Health Care Providers Are Missing Chances to Help Victims of Sex Trafficking

As if adrift in the dark, Margeaux Gray sweeps her foot across the sidewalk and taps her toes along the lip of the stairs. 

Her guide dog—a weary, once-golden Labrador retriever named Junebug—hovers patiently at her ankles until the two safely descend. A few yards away, schoolchildren shriek, laugh, and ricochet from the slides to the swings to the monkey bars. Their feet hardly touch the ground. 

Gray finds a park bench. She asks if it’s empty, which it is, and she sits. Junebug slumps down into the shade beside her. The air is hot and sticky, typical for a summer in Los Angeles. But the rim of Gray’s floral hat covers her eyes from the sharp sunlight. She murmurs, her smile small and sweet, “There were parts of my childhood that were really wonderful, but it was mostly clouded. Clouded by the fact that I was being abused.”

From age 5 into early adulthood, Gray lived differently from most children in America. On the outside, she was the daughter of a white, two-parent household in south-central Kentucky. But behind closed doors, she endured abuses that caused long-lasting health problems. 

At the hands of an older man, a trusted family member, Gray was a victim of human sex trafficking. 

For decades, sex trafficking has been a peripheral issue in the landscape of human rights. While similar problems like domestic violence, child abuse, and elder abuse have transitioned into the public health space, sex trafficking remains in the criminal justice domain, where it evokes imagery of police raids and handcuffed pimps. 

Recent studies, however, suggest that law enforcement may not be the true frontline in the fight against trafficking. Rather, the people who most commonly interact with victims of trafficking, apart from traffickers and sex buyers, are health care providers. A 2014 study published in the Annals of Health Law found that 88% of nearly a hundred trafficking victims had contact with a health care provider at some point while being trafficked. In most cases, victims went to the emergency department. They also visited pediatric clinics and orthopedics, plastic surgery, and OB-GYN departments as well as dentists’ offices. 

Most doctors and nurses have no idea they’re seeing cases of trafficking in their clinics, says Shantae Rodriguez, a physician assistant who works at a clinic that serves victims of domestic violence and trafficking in Queens, New York. “People, including health care providers, think of trafficking as this mythical or foreign problem. There’s no understanding that it’s an everyday thing that we’re probably seeing,” Rodriguez says. 

As a result, thousands to tens of thousands of patients are filtering through the American health care system each year, never receiving the care they truly need, according to anti-trafficking organizations Polaris project and HEAL Trafficking. “It’s not that they’re not showing up,” says Rodriguez. “We’re not showing up for them.” 

A dull voice emerges from Gray’s purse. It’s a GPS phone app for the blind. She laughs and switches the device to mute. “It’s telling me I’ve arrived,” she says. 

Gray, a month shy of 40, says that her visual impairment isn’t genetic. Clinically speaking, it’s an acquired disorder in which the optic nerves are irrevocably damaged. While it often occurs in countries experiencing famine, Gray’s neuropathy is the result of extreme undernourishment. 

“When I was 10, the trafficking was at its worst,” she explains. “My body was being run down. It can only take so much.” 

Gray’s mother, concerned by her daughter’s recurrent vaginal infections, took her to see a pediatrician. The doctor, though kind and gentle, seemed to suspect nothing, she says. 

At 12, Gray developed anorexia, a disease with the highest mortality rate of all mental illnesses. To cope with her mounting anxiety and depression, she starved herself, pocketed razors, and cut herself in between being sold to sex buyers. 

One evening, Gray’s mother caught her purging in the bathroom and took her to see a psychologist. “I already didn’t trust doctors,” she says. “My trafficker had brainwashed and conditioned me not to say anything to health care workers.” She remembers his words verbatim: “They’re not there to help you. They’re just in it for the money. They’ll call you a whore and throw you in jail.” 

She shakes her head. “When you’re young, you don’t know better, and that fear is enough to keep you silent.”

The psychologist—whose office was a sad, dark place buried in an old Victorian home—spoke with a formality that often unsettled her young patient. 

