From the American Academy of Dermatology, welcome to Dialogues in Dermatology. I'm Dr. Ben Stoff, Editor-in-Chief. Thanks for tuning in. When you join Mayo Clinic's Dermatology Department, you're joining a team that's transforming dermatologic care for the better. Here, you're doing the work that not only makes our patients' lives better, you're doing the work that changes your life. Visit jobs.mayoclinic.org slash dermatology to learn more. Hi there. I'm Dr. Alex Rosen-Egan, and today I am going to be speaking with two experts in the field on identifying and helping victims of human trafficking, the role of the dermatologist in advocating for those affected by trafficking. And I'm honored to be here today interviewing both Dr. Shadi Kourosh and Professor Laura Lederer. Dr. Kourosh, you almost don't even need any introduction, but our time together goes back all the way to when you were Editor-in-Chief of Dialogues in Dermatology, and since then I know this has become a big passion project for you. And we're incredibly lucky to have Professor Laura Lederer here. She's a law professor at Georgetown. She's one of the world's foremost experts on this issue. She has served as an advisor to the State Department and currently to the Department of Defense on this topic of human trafficking. She's also helped craft the original legislation for the U.S. on human trafficking over 20 years ago, and we are incredibly lucky to have her as an advisor to the AAD Task Force on Human Trafficking, which Dr. Kourosh is the chair of this task force for the Academy. So thank you both for joining us here today. Thank you, Alex. Great to be here, and I'm so incredibly proud of you. So this is an incredibly serious topic. A lot of times we're talking about dermatology issues and skin-related stuff, and although this has an overarching theme of being related to dermatology, we're going to be talking about a lot of really important factors as it relates to human trafficking. And Professor Lederer, given your knowledge and your expertise in this field, before we jump in, can you spend some time defining human trafficking for all of our listeners? Yes. So the definition of human trafficking is in the Trafficking Victims Protection Act of 2000, and it defines sex trafficking and labor trafficking. And there's a legal definition. But rather than do that, I think I would present the AMP, Action, Means, Purpose model. Trafficking includes actions, what we call in the law the suspect activities, recruiting, harboring, transporting, providing, obtaining of a person, and the means, through forced fraud or coercion, and then the purpose, either for forced labor or for commercial sex. And that's a really good way of understanding the definition in the United States. So we have those actions, we have the means by which it's done, and then we have the purpose for which it's being done. And the only caveat or the addition is to say that while we say recruiting, harboring, transporting, providing, obtaining by forced fraud or coercion for the purpose of commercial sex or forced labor, in commercial sex, if the person is a minor, you don't have to prove forced fraud or coercion. So that means anybody who's found in commercial sex, in prostitution, or any of the related commercial sexual activities is per se or automatically a victim of trafficking. Can you give us a little background on this topic of human trafficking in the US, as well as your background and how you even got into advising our dermatology community? Yes, thanks, Alex, and very glad to be here. About 30 years ago, we began to notice this new phenomenon of people being taken vast distances, sometimes across the Atlantic or the Pacific Ocean, from one country to another to do somebody else's bidding for somebody else's gain. And it looked a lot like an old kind of slavery, but it had some new twists to it. And as cases began to emerge all around the world, but also in the United States, we realized that the laws that we had on the books were not adequate, the old slavery laws. And we began to have survivors of this, what we began to call trafficking, come to testify in the Senate and the House to tell their story of what had happened to them, that they had been, they had literally been purchased, and then they had either been forced to do labor without pay, or they had been forced into brothels and or onto the street to be sold for sex. And that began a process of drafting and passing a new law called the Trafficking Victims Protection Act that had three parts, prevention, prosecution, protection, and assistance to help to address this what we're calling new form of slavery, modern day slavery. And for a long time, we thought of this as a law enforcement problem and as a human rights abuse. And then as we began to talk with survivors, and I was involved in these early conversations with survivors, we realized that they not only had, you know, law, they had issues with the trafficker and the trafficker needed to be prosecuted, but they also have all kinds of health problems, a whole array of physical and mental health problems, as a result of being trapped in these terrible situations and being bought and sold over and over again. So we began to interview survivors to identify what those health problems were. And so that led me to a whole new field of health and human trafficking. And that's how I met Shadi, Dr. Kurish, when we were talking about the general health issues of human trafficking, but then also there were serious special health problems, including dermatological health problems. So let me just say that we did a study in 2014, 2012 to 2014, and we interviewed over 300 survivors about their physical and mental health issues. And we found that they had all kinds of physical