Form 1 Pilot Training Slides

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Regulatory Language

OMB Control No: 0980-0556

Expiration date: 12/31/98

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHHS/ACF Reports Clearance Officer; 370 L’Enfant Promenade, S.W.; Washington, D.C. 20447  

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Learning Objectives

At the conclusion of this educational activity, participants should be able to:

1. 1.Describe the scope, diversity, and types of human trafficking in the United States. 

2. 2.Recognize the common indicators and high-risk factors for human trafficking. 

3. 3.Use trauma-informed techniques when interviewing a potential victim of human trafficking. 

4. 4.Identify and engage local, state and national service referral options for trafficking victims.  

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Why is this training important?

• •Human Trafficking is a crime.  

• •Human trafficking is found throughout the United States.  

• •Healthcare Professionals may encounter victims of human trafficking.  

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Start the presentation by addressing the importance of the training and why healthcare professionals need to participate in the training.

First of all, human trafficking is a crime under both federal law and in the vast majority of states. It is a crime that results in serious health problems like other crimes such as rape and child abuse.

Human trafficking is found throughout the United States in both rural and urban settings

Healthcare professionals may encounter victims of human trafficking and with training will be better equipped to help these victims.

Human trafficking is quite prevalent and found throughout the United States. It occurs both in urban and rural settings.

Healthcare professionals are one of the few professional groups of our society to regularly encounter victims of human trafficking. However, due to lack of training, most of these victims are missed during the encounter.

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Why is this training important?

• •Healthcare professionals want to improve the lives of the patients they encounter  

• •They need to learn what to do as new issues, such as trafficking, arise 

• •Identifying and helping victims of trafficking requires specialized training 

• •This training will help you learn not only how to identify potential victims of trafficking, but also how to properly respond and care for the victim 

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Professionals within the healthcare arena naturally want to improve the lives of the patients they encounter. In order to do that, we go through extensive training on how best to diagnose and treat a variety of medical conditions.

Similarly, training is required when a new issue such as human trafficking arises. Training will enable you to know what and what not to do. It is possible that as a result of your encounter with a victim of trafficking, you may possibly save their life.

Therefore, this training is important because identifying and helping victims of trafficking is a very complicated issue and requires specialized training.

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STOP.
OBSERVE.
ASK.
RESPOND to human trafficking.  

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To assist healthcare professionals identify potential cases of human trafficking, the Department of Health and Human Services has initiated SOAR to Health and Wellness Training.

The purpose of this initiative is to train healthcare professionals to STOP. OBSERVE. ASK. and RESPOND to human trafficking.

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STEP 1 = STOP
 

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Healthcare professionals have a unique and critical role in the identification of victims of human trafficking. A visit to the hospital or clinic may be the only time a victim has access to help.  This is the healthcare professional’s opportunity to STOP and consider if the patient they are caring for could be a victim of human trafficking and then take the appropriate steps.

In order to STOP and consider whether the patient might be a victim of human trafficking, you need to possess a basic understanding of the definition and certain characteristics of human trafficking.

We will cover the definition of human trafficking, types of human trafficking encountered in the United States, types of traffickers and finally the recruitment of victims into trafficking.

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• •  Force 

                Use of rape, beatings, confinement to control victims

• •  Fraud 

                Use of false offers to induce victims into trafficking situation

• •  Coercion 

                Use of threats against the victim or victim’s family that can cause an individual to feel as if they cannot leave the situation they are in

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Remember, only ONE means is required for a person to be identified as a victim of human trafficking.

Force involves the use of rape, beatings and confinement to control the victim. In what is known as the ‘seasoning process’, the trafficker uses isolation, physical or sexual abuse, starvation, or restricts the victim from food, sleep, and even shelter.

 

Fraud usually involves false offers to induce a victim into a trafficking situation such as debt bondage, by offering a job different from reality, or pretending to have a romantic relationship with the victim.

Coercion is defined by the TVPA as:

1. 1.Threats of serious harm or physical restraint against a person 

1. 1.Any scheme plan or pattern that intended to cause a person to believe that failure to perform an act would result in serious harm or physical restraint against any person.  

2. 2.The abuse or threatened abuse of the legal system.  

Share the following scenario with participants:

After graduating high school, a young man is recruited to sell skincare products door-to-door for $350 a week. He joins a crew traveling the Midwest. He was charged exorbitant fees for transportation, lodging, food, and fined for being late or failing to meet sales quota. At the end of each day he only had $20. If he or other members of the crew failed to meet the quota they were denied food, and sometimes abandoned without money. After being assaulted by the crew leader, the young man left without any money, a place to stay, or means to return home.  

Ask participants:  Is this force, fraud, or coercion? Answer- All 3. The physical assault by the crew leader qualifies as force. The promise of earning $350/week qualifies as fraud. Being denied food, and abandoned without money could be viewed as either force or coercion.

 

Types of Human Trafficking

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Under the definition of the TVPA, there are four common types of trafficking encountered within the United States.

Domestic Sex Trafficking- This is the trafficking of U.S. citizens or lawful permanent residents into sexual exploitation.

Domestic Labor Trafficking- The trafficking of U.S. citizens or lawful permanent residents into labor exploitation. It is possible for a victim to be trafficked for both sex and labor.

International Sex Trafficking- The trafficking of foreign nationals into sexual exploitation.

International Labor Trafficking- The trafficking of foreign nationals into labor exploitation.

Remember, under the TVPA, any child under 18 years of age, whether a U.S. citizen or a foreign national, who is in commercial sex is automatically a victim of human trafficking, not requiring proof of force, fraud or coercion.

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Where does trafficking occur?

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Have the audience list any that come to mind.  (Presenter fills in any missing areas as needed)

 

Scope of the Problem

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*The US is one of the top ten destination countries for human trafficking. The top countries of origin are Mexico, Thailand, the Philippines, Honduras, Indonesia, and Guatemala.

The National Human Trafficking Resource Center provides a map of the areas in the US that reported potential human trafficking cases from 2007-2012. There were a total of 4120 cases that exhibited high indicators of being trafficking and 5178 cases that exhibited moderate indicators of being trafficking.