At one appointment, Gray arrived visibly weak and tired. The doctor, disconcerted by her appearance, whipped out a thick medical textbook, flipped to a photograph, and turned the book to Gray. It was a picture of an adult woman, standing sideways, naked—her torso pale and emaciated. “[The doctor] pointed to [the photo] and said, ‘This is what an anorexic looks like.’”

Gray winces. “It was traumatizing. Even now, that image is imprinted in my brain,” she says, her voice trembling. “I cried. In that moment, I knew I was done with her and I was never going back.” 

For centuries, victims of trafficking had few legal protections against their abusers. Beyond the fuzzy strokes of the 13th Amendment, which abolished slavery, there was no comprehensive federal law against human trafficking in the U.S. until October 2000, when Congress passed the Trafficking Victims Protection Act. 

The TVPA defines “sex trafficking” as the commercial sexual exploitation of a human being through use of force, fraud, or coercion. (Prostitution and human smuggling, by comparison, do not require such tactics.) As a global enterprise, sex trafficking, often referred to as “modern-day slavery,” generates an estimated $99 billion in tax-free international profits every year, according to the International Labour Organization. When combined with forced labor, it makes up one of the most lucrative illegal industries, second only to the drug trade. 

While the exact number of cases in the U.S. is unclear, it is estimated that between 57,000 and 403,000 people are currently being trafficked across the country, from major port cities like Baltimore and New York to the rural South and Native communities in Alaska. Additionally, around 300,000 children living in the U.S., some as young as 3 years old, are at risk for sexual exploitation. 

Among those most vulnerable to exploitation are LGBTQ individuals, people with disabilities, undocumented migrants, runaway youth, children in foster care, homeless people, and low-income individuals. While foreign nationals seeking work are also frequently targeted by trafficking organizations, 83% of confirmed U.S. sex-trafficking cases in 2011 were U.S. citizens, according to the Department of Justice. In fact, the State Department ranked the U.S. as one of the top three countries of origin for victims of human trafficking, along with Mexico and the Philippines, in 2018.

Shandra Woworuntu, a petite 43-year-old Indonesian woman, shifts uncomfortably on a plastic stool in her kitchen. Her lightly dyed, chest-length hair is pulled back behind her ears, and her glasses, thick and square-framed, droop down her nose. Frustrated, she stands. Nothing can stop the blinding pain in her pelvis. 

As a global enterprise, sex trafficking ... generates an estimated $99 billion in tax-free international profits every year. When combined with forced labor, it makes up one of the most lucrative illegal industries, second only to the drug trade.

“No one chooses this,” she says. “Being sold for sex was not a choice. We are not prostitutes, and this was not a job.”  

Woworuntu worked as a federal bank manager and money market trader in East Java, Indonesia, until civil and political unrest rocked the country in 1998. Finding herself increasingly unsafe in the city, she paid a recruitment agency $3,000 for a visa and accepted a six-month hotel management position in Chicago. In January 2001, she left her 3-year-old daughter with her mother and flew to John F. Kennedy airport in Queens, New York. 

“Lady Liberty attracted me,” she says. “I was coming to the land of the free.”

At the arrival gate, Woworuntu was approached by a man holding a photocopy of her passport, claiming to be her chauffeur to Chicago. Instead, he delivered her to a brothel later that night, in exchange for an envelope of cash. For the next two years, Woworuntu was trafficked and raped in brothels, apartment buildings, and casinos along Interstate 95. “They told me my freedom cost $30,000, but that I [could] only pay back the debt serving men, $100 at a time.” 

Job recruiters often charge victims inflated fees, forcing them into steep debt with traffickers, according to the National Human Trafficking Resource Center. The traffickers further leverage the restrictions under certain work visas, as well as their victims’ economic dependency and social isolation in a new country.

“It was many months, all day, then all night. I stopped counting how many men I served. I have no idea how much debt I had paid,” she says. 

During her captivity, Woworuntu’s traffickers often threatened her with guns, baseball bats, and hunting knives. They drugged her with crystal meth and cocaine and fed her only plain rice porridge, yellow pickles, and whiskey. At her heaviest, she was 94 pounds, and often treated like “a rag doll.” During her menses, she was forced to use makeup sponges instead of tampons—that is, unless a buyer requested a girl on her period. 