health issues, including gastroenterological, cardiovascular, respiratory health issues, neurological health issues, all kinds. And 99% of those who were interviewed said they had at least one physical health issue, but most had multiple physical health issues. And similarly, we found that 98% had mental health problems also, including depression and flashbacks and shame and guilt, anxiety disorders, post-traumatic stress syndrome, suicidal ideation, a series of psychological health issues. And the average number of psychological health issues was about 12. So during trafficking and after trafficking, so these physical and mental health issues were lingering sometimes as long as 5, 10, 15 years after people had escaped the trafficking situation. Wow. Your background and your information on this is so valuable, and I can really see the physical and mental health issues of patients really being at the forefront. Dr. Kurish, can you explain why this topic is important for our dermatologists to know about? As an academic physician, we've had regular required training modules on this topic at our institution, but not everyone is exposed to that kind of information. And so what do our dermatologists need to know about encountering patients and victims and survivors of human trafficking? You're right, Alex. That's a great question. And I'm glad that now in some states and in some institutions, it is becoming a part of the education and the updates and trainings. But this history of dermatologists assisting survivors of trafficking actually really predates this. For me, it began years ago when I started Mass General's pro bono tattoo removal program here at MGH and Harvard Medical School for young people that were trying to get out of gangs and needed their gang tattoos to be removed in order to be safe, to not be identified by their previous associates or their enemies and other gangs by their tattoos, which had led to some people being attacked and even killed in the past before they could escape the gang, and also to be able to acquire jobs and reintegrate to society. So we were running this program, and I know that there are many of our colleagues who may not have formal programs like the one that we had at Mass General, but that are just wonderful human beings who volunteer and give us their time and do this kind of work throughout the country. For example, I have friends and mentors in Texas where I trained. I trained at UT Southwestern Medical School in Dallas, and I had wonderful mentors, Dr. Dennis Newton and Dr. Rebecca Ewer, who used to do this in the community. And that's how I learned the skills of tattoo removal was I was actually working with them, volunteering when I was in my training, lasering tattoos off of young people that were trying to get out of gangs. So that really affected my career and my vision of how we as dermatologists could be of service. So I started this program at Mass General, and then in the process of helping the young people that were escaping from gangs, the same stakeholders in the community that were referring these people, like their local primary care doctors, local community organizations, the nurse examiners from the district attorney's office, started to refer this emerging population of young women who had been forcibly branded with tattoos as a result of their experience of trafficking. And so that's when I realized that there was something going on that we as dermatologists really needed to learn more about. And I started to research everything that I possibly could on this issue. And that's when I came across Professor Letters' paper, her 2014 paper in the Annals of Health Law, because I realized that there was almost nothing in the medical literature, especially at that time. There were scant reports from in the nursing literature. There were a few reported cases in psychiatry literature. So Professor Letters mentioned the extreme psychological damage that these individuals, these patients have endured. So there was actually a paper that had come from a group of psychiatrists in Texas, which is a very high density state for trafficking, saying that they had been caring for this population of women that had escaped trafficking. And of course, trafficking affects both men and women. So far as we know, it's much more women. But I want to be clear that everyone can be affected. And so this group of psychiatrists were saying that, you know, it was such a difficulty and a barrier that they had identified in the medical community, that these trafficking survivors were not being identified until really much too late in their experiences, because it took them a long time to figure out that these people that they had been taking care of were being trafficked. And in this paper, they said, wouldn't it be nice or it would be really helpful if there was some sort of way to identify these patients sooner, for example, by skin signs. So they had noticed on their patients that there were these tattoos and that there were these skin signs, and they had gone to social media to try to figure out what some of these symbols and motifs in the tattoos meant. And so it was interesting, because when I found this paper, I realized that they were asking for our help as dermatologists. We, the specialty of visual pattern recognition and the specialty with the procedural expertise to remove tattoos. And so, but that was all I had found in terms of doctors. I realized that really there were no great papers in the medical literature that could help medical professionals like me learn about the issue. The best paper wasn't written by a doctor, it was written by a lawyer. And that's Professor Laura Lederer, who's here with us today. And so I found her paper in the Annals of Health Law, and I