Of those, almost 64% of the cases involved sex trafficking, and just under 22% of the cases involved labor trafficking. A little over 2.5% of the cases involved both labor and sex trafficking, and almost 12% of cases were not specified. This lack of specification occurs when law enforcement or a service provider contacts the NHTRC for resources and referrals but does not disclose details about the actual trafficking situation due to confidentiality.

The red and orange areas indicate where a large volume of calls were made to the Trafficking Resource Center.  This does not mean human trafficking occurs only in these areas – human trafficking occurs all across the United States. It is possible that the number and concentration of calls is related to the level of awareness of human trafficking in a particular geographic location.

“Trafficking Trends in the United States, National Human Trafficking Resource Center 2007-2012” The Polaris Project (2013).  

*Ref:

The Protection Project

Trafficking in Persons Report 2013

Human Trafficking Around the World, Hepburn and Simon

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Case Study 1

L is a 31 year-old male from Tonga who arrived at the Emergency Room with pain and swelling in his right foot.  He stated the pain started as a small injury several months earlier.  Diagnosis revealed a severe infection and L was admitted to the hospital for several days.

                                                                               

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We understand that this case study is early in the training and you may not know the correct answer, but we want to think about this scenario and the importance of the scenario will be addressed later in the presentation.

Read the case study.

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Case Study 1

What is the one unusual aspect of this case that might lead you to stop and consider whether there is more to the story than what appears?

1. a.The infection started from a small wound 

2. b.That the infection required hospitalization 

3. c.The delay from initial infection to presentation 

                                                                               

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If there is an audience response system in place, have the audience read and answer the question. If there is no audience response system, ask the audience for a show of hands for each answer.

The correct answer is c. It is the long delay from initial infection to presentation that is somewhat unusual and would lead to additional questioning.

Read:

3.  The rest of the story......Labor Trafficking on a Fishing Vessel

During his hospitalization a social worker visited daily and gained L’s trust.  She discovered that L had agreed to work a day job on a fishing vessel in Tonga, but instead was forced to remain on the vessel for 3 months, working long hours and enduring physical abuse and threats.  At one point, he injured his foot on a gaff, but was forced to continue working.  He was eventually dropped off in Honolulu with no papers and with the warning that if he went to the authorities, he would be arrested for entering the U.S. illegally.  L confided that he did not seek medical care for the infection earlier because he was afraid of being imprisoned. Upon discharge, L was referred to an immigration attorney, who helped him attain a T-visa.

Nicole Littenberg, M.D., Hawaii Medical Center West

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Definition of Human Trafficking
Human Smuggling vs. Transnational Human Trafficking

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• •Human Smuggling  

• • • Is a crime against a country’s borders 

  • • Once the border is crossed smuggled are free to leave 

• •Transnational Human Trafficking 

• • • Is a crime against a person  

  • • Once the border is crossed, the person is placed into either labor or commercial sex 

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It is not uncommon for human smuggling to be confused with transnational human trafficking. This slide points out the important differences between the two.

First of all, human smuggling is a crime against a country’s border, while transnational human trafficking is a crime against that person.

Second, human smuggling is the facilitation of illegal entry from one country to another where the smuggled PERSONS are willing participants and once they cross the border are free to leave. However, in transnational human trafficking, once the border is crossed, the person is placed into either labor or sexual exploitation and is not free to leave.

It is possible that a person may begin within human smuggling by paying someone to smuggle them illegally into the U.S., but once they are in the U.S., they may be forced into either sex or labor exploitation. The situation thus may start out as smuggling and end up as trafficking.

Human smuggling IS transportation-based and requires crossing borders.

Please remember, human trafficking can and does occur across international borders, but movement is not necessary for trafficking to occur. People can be trafficked in their own country or even the home where they grew up.

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Potential Victims
Foreign Nationals in the U.S.

• •Refugees 

• •Documented: work/ student/ tourist visas 

• •Undocumented 

• •Married to U.S. citizens 

• •Boys, men, girls, women of all ages 

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Among the potential victims of human trafficking that may be encountered within the U.S. are various classes of foreign nationals. This includes refugees from other countries, documented immigrants as well as undocumented immigrants.

In addition, U.S. citizens may marry an individual from another country and bring them to the U.S. These individuals could then be subjected to labor exploitation that would qualify as human trafficking.

Therefore, it is possible to find foreign nationals being trafficked in the U.S. that are boys, girls, men and women of all ages.

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Potential Victims
Domestic

• •U.S. citizens and lawful permanent residents 

• •Vulnerable populations 

• • •Persons with disabilities 

  • •Native American women and girls 

  • •Runaway and homeless youth 

  • •Children who have experienced prior abuse and neglect 

  • •Lesbian, Gay, Bisexual, Transgender, Questioning (LGBTQ) youth 

  • •Systems-involved youth (Foster Care, Detention, etc.) 

• •Domestic labor and sex trafficking affects all ages, gender, ethnicity, race, nationality, and socio-economic levels
   

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Human trafficking victims are not only foreign-born, but also US citizens or legal permanent residents.

There are certain vulnerable populations that are more likely to be exploited. Case: In Chicago, two mentally disabled renters were tortured, abused, and forced to give their paycheck to their landlord, who was charged with aggravated involuntary servitude, involuntary servitude, and aggravated criminal sexual assault.

Populations at increased risk of being trafficked are children of abuse, those involved in “systems” (i.e. foster care, juvenile detention) and lesbian, gay, bisexual, transgender, questioning youth.  Among all populations boys are estimated to be the most misidentified and underreported victims of domestic sex trafficking.

Important to Note:  Although many trafficking victims tend to be from vulnerable populations, they are not the only populations being trafficked. Increasingly traffickers are starting to identify youth in affluent neighborhoods and schools and exploiting them for commercial sex. (NEXT SLIDE IS CASE STUDY)

Ref:

• • • •ECPAT, 2013 

• • • •   Institute of Medicine and National Research Council (2013). Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Retrieved from http://www.iom.edu/reports/2013/confronting-commercial-sexual-exploitation-and-sex-trafficking-of-minors-in-the-united-states.aspx  

• • • •http://www.chicagotribune.com/news/local/breaking/chi-chicago-crime-labo-trafficking-charge-20131119,0,5628892.story 

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Vulnerability of Victims
Risks

Domestic Victims

• •Prior Abuse 

• •Homelessness 

• •Poverty 

• •Discrimination 

• •Disabilities 

• •Cognitive impairment 

Foreign National Victims

• •Poverty 

• •Lack of economic opportunity 

• •Displacement 

• •Prior abuse 

• •Disabilities 

• •Discrimination 

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One of the differences between domestic and international trafficking are the vulnerabilities that increase the risk of being trafficked. For domestic trafficking, the major factor creating vulnerability is abuse. For international trafficking, the most common vulnerability creating risk for being trafficked is poverty. However, not all international victims come out of poverty. In various cases trafficked individuals were well educated and highly skilled – working as qualified welders, nurses and accountants in their countries of origin (Chuang 2014).

