ROCHESTER, Minn. — Though we may tell ourselves slavery is a stain from the nation's past, our bracing reality is that the control and exploitation of other human beings has traded its chains of iron for those of threats and intimidation, and taken the trade underground.

Research suggests coerced and forced labor obtained through fraud, enticement, manipulation and violence affects 400,000 people in the U.S. A large proportion of these victims are believed to be conscripts in the commercial sex industry and forced marriage, a predominantly female and underage marketplace of sorrow and damaging health outcomes known as sex trafficking.

As health professionals grapple with how to better identify this invisible population living under the sway of captors posing as boyfriends, roommates and uncles, clinicians have turned toward the medical exam as an underutilized window of opportunity for contact with a population outside of the reach of screening protocols and standard pathways to health.

Research has determined that as many as 99% of sex trafficking survivors have reported a medical problem during their time as a victim, with 80% having been taken to a doctor. This common point of contact with the outside world makes the doctor's office a critical target for intervention.

Yet with so many secretive victims presenting at their community clinic for prescriptions, injuries and health problems related to exploitation, doctors are taught next to nothing about what to look for, let alone what to say or do in the presence of a person they believe is being exploited.

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That's the finding of a recent review of published curriculum on sex trafficking for medical trainees, a paper published last month in the American Journal of Preventive Medicine. The project, an initiative of Mayo Clinic Alix School of Medicine third-year student Jennifer Talbott and her adviser at Mayo Clinic Arizona, Dr. Juliana Kling, came about after Talbott's realization that Mayo Clinic Medical School students lacked such a curriculum.

After conducting a systematic search of all published training materials for medical students on the identification, approach and clinical care of presumptive victims of sex trafficking, the review identified just four training publications or Powerpoint presentations serving the nation's tens of thousands of medical students and medical professionals seeking continuing education.

"I thought there would be more out there," says Kling. "It does underscore the point that it's a more recently recognized area of concern. So I guess it didn't surprise me that much."

Kling says 70 to 80% of victims interviewed after becoming free of the sex trafficking industry say they had interactions with health care professionals who did not know they were being trafficked. She says visiting the doctor is often integral to the abuse.

Dr. Juliana Kling. Submitted photo.
Dr. Juliana Kling. Submitted photo.

"If people are being used as a commodity, making sure that their body is functioning well so they can continue to be trafficked will be a priority," Kling says. "Their pimp will bring them into a medical establishment to have the problem addressed."

"There are red-flag signs. They may be subtle — if someone is with a person, but you're not sure who that person is and you get a nebulous answer, and it's difficult to get them away from that person. There may be strange tattoos like a name or a bar code," she says.

Once a doctor has suspicions, approaching the patient is not as simple as handing a presumed victim a brochure. Victims are frequently psychologically unprepared to leave, for one thing. Moreover, there could be a threatening male in the room.

"We talk about that in all of our scenarios," Kling says. "The importance of getting your patient on their own so they have a safe place to disclose. About having a policy in the office to say 'at this point in our visit it's our policy to spend time alone' — to have a medical assistant in the room and have the partner go wait in the waiting room."

"You may not be the one that rescues them," she says. '"It's our job to get away from this rescue fantasy. It may be the case that simply identifying victims and providing resources may be all you can do in this transaction. But simply to establish a trusting relationship, especially in a setting like an outpatient primary care practice, so that person will continue to come back to you and you will continue to work with them with the goal of helping to get them out of the life, then you are going to be more likely to have an impact."

The group has used their inquiry to incorporate Mayo's first formal curriculum for identifying victims of sex trafficking, a standardized patient case offered first-year basic doctoring course. They are in the process of evaluating how well students retained the information.

"I think they are eager to do this," Kling says of doctors in training. "They recognize it may be challenging, that the patient may have their pimp in the room with them. But especially in their first year they are intent on becoming the best physician they can."