was really struck by the extent of what she and her team had described of the health problems of trafficking. And so I went searching for her, and I found her contact information online, and I called her and I said, you know, we're this group of dermatologists trying to help these patients, and could we work together? And she said, you know, I'm so glad you found me, and that the dermatology approach was a really important approach that had not been emphasized before, but that could be really valuable. And it meant a lot to me to have someone with her expertise and her really broad view of the entire field of trafficking say that the role of dermatologists was actually incredibly important. Can I add here that when Dr. Kourosh contacted me, it really resonated for me because very early on, I had worked with a survivor who had explained to me at that point that if you are drug addicted to intravenous drugs and being trafficked, oftentimes there are abscesses and injuries to the skin that are telltale signs. And that was back in 2004 or five, when I toured her facility. And so it sort of was in the back of my mind. And then Dr. Kourosh called me, and I was able to phone round to some other survivors who confirmed that there are numerous signs and indicators of trafficking on the skin or, you know, skin issues. And I realized that this collaboration is really important and that dermatologists have a vital role to play in identifying human trafficking and human trafficking victims and survivors and treating and helping them to recover. So it sounds like these patients are not only presenting in numerous different ways and in numerous different places, but with numerous different physical and dermatologic signs and symptoms. And really, there's a huge role for a dermatologist to play in the care of these individuals. And I imagine it is easy for us to say that these individuals clearly need our help, but that's a really hard thing to then summarize. So how do we even go about doing that? What are some of the barriers that are faced in these situations to providing help for these individuals? Well, I think the first barrier is awareness, awareness and recognition. So after I read Professor Lederer's paper, the one thing that really struck me, I mean, there was a lot that struck me in the paper, but the thing that struck me harder than anything else is that, and Laura, please correct me on the statistic, but I think you found that 88 percent of the human trafficking survivors that you interviewed had passed through the health care system at some point when they were being actively exploited and gone unrecognized. So it meant that their medical teams didn't know. They didn't know what situation they were in and they didn't know how to help them. That is exactly right. And I would say, and Alex, your question is a great one, because there are barriers on the victim side, victim and survivor, and there are barriers on the provider side, too. Before we talk about them, I just wanted to say a little bit about the terminology victim and survivor. The U.S. Department of Justice has sort of struggled with what is the right term. The law, Trafficking Victims Protection Act, uses the word victim. And in order to get services, you must qualify as a victim. And a victim is somebody who has been trapped in either sex trafficking or labor trafficking or in some instances, child soldiering. A survivor is someone who has come out of it and who's in a process of healing. But both terms are important terms and they're sometimes used interchangeably. I say victims and survivors, but both terms are important and neither one is a derogatory term. They're both important to know. So not only are there barriers on the victim-survivor side, which I know you're going to talk about, but there are barriers on the health care side. So can you discuss a little bit about some of those barriers to treatment on both sides of the line? Yes. And Dr. Kourosh, I hope you'll add in. I'll start with the victims. Victims, oftentimes, there's a lack of knowledge. Sometimes they don't even know that they're trafficking victims. They don't know that they're being exploited. They don't understand what the definition of trafficking is. They don't understand their legal rights. They have language barriers or limited literacy or education that hinders communication. They also have a fear, a fear of authorities, particularly law enforcement, but sometimes even medical officials, doctors and other clinicians, if they've had some kind of negative experience along the way, they have a huge fear of retribution from their trafficker. I had one survivor say, yes, my doctor asked me if something was happening. And I think that she had a feeling that there was something going on. But did I tell her? No, because I wanted to live to see another day. They have a fear of deportation if they're foreign nationals or a fear that the reporting could lead to being taken and put in foster care placement if they're a juvenile. Some people fear that if they tell what's happening to them, they'll be separated from their children. And I had one survivor say to me, I didn't say what was going on because I knew they would put me in a shelter that didn't take children. So I lived in my car that winter with my two-year-old. So there are all kinds of things going on that mostly have to do with trust and fear and sometimes lack of knowledge on the survivor side. And as physicians, patients usually come to us for assistance, for a medical problem, especially as dermatologists. People usually present to us with issues that we can see. We're very visual physicians. When talking about these victims, these survivors, how do we identify these patients and where are they typically presenting