Regularly beaten, Woworuntu eventually sustained an injury so severe it caused uncontrollable bleeding. Her trafficker escorted her to a local clinic, but because she didn’t speak English, “he was the one who talked to the doctor,” she says. 

“Traffickers are smart,” she says. “They beat your body parts, never your face, so everyone only sees a girl with a clean face.” 

An estimated 50% to 88% of trafficking victims accessed health care services during their exploitation; however, a 2012 study published in the Journal of Health Care for the Poor and Underserved found that fewer than 5% of doctors had ever identified trafficking among their patients and fewer than 3% of emergency department clinicians had ever received the training to do so. To date, few medical schools or residency programs offer students training on how to respond to suspected human trafficking. And, while nearly all hospitals in the U.S. have mandatory child abuse protocols, fewer than 2% of the 5,686 hospitals in the U.S. had guidelines on what to do with sex-trafficked patients, according to a 2015 study from the Journal of Human Trafficking. 

In late 2001, Woworuntu jumped from the second-story bathroom window of a brothel in Brooklyn. She escaped her traffickers, but the effects of their abuse followed her. 

Like many single mothers in Indonesia, Woworuntu had an IUD, a T-shaped plastic contraceptive, implanted into her uterus. It was a routine family planning measure. But upon being trafficked, the overpenetration from servicing buyer after buyer slowly drove the horizontal hooks of the IUD into the walls of her uterus. As the damage worsened, Woworuntu was forced to seek medical care. 

In 2002, doctors at a hospital in Queens attempted to manually remove her IUD. Not knowing her history, a male physician inserted a speculum, a duck-billed-shaped stainless steel device, into Woworuntu’s cervical canal. Without anesthesia, he repeatedly tugged on the IUD, embedded in her uterine lining. “It didn’t work,” she says. “Blood was dripping.”

Woworuntu was sent to gynecologic surgery. Neither the ER doctors nor the surgical team asked whether her injury could have been the result of sexual trauma. Decades later, Woworuntu still experiences severe discomfort in her pelvis from time to time.

She grips her hips and crumples into her seat. “It is pain that I will have for many years,” she says.

Donna Sabella, a psychiatric nurse Practitioner at a drop-in clinic in Philadelphia, didn’t understand the cases she was seeing. “Patients were coming in with black eyes and bald spots on their scalps, where their hair had been torn out,” she says. “One woman I saw had been branded with her pimp’s initials.”  

It was months before she realized she had stumbled on an invisible patient population.

While the lesson came late, Sabella soon learned that the health issues experienced by victims of sex trafficking run the gamut: jaw and neck problems from being forced to perform oral sex; back problems from working long hours in high heels; missing teeth and physical marks hidden underneath clothing, such as strangulation injuries, stab wounds, bullet wounds, bite marks, and cigarette burns. The list goes on, she says. 

A 2014 Annals of Health Law survey found that 99% of 106 survivors experienced at least one physical health problem while being trafficked, and 98% developed mental health conditions. Over two-thirds suffered gynecological symptoms such as urinary tract infections, sexually transmitted infections, unintended pregnancies, and infertility. In one case, a patient was impregnated by buyers six times and had six abortions. She ultimately lost her fallopian tubes and had to undergo a hysterectomy.

Rodriguez finds that the worst and longest-lasting symptoms are psychological. Common mental illnesses, she says, are complex posttraumatic stress disorder, bipolar disorder, insomnia, flashbacks, memory loss, addiction, and suicidal ideation—a spectrum shared by military veterans who served in either Iraq or Afghanistan. “We have to understand that when someone endures trauma, they’re fractured,” says Rodriguez. “Not just their body, but their mind, their soul, their spirit.” 

Despite the severity of their medical conditions, victims rarely tell health care providers that they’re being trafficked. However, the telltale signs of sex trafficking can often be observed throughout the patient’s visit, says Rodriguez.

Years ago, she recalls, a young girl came into her clinic. At the start of the appointment, the girl handed Rodriguez an insurance card, but when asked to verify the details, spelled the last name incorrectly and provided the wrong date of birth. “[The girl] said she was 19, but based on her appearance and mannerisms, I knew she wasn’t,” says Rodriguez. “There were also two older individuals, claiming to be her cousin and uncle, in the waiting room.” Recognizing several red flags, Rodriguez carefully probed further and eventually offered to link the girl to victim resources. 

