Shadi Kourosh: Medical Community Efforts to Identify and Combat Human Trafficking

You are the founder of Massachusetts General/Harvard’s Pro Bono Tattoo Removal Program and frequently treat patients escaping gangs and human trafficking. Can you explain how you became involved in this line of work and why dermatologists are so critical to the identification of human trafficking victims?

I became intimately aware of the issue of trafficking through my work on the Pro Bono Tattoo Removal Program that I founded at Massachusetts General Hospital and Harvard Medical School. We initially started the program to help young people escape gangs by removing their gang and crime-associated tattoos. This can often be a cost-prohibitive procedure for those who truly need it. But by allowing the tattoos to remain, individuals are vulnerable to further violence or exploitation by gangs and can find it difficult to get a job and reintegrate into society. This tattoo removal clinic was a great forum to teach our medical students and dermatology residents the science of tattoo removal and to show them the importance of community service and social impact work.

But over the years, we started to notice a particularly disturbing trend among our patients—young women who had been forcibly branded with tattoos during their experience of human trafficking. Their stories of exploitation were shocking, and we quickly realized that the problem was far more prevalent than we had imagined, both internationally and within communities in the United States.

In response, my students and I began researching medical and academic literature for information on human trafficking, including treatment protocols for victims and the most effective way to engage in patient advocacy. What we found was scarce.

In fact, the only paper on health and human trafficking we could find was published by Laura Lederer, a law professor and human trafficking expert who interviewed more than one hundred survivors of trafficking in shelters across the United States about their associated health problems. Professor Lederer ultimately found that 88 percent of these victims had passed through the healthcare system while they were being actively exploited and went unrecognized.

Learning that we, as a medical community, were missing critical opportunities to help affected patients was startling.  We decided to act by using the information and experiences we had from our years caring for trafficking victims and published the first medical paper on the skin signs of human trafficking. The leadership of the American Academy of Dermatology took note of this work, and I was subsequently appointed chair of a national task force on trafficking in the medical community.

I also started working directly with Professor Lederer, joining forces to spur mentorship and collaboration between the medical, legal, and policy communities.

For the past few years, Professor Lederer and I have been working with national medical organizations to identify gaps in knowledge and create training programs so that the healthcare workforce can effectively recognize and advocate for patients who experience human trafficking. We are also working with physician colleagues who care for migrant and trafficked patient populations in Europe and have connected with staff at the U.S. Department of State who work on trafficking. Going forward, we intend to continue to expand our team of stakeholders as well as our data-gathering and educational initiatives, both across the United States and internationally.

What trends are you seeing among your patients, particularly among human trafficking victims? What skin signs are most prevalent? Are there trends that you would like policymakers and others to be aware of? For example, are your patients primarily young or female? How do patients end up in your care?

Through our work, we have learned that human trafficking—which includes both labor and sex trafficking—affects women, men, and people across the spectrum of gender and social and economic backgrounds. Human trafficking takes place in most countries and every U.S. state. Women are commonly affected by sex trafficking.

In terms of the skin signs of trafficking that have emerged as trends in the United States, we have seen that labor trafficking victims tend to show skin signs related to abuse and trauma to the skin and infections because of poor living conditions. Tattoos are more prevalent with sex trafficking victims, and we have identified the following three categories for signs of sex trafficking, which we describe as the three “I’s”: infections, injury, and imagery.

• Infections: The first “I” is for infections. These are largely sexually transmitted infections but also could be infestations or other skin infections due to the poor living conditions of many individuals we see.
• Injury: The second “I” is for injury because of trauma to the skin from physical abuse or self-inflicted harm, such as wounds from cutting behaviors and scars arising from anxiety and trauma. These scars might require different types of laser treatments.
• Imagery: The third “I” category refers to imagery. Specifically, we started to notice that there were certain motifs in gang tattoos and trafficking-related tattoos.

When I first started working with people trying to dissociate from gangs, we partnered with a specialized police task force with expertise in gangs. We learned from an officer that some symbols could be highly specific and regional—for example, the Roman numeral for eighteen was a symbol for a specific gang—while others could be more general, such as those involving weapons. And we learned that the location of these motifs and imagers could be important signs.

We, as dermatologists, are trained to notice visual patterns. We have seen weapons and violence in gang tattoos, and we have seen others for sex trafficking victims, such as those that depict romanticism or valentines, including hearts, teddy bears, and sometimes the traffickers’ name or initials to indicate ownership or that the person is being trafficked by someone they consider to be a boyfriend or a romantic interest. We have also seen currency-related motifs, such as dollar signs.