and what do they typically present for? So I hope that Dr. Kourosh will also answer this, but what we've done recently, I know the Department of Health and Human Services has just a laundry list of signs and indicators. But when we went to do the health and human trafficking training, we divided it into what a scheduler or a receptionist might see or hear, what on the first interaction at the healthcare facility, what signs and indicators might be present, what signs and indicators might be present in the medical history, and what signs and indicators are present in the exam. So I'll take a couple of these and then Dr. Kourosh, maybe you can take the others. But we noted that when scheduling or describing the chief complaint, if the patient isn't the one making the phone call or isn't the only one on the call, or if it seems like there's somebody prompting them, or there's a kind of a list of chief complaints that many physicians have said might have been, and I don't know how many of these would be for a dermatologist, but requests STI testing or pregnancy testing or contraception, or if there's any kind of anal genital complaint or acute sexual assault or injury, some kind of either broken bone or knife wound or gunshot wound. We have all kinds of stories of patients who've presented with these and they've been treated and then released back to the trafficker. If on first interaction with the healthcare facility, the person is escorted or guarded by someone or seems to be controlled by someone, if they have no identifiable home or address, one survivor said to me that her trafficker had a circuit from Hawaii to Las Vegas to Los Angeles to San Francisco and back to Hawaii. And she was 17 and she said, I would wake up and I had no idea what city I was in. And we didn't have an address to give people. And so if there's no identifiable address or home, if there's an age inappropriate partner accompanying them, if they show signs of physical abuse or fear, agitation and so on. And we've created these little pocket cards, basically, that can be at the desk or in a nurse's pocket and can be pulled out that are the signs and indicators. And what we really need is something that is specific for dermatology. And I'd be happy to work with you on that. Yeah, that's a great point, Professor Ledera. And we are working to distill the content of our AAD trafficking toolkit website onto small cards, just as you say, that's one of the things that's in development. And to answer the question of where dermatologists may see these patients. So as I mentioned, I and colleagues like Dr. Paul Friedman and Dr. Emily Go, who works with him and many of our colleagues who are now doing volunteer assistance of these patients have seen them in the context of tattoo removal. Person needs a tattoo, cannot afford it to have it removed. That's a situation where we're seeing someone at a later stage of their recovery, usually, because they are seeking to take steps to come out of their circumstances, which involves tattoo removal. So that's one stage in which dermatologists can help. But then the other stage is the earlier identification. And that's where knowing the skin signs that we discussed and then understanding the broader context of patient interactions and trauma-informed care and these principles that Professor Lederer discussed are going to be important. And where that, so far as we know, is happening is more in the setting of county hospital clinics in the ER and sometimes in these safety net clinics. And this is why it's becoming really important to me to educate our dermatology residents that are working in these hospital settings, because I'm not the only member of our task force that has really expressed the concern that it could be our residents that are in the front lines of helping these patients. And we need to make sure that they're educated as well. And so sometimes these patients may present to private clinics from the dermatology standpoint, but we suspect that it's happening in the safety net and in the hospital systems even more. So our academic dermatologists on our survey seem to have greater awareness of this, but we don't know in terms of our residents, how much residency education they're getting. And so that's really a goal of mine in our larger efforts going forward. Great. Well, I think it's incredible what the American Academy of Dermatology is doing, but you also mentioned working with some of our other organizations within dermatology. Can you tell me a little bit about what some of the other organizations are doing to address this topic as well? Yes. It's been very heartwarming in doing this work to see the outpouring of offers of help that has really reassured me that our colleagues in dermatology really are wonderful people, and they're good citizens who either are helping in some way or want to help. And so as soon as we started doing this work in the Academy, as I mentioned, Paul Friedman from the ASLMS and I became teammates in working on this through the two organizations together. And then also other societies have reached out and offered their support from the Women's Dermatology Society, since this issue has tremendous women's health and advocacy implications, the ASDS, the European Academy of Dermatology and Venereology, which is a wonderful partnership because of their ties with the WHO and what they can teach us about trends of trafficking in Europe versus the United States. And so what is really forming around this issue is a coalition of all of dermatology in efforts to do what we can to help. Because as we have been learning, this issue is bigger than all of us. It's going to need everyone in the medical community to do their part. And the American Medical Association has also reached out