be appropriate.
[Dr. Julia Geynisman-Tan]
No, the commitment I have with the ERASE clinic is that it is a concierge practice, essentially. There are no learners of any kind, and patients have my direct phone number to talk about anything. My nurses, honestly, are not involved. I don't have nurses calling patients with test results. I do it all myself. To me, that is one way to rebuild trust, and I want to make sure that patients know that and that the other people involved in their care, whether that's their social workers or whoever, know that they have direct access to me, because, oftentimes they need emergency services.
They were fine when they saw me last week, and then something happened, and they were back with the trafficker, or they were in some situation, and their social worker calls me and says, "Listen, she needs to get back in and get another test done." I can't have them calling Northwestern's call center and going through five chains of people to somehow get to me. The thing is, my clinic is a little bit hidden. I don't advertise the address. People don't know where this is. I don't want traffickers showing up there. The number that I use for the clinic is an encrypted number, and so it is hard for the institution itself to actually get to me. I try to--
[Dr. Mark Hoffman]
You're not giving out your cell number. You've given the direct line to the clinic?
[Dr. Julia Geynisman-Tan]
It's a direct line to the clinic.
[Dr. Amy Park]
How do you continue your work? This is draining work.
[Dr. Julia Geynisman-Tan]
Yes, it is. That's why I do it as a urogynecologist because 99.9% of the time, I'm doing elective quality-of-life surgery that is restorative and fulfilling. I teach, and I do research, and I do all these other things with 99% of my time. This 1% of my time is incredibly draining. There's no way I could do this full-time.
[Dr. Mark Hoffman]
How often are you doing the clinic?
[Dr. Julia Geynisman-Tan]
It's as needed. The clinic is not a standard day and time. Anytime patients need me, they will just see me that day as part of my regular clinic hours or whatever. I'm at the hospital that day operating, and I tell them, "Okay, come on in between 12:00 and 1:00 when I'm turning over a case. I'm just constantly seeing patients as they need me.
[Dr. Mark Hoffman]
It's incredible.
[Dr. Amy Park]
That's amazing work. Jules, thank you so much for giving your time to us and to our listeners to talk more about this topic. I always learn more and more. I've heard you talk about this now a couple times, and I'm always learning more. I think what we should do, Mark, is link to some resources that Jules can give to us and to our listeners, because that would be awesome just to some of the organizations that you had listed, like Polaris. Thank you so much for coming and for sharing your knowledge and insights on this super-important topic.
I love that there's more attention to it now. I see it in the airport, I see it in our bathrooms. I think it's way more common. I've seen a couple of these talks, and it just makes you realize how common it is. Thank you. Thank you. Hopefully, there's more people in this space. I think our journals should be paying more attention to this. I encourage you to submit review articles [laughs] on that topic. It's amazing.
[Dr. Mark Hoffman]
Thank you so much. It's such an important topic that, as my ignorance highlights, that there's a need to shine a light on this. It's something that I think most of us just have not been exposed to. To be able to talk about this and share with other clinicians and providers. The work you're specifically doing is just truly incredible. Thank you for what you're doing.
[Dr. Julia Geynisman-Tan]
No, thank you, guys.
[Dr. Mark Hoffman]
I know your patients are grateful to have you, but hopefully, others who listen to our show are inspired to follow up. We'll, again, like Amy said, share any of the links that you can share with us into our show notes so our listeners will have access to as much educational material as we can.
[Dr. Julia Geynisman-Tan]
Absolutely. Thank you guys so much for having me. It was great to talk with both of you.
Podcast Contributors
Dr. Julia Geynisman-Tan
Dr. Julia Geynisman-Tan is an OBGYN at Northwestern in Chicago, Illinois.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2024, November 19). Ep. 71 – Human Trafficking: Red Flags & Clinical Guidance [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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