There are many other “suspicious circumstances” that could alert hospital employees to potential trafficking, says Sabella: a male companion who refuses to leave the patient; a vast age difference between a companion and patient; a submissive or apathetic patient; an incompatibility between the patient’s backstory and their injuries; the absence of a medical record; the lack of a driver’s license or passport; and the presence of multiple medical problems at the same time. 

But the purpose of recognizing red flags isn’t to force a disclosure or “rescue” a victim from their trafficking situation, says Kanani Titchen, a pediatrician from Bronx, New York. Rather, health care providers should try to develop a trusting relationship with the patient, so that the patient feels comfortable and safe enough to return to the clinic in the future.

“We now know that the moment a victim decides he or she is ready to leave their trafficker is actually the most dangerous time for them,” says Titchen. This is because traffickers are hypersensitive to changes in their victims’ behavior. (On average, it takes victims five to seven attempts to successfully leave their trafficker.) “If a victim doesn’t feel like they have someone they trust to go to once they escape, our patients can end up right back in the hands of their trafficker—sometimes even a new one,” she says. 

We now know that the moment a victim decides he or she is ready to leave their trafficker is actually the most dangerous time for them. If a victim doesn’t feel like they have someone they trust to go to once they escape, our patients can end up right back in the hands of their trafficker—sometimes even a new one.

This was precisely the case for 37-year-old Kristie Kiefer. Sex-trafficked for seven years starting at age 21, Kiefer says she went to the emergency department early on. At the time, she was homeless, exhausted, and reeling from the physical effects of heroin and crack cocaine. Instead of receiving crisis support, Kiefer was handcuffed to a bed and then sent to a facility where she lay for three days, painfully withdrawing from heroin. “No one talked to me, my situation didn’t get better, and I thought, ‘Well, I’m not going to do this again,’” she says. 

Upon discharge, the hospital staff told Kiefer they would release her only if someone picked her up. “I didn’t have a good relationship with my family, and all I had was the phone number of a guy I met outside a grocery store,” she says. “He came, picked me up, and then held me hostage at his house for three days, doing horrible things to me. 

“The medical [system] put me in a terrible position,” says Kiefer. “[To] this day, I don’t really go to the doctor.”

Margeaux Gray bends the brim of her hat upward and breathes in the sunlight. In May, the jacaranda trees in the park will blossom with bright, purple flowers. “It always smells beautiful here in the spring,” she says.

She unzips her fanny pack and pulls out a dog biscuit, but Junebug doesn’t move. At 10 years old, she’s increasingly sluggish and, according to Gray, close to retirement. 

In January 2016, Junebug accompanied Gray to Washington, D.C., where she and 20 other survivors were honored at the Department of Justice for their activism against trafficking. Following the forum, the two embarked on a whirlwind speaking tour, flying back and forth cross-country. “It was exciting,” she says. “As an advocate, I gained freedom in helping others.” 

A few months in, Gray realized the constant travel was taking its toll. “We were at this one conference, and Junebug was burnt out. She wouldn’t listen to any of my commands. She wouldn’t walk. She was just done.” Panicked, Gray cut the trip short, and the two flew home.

Gray says the hiatus has given her time to focus on her health. In addition to her visual disability, she has PTSD, peripheral neuropathy, adrenal issues, and violent stomach spasms that affect her digestion. Each illness requires a prescribed medication, which has been a challenge to overcome on its own, she says.

“When I was a kid, [my trafficker] gave me medicines that made me sleepy, but he told me they were vitamins,” she says. As a result, she feared and abstained from medicine for years. Only through therapy did she eventually let go of her phobia. “With visualization, I’ve learned to see [medicine] as sunlight entering my body and nourishing my cells,” she says. “You have to be strong, and if you’re a survivor, you are strong.”

By late morning, the children on the playground have tired. One by one, they scoot down the slide and pat the sand off their pants. As they run to their parents, arms outstretched, their gleeful screams fade and blend into the low hum of midday traffic.