to us. And I'm really proud to say that dermatology is an integral part of leading the educational initiative around educating the medical workforce around human trafficking with the AMA. And so there's more to come on that. And so I would say that this is really becoming a team-wide initiative of all of dermatology, and each organization has come forward to offer to help and to do their part in a way that is specific to their skills and their emphasis. And more exciting things are going to come from that. Yeah. And Dr. Croce, you want to talk a little bit about some of the barriers that you've seen or heard of on the healthcare side? Absolutely. I think the biggest one, as we were saying, is simply the lack of knowledge and awareness that this is even an issue. So after I read Professor Letterer's paper and really couldn't find anything else in literature, my team at Mass General set out to start describing what we had seen in our experiences and cover everything that we could find in a review on the skin signs of trafficking. And we published that paper in the International Journal of Women's Dermatology. And we found that there are three main categories of skin signs. And I like to describe them as the three I's. The first I is infection. And a lot of that is STI, sexually transmitted infections, which Professor Letterer's paper, she had also described that a lot of these patients have repeated STIs because of the kind of work that they're forced to do. And also infestations. They could have infestations in terms of infections because of their poor or substandard living conditions. So that's the first I, is infections and infestations. The second I is injury. So as Professor Letterer mentioned, they could have scars from drug abuse, IV drug abuse, track marks and things like that. They could also have injuries or scars to the skin from being physically abused. And sometimes they could have it from self-harm because of the tremendous mental health impact that their trauma has had on them. So we found that some patients are cutters or that they sort of harm themselves compulsively as a response to their trauma. So that's the second I is injury. And then the third I is imagery. And that's where we are looking at the themes and patterns in trafficking tattoos, which we are describing. I've given talks on now for some of our different dermatology organizations and which we are currently gathering information about. So one thing that we have created is an international trafficking registry that the American Academy of Dermatology is now working with multiple medical organizations, not only here in the U.S., but we are also now collaborating with dermatologists in Europe at the WHO and also collaborating with other entities to create and to populate this international registry of the skin signs of trafficking. And this is already up and running. It is behind a red cap firewall, IRB approved, and it allows anyone, any medical professional or any other party that may work with victims and survivors of trafficking, such as social workers, law enforcement, to in an anonymous way, document the skin signs. Because right now we are in the realm of expert experience on this issue. There are some of us in the field who have been doing this work. And I also want to shout out to my dear friend and colleague, Dr. Paul Friedman, who is someone else that I began to work with and collaborate with because in writing about this and publishing the work and finding out other doctors in the field, I found that he had been treating human trafficking survivors in Houston. And through his leadership of the American Society of Laser Medicine and Surgery, he was trying to mobilize and has mobilized to his credit a very large number of dermatologists that are now volunteers that are happy to help anyone like what you were telling me yourself, Dr. Rosen, that you are creating at the University of Miami, volunteers who are willing to remove tattoos. And so we hope that all of these individuals will access this registry of the skin signs and that our real knowledge and data about the patterns we've already identified will become more accurate and be able to guide this identification. Because the other thing that we found in now leading the American Academy of Dermatology's task force and initiative on this issue is we surveyed a sample of the membership of the AAD, and we found that the overwhelming majority of dermatologists did not have a real awareness of trafficking going on in their communities. Like they had an awareness that trafficking was going on somewhere in the world, but that it wasn't really on their radar to be thinking about it for their patients. And so we're hoping that as we continue to gather data and raise awareness, this major barrier of physician awareness of the issue will be overcome. And then the second barrier the professor letter also had alluded to is this idea that patients are extremely traumatized and depending on our specialty or our role in the medical workforce, many doctors may not have specialty training in trauma-informed care. And so I think that that's another barrier that we have to overcome is we have to prepare our medical workforce, not only to recognize people that are being trafficked, but to interact with them in a way that will make them feel safe enough to disclose their situation, which as professor letter mentioned has been a real barrier because they're afraid. As physicians and as dermatologists, there's so much for us to be aware of. And there seems like there are so many incredible ways for us to be able to help these victims, these survivors, and to better arm ourselves with information. Other things that I know are really important as physicians are empathy, giving our time to