Poverty does not cause trafficking…it increases the likelihood of someone being trafficked.

Other vulnerability risk factors for domestic trafficking include homelessness, poverty, discrimination and as already mentioned disabilities and cognitive impairment.

Note- Homelessness of minors that causes them to engage in commercial sex, also known as survival sex, is a form of sex trafficking

Other vulnerability risk factors for international trafficking include lack of economic opportunity, displacement, prior abuse, disabilities and discrimination.

Prior Abuse – child maltreatment, interpersonal violence

Displacement – crisis, conflict, disaster, political instability, immigration status

Discrimination – cultural, ethnic, religious, gender, sexual orientation, age discrimination that increases risk of poverty or other factors.

FOLLOWING case studies demonstrate which vulnerabilities?

Ref:

Caring for Trafficked Persons: Guidance for Health Providers

IOM Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States

2008, UNODC, An introduction to HT: Vulnerability, impact, action

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Michigan – U.S. vs. Jean-Claude “Kodjo’’ Toviave

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Types of Traffickers

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Systemic

Organized Crime – Shandra Woworuntu was lured to the US from her native country of Indonesia in response to a job offer to work as a waitress. When she arrived to the US her passport was taken and was trafficked to work at a brothel.

Corporations

Operations/industries- In March 2007 over 500 men from India arrived at Signal's shipyards in Texas and Mississippi. They came on H-2B guest worker visas, but had been promised green cards - permanent residency - for themselves and their families. They paid dearly for these promises and a chance at the "American Dream" - going into debt to pay as much as $20,000 in recruitment fees, the equivalent of years of wages in India.

Diplomats- Diplomats have been found to use domestic servants within their home that would qualify as victims of labor trafficking. An Indian woman who said in a 2010 lawsuit that she was brought to New York by an Indian diplomat at the United Nations, forced to work 16-hour days without pay,

sleep on the floor and threatened with beatings if she tried to flee. In March, a federal judge ordered the diplomat, who returned to India, to pay $1.4 million in back wages, punitive damages and emotional duress. The money has not been paid.

Governments -  many standing armies rely heavily on trafficked labor of both adults and children, often through forced conscription for combat and logistical roles (Chuang 2014).

Gang-controlled: Theresa Flores was trafficked for sex by a gang in Detroit, Michigan. Theresa was sexually assaulted and blackmailed into cooperation by gang members.  

Non-systemic

Business Owners: In an Illinois federal court in 2012, prosecutors secured a life sentence for a Chicago pimp who forced women not only into prostitution but also to work at his massage parlors.

Individual/Pimp-controlled: Holly Austin Smith became a victim of commercial sexual exploitation, after meeting a man at the mall, who turned out to be a trafficker. Holly was 14 years old.

Family-controlled: Minh Dang’s parents groomed her via sexual abuse and started selling her for sex at the age of 10.

Ref:

Walking Prey by Holly Austin Smith

http://www.sfgate.com/news/article/70-Immigrants-Found-In-Raid-on-Sweatshop-Thai-3026921.php

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Types of Traffickers
Relationship to Survivors

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Youth of Covenant House New York

36%

27%

14%

14%

9%

 

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In this study from Covenant House, a service provider for victims of domestic minor sex trafficking, they collected data on the relationship of the trafficker to the survivor. Most importantly, they found that 36% of the children in this study were trafficked by their parents or immediate family members. If the patient is showing multiple indicators of possibly being trafficked, don’t discount the possibility that the child may be trafficked just because the child or adolescent is presenting with his or her parent.

(Homelessness, Survival Sex and Human Trafficking: As Experienced by the Youth of Covenant House New York, May 2013)

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All across the world, markets for the following drive the demand for trafficking:

1. • •Cheap products 

1. • • • • •Clothing 

         • •Food 

         • •Electronics 

         • •Jewelry 

   • •Cheap labor 

   • •Sex industry 

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What is driving the recruitment of individuals into human trafficking?

It is demand…demand for cheap products like cheaper clothing, cheaper food, cheaper electronic gadgets and less expensive jewelry including diamonds. Demand for cheaper products drives the search for cheaper labor, including child labor. Finally, the demand for commercial sex is a major factor pushing recruitment into the realm of sex trafficking.

Since these demands are global, human trafficking occurs in every country and intersects with legal and illicit global markets.

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This demand drives recruitment in the following scenarios:

Domestic

1. • •Within victims’ own city, state, or country 

Transnational

1. • •Within their home country with promises of better jobs and pay in another country 

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Victims can be recruited into human trafficking through a variety of scenarios.

First, they can be recruited into trafficking in their own city, state, or country.

Second, they can be recruited within their home country to travel to another country with promises of a better job or better pay at the same job.

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H-2A visa10

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As opposed to domestic trafficking, international trafficking usually starts out with fraudulent promises of better working conditions, better opportunities and better wages in the destination country. The trafficker will also agree to arrange transportation and the obtaining of travel documents. These travel documents can be obtained either legally or illegally.

The fraudulent ruse is then maintained during the recruitment stage and the transportation stage until the victim is in the destination country. After they safely pass through customs in the destination country, the situation often rapidly changes. The trafficker takes the travel documents and now switches to force and coercion to control the victim and to exploit them into whatever trafficking scenario that is planned for them.