As I mentioned, location can also be an indicator. For example, gang tattoos tend to be in more visible locations, such as on the face, neck, arms, or hands, to clearly identify an individual as a member. In trafficking scenarios, we have seen some of the tattoos in visible locations overlapping with the gang tattoos. But we have also seen tattoos in discreet areas like on the breast or in the genital region.

Our European colleagues are working on similar efforts to identify trends and patterns, although they have been much more focused on infections and signs of abuse rather than specific tattoo markings. We are hopeful that continued collaboration and data-gathering initiatives will help us paint a more complete picture of regional and international trends.

Tattoo removal is a critical piece of care for your patients, but can you comment on other services your patients need that they aren’t receiving, such as mental health services? Do you worry that without sufficient support your patients could again face victimization?

This is a very important question. Effectively caring for someone who has been trafficked and helping that person transition into a healthy and independent life is truly multifaceted and requires an interdisciplinary team, including mental health professionals and social workers, as well as different specialties of doctors, depending on what health complications a person may have. Through my close work with patients, I have been able to recognize those patients who need referrals to my colleagues in areas such as psychiatry, social work, infectious disease, and gynecology.

As I mentioned, gang and/or trafficking tattoos can be a logistical barrier to safety and reintegration into healthy circles of society for many of my patients. They often fear that continuing to bear these brandings leaves them vulnerable to re-victimization by their previous captors. They may also seek removal because visible tattoos could prevent them from getting a job or because it is traumatizing to look at a reminder of what was done to them.

Tattoo removal can require many laser treatments, often costing thousands of dollars. So that is why free tattoo removal programs like ours at Harvard are so important. I am pleased that several of my colleagues throughout the country are setting up similar volunteer tattoo programs through their dermatology clinics.

However, this is only one step in a complex path to recovery. It is critical that many of our patients have the opportunity to work with psychologists or psychiatrists who have experience with trauma-informed care of trafficking victims, as well as social workers who can help connect patients with resources such as shelters and transition programs. We have learned that traffickers are often able to lure victims because they offer basic needs like food and shelter to people who are at risk of homelessness. So, it is important that our programs have the tools they need to meet these needs to help build resiliency within vulnerable populations.

You have been instrumental in efforts to create a registry of skin signs of human trafficking victims. Can you explain how the registry works and how much it is being utilized by medical practitioners? Is there a need for more education and training for dermatologists and other medical professionals?

We have created an international registry that includes data from around the world on the skin signs of trafficking in the hope that it will strengthen our educational and training programs for the medical workforce. Health workers and other stakeholders who work with trafficked persons—including NGOs, shelters, or government agencies—can log cases of observed physical signs of trafficking in the registry. This does not include any personally identifying information about victims; rather, it only asks for geographic data so we can better understand trends in different regions of the world. The registry is shared through networks of medical organizations, shelters, and related organizations, both in the United States and abroad. More participants will only help strengthen the value of the registry. It can be accessed through this link or through a smartphone app that we have developed called SSTEAR (Skin Signs of Trafficking, Education, Advocacy, and Resources). The SSTEAR smartphone app also contains an educational toolkit and other resources for healthcare workers who may encounter people experiencing trafficking.

Can you talk about the efforts you are undertaking internationally, including with doctors from the World Health Organization? Is there a formal structure in place for collaboration and the sharing of tools and best practices? Is this something policymakers in Washington should be aware of, and is there a need for financial and other support?

With colleagues in Europe, we have formed an international coalition of physician experts on trafficking to gather and understand trends and help inform education and best practices in the medical community around these issues. Some of our doctors work with the World Health Organization, and we collaborate with multiple medical organizations such as the American Medical Association and the principal sponsors of our work—the American Academy of Dermatology’s (AAD) task force on human trafficking and the International League of Dermatology Societies working group on migrant health.

As I mentioned, systematic data-gathering efforts, training programs, and technological innovations like smartphone apps and an international infrastructure for capacity building in the medical community are all underway, making the national medical organizations working on trafficking—including the AAD—among the most valuable partners for policymakers, philanthropists, and other stakeholders who are working to combat trafficking. Through the guidance and mentorship of Ambassador Mark Lagon—a former Director of the U.S. Office to Monitor and Combat Trafficking in Persons—we have also begun collaborating with state department personnel who work in regions where trafficking is prevalent, such as in Malta. There has been a lot of enthusiasm around these partnerships, bringing together the medical and policy communities to make a powerful impact.