these individuals without bias or judgment. So what are some of the best practices in a dermatology setting that we can provide? I think there are a number of them. The first two you've alluded to them really is that our care needs to be victim-centered and trauma-informed. And a victim-centered approach is one in which the victim's concerns and safety and wellbeing take priority in all matters and all procedures. And there are many trainings on trauma-informed care, but I think the main thing is the importance of realizing the prevalence of trauma in trafficking victims. These are people who've been bought and sold over and over and over again. And the physical, mental, emotional, and spiritual devastation, once this has happened to you and you've been trapped in it is almost complete. And so the prevalence of trauma, realizing that, recognizing the impact of trauma on the patient, responding by integrating your knowledge about trauma into all your policies and procedures, and resisting re-traumatization. Those are the four R's of trauma-informed care. So victim-centered approach, trauma-informed care, and then the last would be a multidisciplinary approach because even in health, no one medical professional really has all the answers. And so knowing where to go and how to connect those who've been trafficked to other needs that they have, whether it's emergency needs like food, clothing, shelter, other kinds of medical assistance or legal assistance, and being able to do a warm handoff to make sure that they get those other services is really important. When we first started training doctors, doctors used to say to us, but I'm not law enforcement. I can't be law enforcement. And we would say, we don't want doctors to be law enforcement. We just want you to know where to go if you need to contact law enforcement, if you have a duty to report this. Or they would say, but I'm not a social worker. And we would say, we don't want you to be a social worker. We know what your mission and mandate is, but we want you to know how to contact a social worker who knows how to help a trafficking victim or survivor. And so I think that multidisciplinary approach is also an important best practice. Great. I think it's really important for a dermatologist to know all this and have all these tools to be able to best care for these patients. And I know that there's a lot of ongoing, emerging and evolving issues surrounding this topic as well, that we really don't have time in this one episode to discuss, but things like ICD-10 codes and billing and how you keep electronic health records, which Dr. Krosh, you kind of alluded to as well. If people want to learn more about what is next and what the future of human trafficking as it relates to dermatology in the field of medicine, where can they go to find information? Great question. Well, I'm very glad to report that after two years of very hard work of the American Academy of Dermatology Task Force, largely in collaboration with Professor Lederer, we have posted already multiple resources for dermatologists online. And you can find these on the AAD's Trafficking Toolkit, which is a website within the American Academy of Dermatology site that is specifically dedicated to our efforts to advocate on this issue. And you will find a lot of information on background, including statistics and all kinds of scientific information. For example, the skin signs of trafficking on this Trafficking Toolkit website. You will also find guidance for how to document a medical visit in a way that protects the patient's privacy and information about ICD-10 codes, as well as videos on trauma-informed care. We are delighted to be working with a specialist psychologist. She's actually the director of the Human Trafficking Clinic here at Massachusetts General Hospital, has been a dear friend and colleague of mine for many years. Her name is Dr. Abigail Judge. And she, and one of our other collaborators, who is a survivor advocate herself, and also was the nurse examiner for the District Attorney's Office, who I also worked with, we have the two of them on our Trafficking Toolkit website, talking about an overview of what trauma-informed care means, and sort of providing some guidance on trauma-informed care. And then we also have begun a directory of resources for dermatologists. So as Professor Lederer mentioned, part of being prepared for our patients is being able to do a warm handoff. And what a warm handoff means is that you know your resources. For example, that you know your local social workers, or shelters, or other resources that you might direct a patient to. And that it's so much more effective if you know your resources and can specifically direct a patient to someone that you know and who you have worked with, than simply providing that patient with a phone number and saying, call this 800 number or call this organization. So that's what's meant by a warm handoff. Well, considering that most dermatologists have not had to deal with this issue before and might not know what those resources are, that's one of the resources that we're developing on the American Academy of Dermatology website, is a list of resources by a dermatologist. A list of resources by location. So depending on where you might live or practice, we're hoping to be able to provide more information for a dermatologist to go on there. And so I really encourage all of our member dermatologists and also other physicians of other specialties, because we are making that human trafficking toolkit public. Because we want everyone in the medical community to benefit from it. So I would really encourage everyone to take a moment and go on that website and see the resources that are already there. And it's also being further