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STEP 2 = OBSERVE
 

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1. 1.Role of Healthcare Professionals 

2. 2.Indicators of Control 

3. 3.Inconsistency Indicators 

4. 4.Physical Indicators 

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Victim Encounters with Health Care Profession

87.8% of domestic sex trafficking victims interviewed reported contact with healthcare system

50% of international sex trafficking victims interviewed reported contact with healthcare system

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Role of Healthcare Professionals
Who victims encounter in the Healthcare System*

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This slide shows that there are a variety of healthcare professionals who are being encountered by victims of trafficking. The above graph is based on an anonymous national healthcare survey of human trafficking victims. The respondents were victims of either sex or labor trafficking. A total of 117 patients were interviewed and the % total adds up to 108% since some patients saw multiple providers. As you can see, the most common healthcare professional encountered by human trafficking victims were those working within the emergency department, followed by primary care physicians.

In a separate study, Dr.  Makini Chisolm-Straker examined emergency room personnel’s understanding of HT and found that although 29% understood human trafficking to be a problem among their emergency department population, only 13% felt confident or very confident that they could identify a trafficking victim and less then 3% had been trained on identifying victims of human trafficking.

Healthcare professionals who lack training on human trafficking run the risk of misidentifying trafficking victims as rape victims, prostitutes, runaways, domestic violence victims, or illegal immigrants.

Ref: (Chisolm-Strike M, Richardson L. Assessment of emergency department provider knowledge about human trafficking victims in the ED. Acad Emerg Med 2007; 14(suppl1):134). (Isaac et al, 2011; Haynes, 2004; Garza, 2011; Barrows & Finger, 2008 (From HHS Clawson)

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Role of Healthcare Professionals
Identification

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In summary, many human trafficking victims are encountering healthcare professionals and yet they are not being recognized. The reason for this is that there are many barriers to identification. These barriers fall into two different categories. There are patient-related barriers and provider-related barriers.

Patient-related barriers include:

Don’t self-identify- patients rarely self-identify as victims for a variety of reasons such as shame, fear of trafficker, previous poor experience with the “system”.    

Lack of awareness of victim status- They may not understand or recognize that they are a victim

Lack of knowledge of US laws- They may not understand that what is happening to them is illegal      

Contractual obligations – may think signed documents legitimize their circumstances.

Language barriers – international victims with limited language proficiency or difficulty in explaining complex emotional trauma. To ensure a victim is safe and identified, an independent, confidential translator needs to be available (sometimes not the case).

Illiteracy  - It is possible for victims (more international than domestic) to be illiterate and unable to read pamphlets, posters, etc. related to trafficking within the healthcare setting.

Provider-related:

Misclassification: For example, sex-trafficking cases are often misclassified as domestic violence particularly where the victim is romantically involved with trafficker.

Lack of cultural humility – limited understanding of a different culture may cause the healthcare professional to dismiss certain signs that the patient is being exploited.

Re-traumatization – may occur within healthcare settings through insensitive questioning of the patient that leads to false assumptions and accusations.

Lack of knowledge regarding human trafficking- healthcare professionals can’t recognize something they don’t know about. This is why training in the medical field on human trafficking is so important.

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General Indicators of Trafficking

O – Overly submissive

B – “Buddy” present who answers most questions

S – Signs of physical abuse

E – English language barriers

R – Rare to have identification

V – Variety of health issues

E – Exhibits fearful behavior    

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3 Categories of Indicators for Victims:

• •Indicators of being controlled 

• •Inconsistencies 

• • Medical history  

  • Living conditions 

  • Age  

• •Physical indicators 

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In addition to these general indicators, there are 3 specific categories of indicators that victims of human trafficking might display while in the healthcare setting. They are:

1. 2.Indicators of being controlled 

2. 3.Inconsistencies- these occur mainly within the medical history, regarding their living conditions, and when they attempt to lie about their age. 

3. 4.Physical indicators 

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Control Indicators for Victims

• •“Buddy”- accompanying person who controls the conversation 

• • • • •May be male or female 

• • • •Family member  

    • •Trafficker or “bottom” (If sex trafficking) 

• •If patient is accompanied by a controlling person, they may exhibit signs of: 

• • •Fear 

  • •Shame 

  • •Anxiety 

  • •Restricted communication 

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All victims of trafficking are by definition under the control of their trafficker. That control can be exerted through direct threat of force or violence, or it may be exerted through psychological control.

Foreing National victims of international trafficking again, are more likely to be controlled through force and coercion. They will commonly be accompanied by a very controlling person who attempts to control the conversation and answer all the questions. They will commonly act as translator for the victim. They may pose as a family member or even spouse.

In sex trafficking, a trafficker may send someone else to exert their control. This person is often referred to as a “bottom”. She is frequently the most trusted woman working in prostitution under the control of that trafficker. She may be known as the “aunt” or “sister” of the patient. Typically, she will be older than the victim. Their role in accompanying the victim/patient is to make sure the girl acts in a manner consistent with the desires of the trafficker.

When victims are accompanied by a controlling trafficker, they will often display non-verbal signs of fear, shame and anxiety. They may have their head down. If you closely observe the patient, you might get the impression that there is more they want to say…but are afraid to say it.

Finally, the patient may frequently look at the person accompanying them for approval of their answer.

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Control Indicators for Victims

Control may be psychological and displayed through:

1. • •Frequent texting or phone calls during visit 

   • •Patient appearing unusually anxious or in a hurry 

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Alternatively, the trafficker may feel that they have enough control over the victim to allow them to enter the healthcare setting without anyone accompanying them. This is far more common for domestic victims than for international victims.

In that case, they often keep close communication with the victim via texting or periodic phone calls. Many times traffickers are able to achieve this level of control by having a child with the victim and keeping the child at home with them, knowing that the mother will be obedient.

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Control Indicators for Victims
Male victims

• •Remember that boys and young men are victims of sexual exploitation 

• •They are less likely to be controlled by a trafficker than young girls or women 

• •If they are <18, they still qualify as victims of sex trafficking under the TVPA 

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One of the often forgotten groups of trafficking victims are young males involved in sexual exploitation.

While limited data shows that these boys and young men are less likely to be under the control of a trafficker when compared to girls and young women, they are still victims of exploitation.

If they are under the age of 18, they are by definition victims of trafficking under the TVPA.

