How can dermatologists identify and help victims of human trafficking?

By Kathryn Schwarzenberger, MD, FAAD, March 1, 2024

DermWorld interviews Shadi Kourosh, MD, FAAD, chair of the Ad Hoc Task Force on Dermatologic Resources for the Intervention and Prevention of Human Trafficking, about how and why dermatologists can and should engage with the problem of trafficking and how they can report suspected trafficking to a new registry. 

The AAD Ad Hoc Task Force on Dermatologic Resources for the Intervention and Prevention of Human Trafficking created a Trafficking Toolkit that includes medical and educational resources to help dermatologists provide timely support and advocacy for those who are trafficked.

DermWorld: Why do you believe it is important for dermatologists to be aware of human trafficking? 

This issue first came on my radar years ago after I founded the pro-bono tattoo removal program at Massachusetts General Hospital and Harvard Medical School to help young people trying to dissociate from gangs to remove their gang tattoos so they could be safe and get jobs. The local organizations with whom we worked began referring an emerging population of young women to our clinic who had been forcibly branded with tattoos while they were being exploited in human trafficking.

In trying to learn more about this issue, I connected with Professor Laura Lederer, a law professor and advisor to the U.S. State Department and Department of Defense whose team went into shelters throughout the country to interview survivors and found that over 85% of people who were trafficked in the United States passed through our health care system while they were being actively exploited and went unrecognized.

A major barrier faced by our colleagues working in government and the medical community was how to better identify and help people being trafficked and some specifically asked if there were any “skin signs” that might prompt recognition.  

DermWorld: What are some common signs of human trafficking? 

Dr. Kourosh: So far, we have found three major categories of skin findings that one can remember as the three I’s:  

1. Infection: often sexually transmitted infections or infestations from sub-standard living conditions 

2. Injury: manifesting as scars from trauma or abuse or self-harm 

3. Imagery: specifically certain themes found in tattoos, such as those of weapons or violence, valentines or sentiment, cash or currency as the person is being used in transactions, and/or the names of individuals, indicating ownership by the trafficker 

The location can also be relevant for trafficking tattoos. Like gang tattoos, they may be intentionally placed in highly visible locations such as the face, neck, or hands. However, with sex trafficking tattoos, they may also be placed in private locations. 

There may be more skin skins beyond these, and to learn more in a data-driven way, we have created a Skin Signs of Trafficking Registry where dermatologists and members of their health care teams can log cases in an anonymous way, including any skin signs they have seen, such as certain tattoos or other findings we may not yet have seen that could help us learn more in our efforts to educate the medical community and our partnering organizations.

DermWorld: What should a dermatologist do if they suspect one of their patients is a victim of human trafficking? 

Dr. Kourosh: Our AAD Task Force is gathering multiple resources for dermatologists for our online toolkit!  

The AAD Trafficking Toolkit already has educational content and videos on multiple aspects of this issue, including background information on human trafficking and its signs, how to navigate an encounter where trafficking is suspected, how to document in a way that protects patients, and a directory of resources for health care teams and patients. 

There is also a link in the toolkit to the Skin Signs of Trafficking Registry where dermatologists who have encountered trafficked patients can log cases of skin signs they have seen in an anonymous way. We are also creating trafficking-related CME content so that dermatologists can get CME credit for learning about this issue.  

All these resources to help us learn and advocate for affected patients will soon be conveniently accessed through a free smartphone app, Skin Signs of Trafficking Education Advocacy and Resources (SSTEAR)!  

DermWorld: What are some things dermatologists should keep in mind when dealing with a patient they suspect is a victim? 

Dr. Kourosh: Our AAD Task Force has worked closely with national experts on caring for human trafficking survivors to learn about trauma-informed care and best practices for navigating these patient visits. Two of these experts, a psychologist and nurse examiner from the district attorney’s office, helped create a special video for dermatologists illustrating some of these clinical pearls for caring for trafficking survivors, which can be found by scrolling to the bottom of our Trafficking Toolkit.

DermWorld: Are there any myths about human trafficking dermatologists should be aware of? 

Dr. Kourosh: As I become more educated on this issue, I’m learning there are a lot of myths we didn’t understand. Probably the greatest myth is that human trafficking is some sort of foreign or international issue that doesn’t really affect Americans. Meanwhile, most of the trafficked patients for whom I and my colleagues have cared have been young American girls who were recruited and/or exploited in our own communities under the radar. This is a more local issue than we had imagined.  

DermWorld: What steps should a dermatologist take if a patient they suspect of being a victim of human trafficking isn’t receptive to help? 

Dr. Kourosh: The guidelines depend on the age of the patient. For pediatric patients reporting is mandatory and guidance for reporting can be found on government websites, the American Academy of Pediatrics, or by contacting the Child Protective Health Clinic at your local children’s hospital.  

For adults, it is up to the patient to get help and the person may be afraid for various reasons to try to escape their circumstances, and thus helping the patient may be a more gradual process. In these cases, Dr. Abigail Judge, trafficking expert psychologist who is advising our AAD Task Force, has emphasized the importance of building trust with patients in the initial visits so that they feel comfortable returning to get help, and that intervention may be a process of also helping the patient establish connections with various resources such as shelters and social work, among other basic needs, so that they feel they have the resources to become independent of traffickers.  

Being patient and building trust according to the principles of trauma-informed care and knowing our local resources are key to helping patients receive help. In all cases, it is critical to maintain discretion and privacy to the greatest extent possible so that traffickers do not become aware of attempted interventions, which could endanger patients. This highlights why getting as much training as possible about best practices and resources ahead of time is important.  

DermWorld: Where can dermatologists find additional resources on this issue? 

Dr. Kourosh: Our AAD Trafficking Toolkit website offers educational content and resources; our Skin Signs of Trafficking Registry allows you to log any cases of skin signs of trafficking that you may see; and the smartphone app, Skin Signs of Trafficking Education Advocacy and Resources (SSTEAR), where you will soon be able to access these resources, are great resources that dermatologists can utilize. 

I’m excited for our CME content on this issue and that our partnerships with our state societies and some of our sister dermatology societies are also going to provide additional resources and opportunities to volunteer.  

DermWorld: How can dermatology help in this effort? 

Dr. Kourosh: We as dermatologists are uniquely positioned to assist those experiencing trafficking with our training to recognize and diagnose relevant signs on the skin and to assist patients with certain aspects of care and recovery, including the treatment of diseases, scars, and tattoos. 

Our Academy Presidents Mark Kaufmann and Terry Cronin deserve a lot of credit for immediately mobilizing our AAD efforts on this issue. They worked together to appoint the AAD Ad Hoc Task Force on Dermatologic Resources for the Intervention and Prevention of Human Trafficking so that we could streamline our knowledge and resources among Academy members and begin educating ourselves and the larger medical community on how to advocate effectively.   

Our AAD Task Force is now working with national and international experts on trafficking from psychologists, members of law enforcement, NGOs, and government advisors such as Prof. Lederer who have told us that the dermatology approach to assist those impacted by trafficking is among the most innovative they have seen and that the AAD is now leading the way for other medical societies to assist in these efforts in a focused and organized way.  

Some of our state societies like Florida, Texas, and California, where trafficking is the most intense, have risen to the occasion and asked how they can assist within their states. Other national and international dermatology societies have also offered their support to partner with our AAD initiatives to see how each society can do their part in our dermatology efforts. 

What has been most heartening is that I haven’t really had to convince anyone why dermatologists’ awareness about human trafficking is important. Our colleagues have continually confirmed my belief that our dermatology community is full of truly decent people who upon hearing of this issue come forward on their own and ask how they can help.  

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