developed. There is a link on the human trafficking toolkit website for the International Registry, the database we're creating of the skin signs of human trafficking. So if you're in a position where you realize that you're seeing someone that may be affected by this, you can go on that website, prepare yourself with resources to be able to help that patient. And also after the visit, log the case and share with your colleagues in an anonymous way what the skin signs were so that we can grow from that experience. And then the next step, even beyond that, is that we have created an app. There's a smartphone app that's coming out. It should actually be available from the app store very soon. And it's called STEAR. S-S-T-E-A-R. And that stands for Skin Signs of Trafficking Resources, Education, and Advocacy. And so we encourage everyone to go on the smartphone app stores and download this free app that also will contain all of the resources on the human trafficking toolkit, a link to the international database and registry of the skin signs of human trafficking. And also what's coming soon is that Professor Letter and I are working together with the task force to create free CME content for the American Academy of Dermatology, where every dermatologist can get free CME credit to learn about trafficking. So I would say, look out for that on the trafficking toolkit website. It's coming soon. All of the work that the two of you have done and are continuing to doing on this really important topic is so valuable to the community. And what's amazing to see is that the really dermatologists and the American Academy of Dermatology and our partner organizations are really leading the education on this topic for a lot of physicians. And so I really applaud all of the work that you have done. And it seems like there are so many ways that our fellow dermatologists can really get involved. And unfortunately, our time is coming to an end soon. So I would really like to give you the opportunity to talk about what, maybe you could summarize two big key takeaway points for the colleagues listening to this incredible talk today. Professor Letter, I'll start with you. Yes. Well, I only have one. That is that everything that we're talking about today, for me, boils down to two things. One, know the signs and indicators of human trafficking in a dermatological setting. And two, know how to respond appropriately. And that response, there's a whole set of responses from the actual treatment. And Dr. Karosh, anything that you would want to add a big key takeaway point for our colleagues listening today? Yeah, I'll never forget the first time I called Professor Letterer and she said, I'm so glad you found me. And one of the things that she said was, you, the medical community, are the first responders to this issue. That as we've discussed, these patients often avoid law enforcement because they're scared. They're scared of the possible impacts from their traffickers, for example. But they seek medical care. As her study showed, 88% of them had passed through the healthcare system and gone unrecognized while they were being exploited. And so what I take away from that is that the medical encounter is the key point of contact to help these patients. That we, the medical community, are the point of contact. We have this opportunity, this very unique opportunity to make a difference. And so we have to be prepared to make that difference. And this whole initiative of all the resources that we are building in the American Academy of Dermatology with our online trafficking toolkit, with our new smartphone app that's coming out, with our international registry of documenting the skin signs of human trafficking, and with our new CME program, the whole point of all of that is capacity building in the medical community so that we can be prepared for our patients when that opportunity comes and that we can best advocate for them. So my biggest takeaway would be to encourage all of our colleagues, not only in dermatology, but in other aspects of medicine, because we are going to make these resources available for everyone, to take a moment to learn these resources and go on these websites and see what's available for you so that when the opportunity arises, you'll be ready to make a difference. Well, I hope that in the near future, we can get together again and talk about all of the incredible work that is still evolving and emerging, like the CME content you mentioned, as well as updates on any sort of reporting and ICD codes and Medicaid. There seems to be an endless amount that we could talk about. And I really want to thank the two of you so much for being here today to just chat with me about such an important topic that really impacts everyone in our medical profession. Thank you so much again for your time today. Thank you for having me. Thank you. When you join Mayo Clinic's dermatology department, you're joining a team that's transforming dermatologic care for the better. Here, you're doing the work that not only makes our patients' lives better, you're doing the work that changes your life. Visit jobs.mayoclinic.org slash dermatology to learn more. Thanks again for tuning in to another edition of Dialogues in Dermatology. For more dialogues, subscribe to us through the website of the American Academy of Dermatology, then link your subscription through your favorite podcast app. Remember, the subscription is free for residents. New podcasts are released each week in addition to free special bonus episodes. You can also listen to Dialogues online through the AAD website.

human trafficking

dermatologists

victim assistance

skin-related issues

trauma-informed care

American Academy of Dermatology

Trafficking Toolkit

healthcare providers