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Inconsistency Indicators for Victims

• •Patient doesn’t know his or her address 

• •Doesn’t know what city he or she is in 

• •Multiple hotel key cards 

• •Large amounts of cash 

• •Unwarranted hostility from patient 

• •In sex trafficking, victims call the man with her “Daddy” 

• •Clothing inconsistent with weather 

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There are a variety of inconsistencies that may arise while getting a history from the patient.

First of all, many trafficking victims may not be able to provide information as simple as their address.

Because girls and women in sex trafficking are often moved in a regional circuit, they often don’t know what city they are currently in. They may never have been to that city before and simply ask the nurse… “By the way…what city is this?”

While undressing for the exam, the nurse may find multiple hotel key cards or large amounts of cash. Finding large amounts of cash may happen if a young girl or woman needs to have medical care after they have been working through the night before they go back to their trafficker/pimp to give them the cash.

One survivor has mentioned that at times they were hostile to healthcare because “they have been so poorly treated by so many people, including HCP, they are defensive….”

Traffickers (pimps) often refer to themselves as the girl’s “daddy” and tell the girls to refer to them that way.

Finally, sex trafficked girls are often forced to wear sexually suggestive clothing, even in conditions of poor weather. Therefore, a girl or woman presenting during the winter with inadequate clothing to protect her is suspicious.

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Inconsistency Indicators for Victims

• •False ID’s 

• •Patient lies about age 

• •Patient is a very poor historian 

• •History keeps changing 

• •Not giving the full story 

• •Late presentation 

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Other inconsistency indicators, especially for young victims of domestic minor sex trafficking, include having what appears to be a false ID. ID documents for international victims may also appear suspicious.

Young victims of domestic sex trafficking are often told to lie about their age to authorities, including healthcare professionals. Someone who appears to be much younger than they say they are may be exhibiting an indicator that they are being trafficked.

The trauma that occurs within trafficking often causes patients to be very poor historians. The reason for this is that trauma causes a person to lose the sense of time. They are unable to place certain events within a normal timeline. This causes them to have difficulty giving answers to “when” questions, and thus they will appear to be poor historians.

In addition, patients who are trauma bonded to their trafficker may actually make up facts that causes the story to keep changing. They may be protecting themselves because of certain criminal acts they have committed thinking that giving that information may lead to their arrest. So it is possible that the healthcare professional gets the distinct sense that they are not getting the whole story and that the patient is hiding something.

Finally, traffickers usually do not allow their victims to visit healthcare at the first sign of a medical problem. They often want to wait and see if the problem will take care of itself. Therefore, it is not unusual for these victims to present very late in the course of an illness that might even cause the nurse or physician to question why they waited so long before coming in.

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Finally, I want to address some of the physical indicators that patients may display if they are victims of human trafficking.

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Physical Indicators of Human Trafficking
Signs of trauma

• •Suspicious Injuries 

• • •Fractures 

  • •Concussions 

  • •Mutilations 

• •Scars from cigarette burns 

• •Eye injury  

• •Hearing loss due to injury 

• •Dental injury 

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• • Suspicious Injuries (e.g., fractures, concussions, bruises, scrapes, burns, mutilations) 

• • Scars from cigarette burns (in inconspicuous areas such as the lower back or feet) 

• • Neglected chronic illnesses or chronic pain (i.e. back pain, arthritis, stomach pain, diabetes, hypertension, etc. that has not been well managed) 

• • Unusual Infectious diseases (e.g. Tuberculosis, AIDS, Hepatitis, etc.)  

• • Vision problems, Eye strain or injury – from working in chronic low-light conditions 

• • Dental injuries or neglect: caries, missing or broken teeth 

“Some individuals in the commercial sex industry are beaten in such a way as to preserve their physical appearance.  One type of beating that is common worldwide is ‘falanga’ or ‘bastinado’ which involves beating/caning of the soles of the foot.  It is exceptionally painful, preserves their appearance, and if done ‘correctly’ can potentially leave no permanent damage to the ligaments/bones” (Chuang 2014).

VAWA Program 2012; Chuang 2011; Crane & Moreno 2011; Isaac et al. 2011; Dovydaitis 2010; Zimmerman et al. 2003

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Physical Indicators of Human Trafficking
Other indicators

• •Unusual infectious diseases 

• •Headaches 

• • •Tension from stress  

  • •Migraine 

• •Gastrointestinal issues from chronic stress 

• •Unusual tattoo’s 

  • •“Daddy” 

  • •“Property of…” 

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Other physical indicators include:

Unusual infectious diseases such as tuberculosis, or infectious diseases that are normally prevented by immunization.

Migraine or tension headaches from the undo stress

Gastrointestinal complaints from chronic stress

Lastly, but very important are certain tattoos that might be found on the patient. Domestic traffickers commonly have the girls under their control tattooed with either their street name, or with some other phrase that communicated that they actually “belong” to the trafficker. A tattoo like the one shown is very suspicious because traffickers again often want the girls to call them “Daddy”. These tattoo’s are commonly located on the neck or lower back.

Any tattoo that states “Property of”…is highly suspicious.

VAWA Program 2012; Chuang 2011; Crane & Moreno 2011; Isaac et al. 2011; Dovydaitis 2010; Zimmerman et al. 2003

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Signs & Symptoms of Trauma
Psychological Issues

• •Substance abuse issues 

• •Affective/ Anxiety symptoms 

• •Post Traumatic Stress Disorder (PTSD) 

• •Complex PTSD 

• •Emotional blunting 

• •Sleep problems 

• •Somatization 

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In addition to physical signs of trauma, a patient may exhibit psychological signs of trauma or of increased stress found within the trafficking scenario.

Substance abuse is relatively common among victims of trafficking to help them cope with the trauma they are enduring. Substance abuse is also used as a control mechanism by traffickers. Signs of Post Traumatic Stress Disorder (PTSD) or complex PTSD may be found in this population. More commonly, patients may complain or exhibit signs of anxiety related to their debt, emotional blunting, apathy, or sleep problems. They may also be experiencing somatization of their emotional stress as their presenting symptom in which no identifiable organic etiology can be found. This may commonly present as GI or neurological complaints.

Other emotional indicators include depression, unexpected hostility, low self esteem, suicidal ideation, disassociation, excessive guilt or shame and a poor ability to develop interpersonal relationships.

