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You Have to be Comfortable Being Incredibly Uncomfortable

Monday, March 12, 2018 - 13:00


Approximately one month into her child abuse pediatrics fellowship at Hasbro Children’s Hospital, Dana Kaplan, MD, had a 16-year-old patient in the clinic who had been exchanging sex for money.

“I went to go speak with her, and I didn’t know what to say,” says Dr. Kaplan, who is now Director of Child Abuse and Neglect for the Department of Pediatrics at Staten Island University Hospital. “I didn’t know what was relevant to ask. I didn’t know what was pertinent to provide her medically.”

Before those questions could be answered, Dr. Kaplan searched on her laptop for a definition of this population of patients. “Domestic Minor Sex Trafficking (DMST)” describes activities involving a person under the age of 18 who resides in the United States and is exchanging sex for money. Starting there, she was able to learn about the dynamics of this population.

“But my main question was, what do we do medically?” she says.

This question was the impetus for a three-year quality improvement (QI) project, Creating a Medical Response to Victims of Domestic Minor Sex Trafficking. Dr. Kaplan earned 25 points of quality improvement credit (MOC Part 4) for her project by completing the ABP’s simple, online application.

“There was nothing in the published research in terms of medical follow up,” says Dr. Kaplan. “The existing information on medical evaluation was limited to the guidelines that are utilized to treat the patients when they seek medical care after an acute sexual assault. That’s really limiting in DMST because of the ongoing risks to a patient’s physical well-being, such as ongoing exposure to sexually transmitted infections.” 

Most of the patients told me, ‘I don’t care what you tell me. I’m going back out there.’” With this in mind, Dr. Kaplan began to explore how to reframe her approach, to understand how to talk with this patient population, how and when to take a medical history, and what to ask and what not to ask. “I needed to know how to help this patient population, but also understand that I am not going to be able to make my patients stop going back out there Kaplan says. “That’s not something I’m going to be able to do in a single encounter, and I really had to come to terms with that. I think the hardest part of coming to terms with that is you have to get comfortable being incredibly uncomfortable when you send a patient back out into ‘the life’ of DMST.”

“The life” is a term used to describe someone who is involved in DMST. Dr. Kaplan says her focus was to try to find ways to get DMST patients to return for follow-up appointments because of the victims’ ongoing exposure to violence, illegal substances, untreated medical needs, risk for acquiring sexually transmitted infections, risk for pregnancy, and risk for acquiring HIV.

“You need to have this person know that they can trust you,” she says. “I needed to find a way to gain rapport and really make these patients know that they could find a safe place with me — truly become their medical home. The first step is to remove judgment and to let them know they can talk to me about anything.”

At the end of her QI project, approximately 50 percent of the patients evaluated at The Lawrence A. Aubin Sr. Child Protection Center at Hasbro Children’s Hospital had returned for at least one follow-up visit.

“That is unheard of in acute sexual assault, let alone sex trafficking,” she says. 

Dr. Kaplan says because each patient and situation is different, it is hard to create a standardized care pathway.

“What I came to at the end of that phase of the fellowship QI project is that physicians should provide STI [sexually transmitted infection] testing and treatment based on risk and the patient’s disclosure,” Dr. Kaplan says. “So if they say, ‘I know I was just here a couple weeks ago, but I was actually out, and I’ve had many different encounters since then. And I really think I need to be tested and maybe treated again,’ then you hear that and consider that in your approach. It’s not a guideline. It’s really hearing the needs of your patient and being able to assess that risk and then test accordingly.”

Dr. Kaplan says another component of the project was to determine how to best prevent pregnancy. 

“It does not work for this population to be on birth control pills. If they’re on the run, they’re not taking their pills with them, and they’re not going to a pharmacy to refill their pills,” she says. “Even if they have something like Depo-Provera [a contraceptive injection], which is every three months, again, are they going to come back in three months to get that Depo?”

To improve her patients’ birth control options, Dr. Kaplan became trained in Nexplanon, which is a long-acting reversible contraceptive implant that goes into the arm and prevents pregnancy for up to three years.

While Dr. Kaplan has completed the QI project and her fellowship, this patient population is still her passion. After fellowship, in addition to her role as the Director of Child Abuse and Neglect at Staten Island University Hospital, she began to collaborate with Love146, an international human rights organization that focuses on child trafficking and exploitation, assisting the organization as their medical liaison. She collaborates with Love146 to raise awareness and to develop resources and strategies for creating a medical response for victims of domestic minor sex trafficking.

“The literature demonstrates that 30 to 88 percent of victims access health care at some point during their involvement in trafficking,” she says. “So the health care setting is an incredibly important venue, not only to identify patients involved in DMST, but to provide medical intervention.”