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Signs & Symptoms of Trauma

“Despite suffering often severe physical damage, the majority of the women I’ve worked with tell me they feel that this can be overcome; it’s the emotional and psychological damage they find more devastating.”                       

                                                                                                                        - Sabella

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How does this quote impact you as a healthcare provider?  Take a moment to think and write down some self-reflections.  (Not to be a group discussion).

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Physical Indicators of Human Trafficking
Sexual/Reproductive Issues

• •Chronic pelvic pain and/or dyspareunia 

• •Chronic pelvic inflammatory disease 

• •Chronically changing vaginal discharge 

• •Multiple sexually transmitted infections (STIs) 

• •Abortion-related complications 

• •Unwanted pregnancy 

• •Neglected pregnancy complications 

• •Anal trauma 

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Physical indicators under the category of sexual or reproductive issues may include:

• • Chronic Pelvic Pain and/or dyspareunia (pain with intercourse) resulting from pelvic adhesions. 

• •Chronic Pelvic Inflammatory Disease  

• • Chronically changing vaginal discharge 

• • Multiple Sexually transmitted infections 

• • Abortion-related complications such as retained products of conception, severe blood loss, acute pelvic infection; 

• • Infections caused by the use of sponges, cotton batting, & other materials in the vagina to stop menstruation (Chuang 2011; Isaac et al. 2011).  

• • Unwanted pregnancy 

• •Neglected pregnancy complications- Severe undiagnosed hyperemesis gravidarum; significant blood loss from threatened or incomplete miscarriage 

• • Anal trauma - victims that are forced to smuggle drugs may have anal tissue tears from drug malfunction or systemic poisoning from the drug rupturing inside them.   

Another issue encountered is that of underage girls who are often forced to take injectable Depo-Provera to stop menstruation (SOAR TWG, May 2014).

A complete genital and rectal examination of men and boys who are victims of sexual abuse should also be conducted. Care should be taken to reduce as much pain, trauma, and discomfort as possible for both males and females (Zimmerman & Borland 2009; Sabella 2011).

VAWA Program 2012; Chuang 2011; Crane & Moreno 2011; Isaac et al. 2011; Dovydaitis 2010; Zimmerman et al. 2003

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Physical Indicators of Human Trafficking
Signs of neglect

• •Neglect of chronic illness or injury 

• •Dental neglect 

• •Weight loss/malnourishment 

• •Dermatological problems from occupational hazard 

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Other physical indicators besides those of trauma are indicators of neglect. Examples of this include:

Neglected chronic illnesses or chronic pain (i.e. back pain, arthritis, stomach pain, diabetes, hypertension, etc. that has not been well managed)

Dental neglect: caries or abscess

Weight Loss/ malnourishment – may be especially severe in children (retarded growth, poorly formed teeth, etc.)

Dermatological problems (e.g., rashes, scabies, and lice)

VAWA Program 2012; Chuang 2011; Crane & Moreno 2011; Isaac et al. 2011; Dovydaitis 2010; Zimmerman et al. 2003

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Conditions that Cause Health Problems

• •Deprivation of food, shelter, and sleep  

• •Extreme stress  

• •Hazardous travel 

• •Poor sanitation/ poor hygiene  

• •Hazardous working conditions  

• •Lack of preventative health care 

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In addition to physical indicators that may be found on physical examination, it is important to be aware of the various conditions human trafficking victims are exposed to that may cause various secondary health problems.

These conditions include:

Deprivation of food, shelter, and sleep

Extreme stress

Hazardous travel

Poor sanitation or conditions that cause poor hygiene such as lack of access to clean water

Hazardous working conditions

Lack of preventative health care

While we understand that any one of these could be present for an individual, no single issue is indicative of trafficking but putting different pieces together should increase our index of suspicion (SOAR TWG mtg, May 2014).

“Diagnosing the health needs of trafficked persons is often complex because their symptoms generally reflect the cumulative effects of the health risks they face throughout the trafficking process” (Zimmerman & Borland 2009).  

Preventive health care for trafficking victims is virtually non-existent and health problems are typically not treated in their early stages.  These problems tend to fester until they become critical, life-threatening situations....this is often when they are seen by a healthcare provider (Sabella 2011).

Dovydaitis, 2010

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STEP 3 = ASK
 

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Having found suspicious signs in a patient pointing to the possibility that they are a victim of human trafficking, we will now move into step 3, which is to ask.

Prior to starting these slides ask attendees what is trauma-informed care? Why is it important?

1.        Trauma-Informed Care

                A.  Definition
        B.  Why it is important

2.        Interview Reminders

A.  Interpersonal skills

B.  Communication techniques

1. • • • 1. C.  Cultural humility 

         2. D.  Cultural considerations 

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Trauma-Informed Care
Definition

Trauma-informed care is defined and includes :

• •  A basic knowledge of trauma and its impact 

• •Understanding trauma triggers (victims’ and one’s own) to minimize re-traumatization 

• •  Providing information about trauma to victims 

• •Helping victims manage feelings, feel in control of situations; give input on program/services 

• •  Supporting emotional safety for victims and staff 

                                                                                               

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When interviewing a potential victim of trauma such as human trafficking, it is critical to use trauma informed care.

A trauma-informed care approach recognizes the impact, and interrelatedness, of traumatic experiences to the presence of trauma symptoms from past and present abuses.  It seeks to encourage an understanding within healthcare professionals of how traumatic experiences may affect the behaviors, health, and body perceptions of their patients – e.g. through substance abuse, eating disorders, depression, anxiety, etc. (SAMHSA website 2014; Zimmerman and Borland 2009).

** “One caveat about trauma-informed care is that the person may not be able or ready to talk about what they’ve been through or to ask for or accept counseling or mental health services. They might need other needs attended to first—work, safety, economics, etc.” (SOAR meeting Jan. 13, 2014, p.3).***

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Trauma-Informed Care
Why it is important?

1. 1.Raises awareness 

        •  For victims

        •  For healthcare professionals

1. 2.Provides a supportive and holistic approach 

1. 3.Empowers the victim 

1. 4.Avoids judgmental statements or actions 

2. 5.Ensures the patient’s rights to information, privacy, bodily integrity and participation in decision making 

3. 6.Adopts a patient-centered treatment approach 

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Why is trauma-informed care so important?

Many victims, whether international or domestic, do not know they are victims of a crime. This is often due to their lack of education and/or understanding of human trafficking and their lack of awareness of their rights as a victim (DHHS – Rescue & Restore 2012; Clawson and Dutch, 2008b).

Trauma-informed care also teaches healthcare professionals to recognize that “symptoms are adaptations.” and “violence causes trauma and…trauma causes violence” (Gillece 2013).

The goal for using trauma-informed care is to provide a supportive and holistic approach to the potential victim which means treating them as a whole person, not just a list of clinical symptoms.  

It also ensures that as much as possible, all care:

        - Empowers and adapts to the individual’s needs;

        - Avoids judgmental statements or actions

        - Ensures the patient’s rights to information, privacy, bodily integrity and participation in decision-making

        - Adopts a patient-centered treatment approach

The nature of the trafficking experience centers on a lack of control and unpredictability in everyday life for the victim, especially concerning abuse and neglect.  It is important to realize that the “loss of personal control over one’s body and actions can have a significant influence on psychological health.”  Thus, it is very important that healthcare providers “restore decision-making power to each individual as quickly and supportively as possible” (Zimmerman & Borland 2009, p.34-35).

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Trauma-Informed Care

“The overall goal should not be solely to get a disclosure, because there are times we will not get one no matter what we do or how trauma-informed we are. The goal should be to convey an 'open-door' within the healthcare system so victims can feel that it is safe to approach healthcare providers.”

                         

                                                                     - SOAR Technical Working Group, 2014

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“The overall goal should not be solely to get a disclosure, because there are times we will not get one no matter what we do or how trauma-informed we are. The goal should be to convey an 'open-door' within the healthcare system so victims can feel that it is safe to approach healthcare providers.”

                         

                                                                     - SOAR Technical Working Group, 2014

This goal is to convey an ‘open-door’ is more likely attained by asking the question “What happened?” versus “Why are you here?” or “What is wrong with you?”  If you ask the question correctly, you will get the information you need to better identify potential victims (Gillece 2013; SOAR Jan 13 mtg 2014).

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Ask

First separate the patient from any accompanying person…regardless of the purported relationship

Use the following excuses:

1. 1. • •Hospital/clinic protocol 

      • •Need for collection of urine specimen 

      • •Need for an X-ray 

Next, assign someone from your staff to spend time developing trust with the patient

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Before you will be able to obtain any accurate information from the patient, a couple of critical things need to happen.

First, the patient must be separated from anyone that is accompanying them…regardless of what they say their relationship with the patient is. Girls have been trafficked by their mothers; women have been trafficked by their husbands.

A variety of reasons can be used for the separation such as hospital/clinic protocol, the need for a urinalysis or the need for an X-ray. You will be unable to obtain any relevant information if the trafficker is with or near the patient.

Next, it is important to have someone establish a level of trust with the patient. This person should be the same gender as the patient whenever possible, and have an understanding of trauma informed care.  Excellent candidates are either SANE or SAFE nurses or trained social workers.

(Barrows & Finger 2008; DHHS 2008; Crane & Moreno 2011, Greembaum 2014; SOAR Jan 13 mtg 2014).

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Interview Reminders
Interpersonal Skills

1. 2.Build trust 

1. 2.Use empowering language 

1. 3.Remember the basics of communication 

1. 4.Be comfortable with the topic 

2. 5.Know how to communicate effectively using an interpreter 

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Here are some interview reminders:

1. 5.Build trust: it is very important to build rapport and trust with these patients but this may be a slow and difficult process. Trust is often built by meeting their immediate needs (physical or emotional). An example of this would be to provide them with food or snacks. Communication style is key because if the “right” questions are asked without the relational aspect, they will not be effective (Barrows & Finger 2008; Zimmerman and Borland 2009; Crane & Moreno 2011; Greenbaum 2014; SOAR Jan 13 mtg 2014). 

       

     If the healthcare professional strongly suspects trafficking, it may be helpful to have the victim return to the clinic/hospital for follow-up to re-evaluate a health care issue when further assessment and questioning is desired to get a patient to open up.

2. Interviewers need to use empowering language rather than language that is accusing. Patients need to know they did not do anything wrong. Ask patients for their own interpretation of what has happened. Don’t assume you know what’s best for them. (Gillece 2013; SOAR Jan 13 mtg 2014).

3. “Remember the basics of communication – configure the room, don’t be checking your phone, apologize if you must be interrupted, let them know they have your complete attention, check your posture & demeanor, etc.” (SOAR Jan 13 mtg 2014).

4. It is important to be trained and comfortable asking questions related to sexual orientation; or exploration questions to filter exploitation or the risk thereof.  Practitioner discomfort is a barrier to disclosure and is very evident to patients” (SOAR Jan 13 mtg 2014, p.4).

5. If the patient speaks a very uncommon language or dialect, the communities may be very small and tight; this makes it necessary to screen interpreters to ensure that they do not know the victim, or the traffickers, and do not otherwise have a conflict of interest (DHHS 2008; SOAR Jan 13 mtg 2014).

Messages for the healthcare professional to convey in private with a suspected victim include a focus on safety, getting healthy, and that the victim’s welfare is the highest priority (Crane & Moreno 2011, p.8).

       

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Interview Reminders
Communication Techniques

1. Use therapeutic communication approaches

2. Remain open & non-judgmental

3. Read the subtle signs/cues

1. 4.If the suspicions are high that the patient may be a victim of trafficking, ask specific questions 

 •          VERA screening tool

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1.  Remember to use therapeutic communication skills:  i.e. open-ended questions, affirmation, silence, reflection, clarification, etc. to foster a trusting and listening environment (Jarvis 2004).  

• • 1. 2.Remain open and non-judgmental. Victims may act or respond differently than expected.  They may be hostile, uncooperative, manipulative, and/or fearful and untrusting of authorities.  They may remain loyal to their exploiter - refer to them as their “protector,” “boyfriend,” or “daddy.”  They may not look, or act, the way you expect – they often blend in with everyone else (Greenbaum 2014).  

• • 1. 2.You may be forced to read the subtle signs and clues that will come through their body language or verbal inflection. Victims are often coached to answer health care questions or to say they are the new wife, or some other relative. Answers may be well-rehearsed, but if that is the case, they will be unable to answer follow up questions. “The story is everything. Ask questions they didn’t prepare for or can’t answer. If they say they are from the area, ask about the neighborhood. If they are passing through, ask where they were before. When there is an open, nonjudgmental conversation, they will share their story” (SOAR Jan 13 mtg 2014). 

       

4.  A validated screening tool has been developed by the VERA Institute. This is the first validated screening tool for use in the U.S.  After an initial assessment, questions from this tool will be helpful in identifying trafficked individuals.   These questions will be shared later in the presentation.

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Interview Reminders
Cultural Humility

Definition- an ability to maintain an “other-oriented” stance in relation to cultural identity

Values orientation

1. • •Individualistic  

   • •Collective  

Components of cultural humility:

1. • •Open minded, non-judgmental attitude 

   • •Use of specialized skill in a safe environment 

   • •Acceptance  

   • •Respecting cultural diversity  

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We are all influenced by culture and are biased toward our own personal culture.  

Lack of cultural humility by health care providers can hinder the care provided to a victim of human trafficking.

Cultural humility can be defined as an ability to maintain an “other-oriented” stance in relation to cultural identity. It is being sensitive to the culture of another, while providing them with the best care possible. The Institute of Medicine defines optimal primary care as including ‘’an understanding of the cultural, nutritional and belief systems of patients and community that may assist or hinder effective health care delivery.’’

Part of culture is values. It is important to be aware of our own values orientation as well as the patient’s values orientation. Values can be individualistic or collective. Some examples include:

Individualistic – nuclear family orientation, competitiveness, individual expression, direct communication

Collective – extended family orientation, cooperation and sharing of resources, conformity, indirect communication

Some components of cultural humility parallel that of trauma-informed care.

Ref: Post-Symposium Brief, Clawson 2008, SOAR TWG, TSA Anti-Trafficking Training 2010

Ref: Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education, Melanie Tervalon and Jann Murray-Garcia

 

Interview Reminders
Cultural Considerations

1. 3.Documented vs. Undocumented 

1. 2.Distrust of authority figures 

1. 3.Stigma of situation 

1. 4.Language and terms used in human trafficking 

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Finally, as you go into the interview itself, remember these additional factors that will influence how the patient responds to your questions:

1. Whether they are a documented vs. undocumented in this country. An undocumented person will have far more reason to be hesitant in answering questions. They may be experiencing intense fear of being deported, which will manifest itself in many forms during the interview- i.e. anxiety, hostility, manipulation, non-compliance, inconsistencies in their medical history, etc. (DHHS Rescue & Restore 2012 PDF; Dill,McKeen,Greenbaum et al. [ppt] 2014).

2. There is an inherent distrust of authority figures (law enforcement, physicians, social workers, etc.) within many cultures from developing countries and they may be reluctant to give out information (HHS – Rescue & Restore).

3. “Many labor trafficking victims are really economic migrants who have come to help their families back home. There is a sense of shame, especially with men, when they realize they now find themselves in a forced labor situation. This results in a largely hidden population that is less likely to come out” (SOAR meeting Jan 13, 2014).

1. 4.Language and terms used in human trafficking- asking if the person is a victim of human trafficking will probably have no meaning to the patient.   

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Suggested Questions for Potential Victims from the Vera Institute

• •Have you ever worked anywhere in the U.S. without getting the payment you expected? 

• •Have you ever worked here in the U.S. where your work was different than you expected? 

• •Have you ever worked anywhere in the U.S. in a place or with people that made you feel scared or unsafe? 

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WILL include link to VERA Screening Tool

• • 1. 1.After an initial assessment, these questions from the VERA Institute Screening Tool can be helpful in identifying trafficked individuals. As mentioned previously, this is the first validated screening tool used for the identification of victims of human trafficking.  

Here are some of their suggested questions. They are very specific and attempt to obtain facts about their living and working conditions.  

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Suggested Questions for Potential Victims from the Vera Institute

• •Have you ever worked anywhere in the U.S. where there were locks on the doors or windows that prevented you from leaving when you wanted to? 

• •Have you ever worked anywhere in the U.S. where you were not allowed to contact your family, friends or others? 

• •Has someone you have worked for or lived with ever threatened to have you deported or to report your immigrant status to the police or other authorities? 

• •Has anyone in the U.S. ever pressured you to touch another person or engage in any kind of unwanted contact with another person? 

• •Have you ever received anything of value such as money, housing, food, gifts, favors in exchange for any type of activity involving sex? 

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This slide contains addition questions from the Vera Screening tool if the interviewer feels they are still unsure regarding the victim status of the patient.

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Suggested Questions for Potential Domestic Sex Trafficking Victims

• •Did anyone you worked for or lived with force you into doing anything you did not want to do? 

• •Did you ever have sex for things of value (for example money, housing, food, gifts or favors)? 

• •Do you have to meet a quota of money before you can safely return home? 

• •Has someone taken sexually suggestive photo’s of you to post on the Internet? 

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These are questions specifically designed for potential victims of domestic sex trafficking.

Questions addressed to suspected victims of sex trafficking are very embarrassing and need to be asked carefully. One survivor suggested prefacing questions like those above with:

“I know that sometimes girls get in situations where people take advantage of them and make them do things they don’t want to.”

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Case Study 3

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Read the case study

A 20 year-old female presents to the Emergency Department with a severe injury to her head. She comes in accompanied by an older man who insisted on bringing her to the Emergency Department when he saw her injury. During the patient intake this man, who claimed to be her uncle, answers all the questions for the patient. When asked by the nurse what happened to her, she replied that she bumped her head in the backyard. The patient said little as her ''uncle’’ answered all the questions for her and she seemed to be distressed and afraid. The uncle insisted on staying with her during the entire time and did not leave her alone. 

 

Case Study 3

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Read the question and possible answers.

The best answer is e.

While c is a possibility, since the injury in this case warrants an X-ray, this is a better time to do the separation more naturally and without raising undo concern with the “uncle”.

Ima Matul’s Story

“When my trafficker hit me with ceramic salt shaker, the husband took me to the emergency room because he said that he could see my brain. Before we left, she told me not to say anything to the doctor or the nurse and let her husband do the talking. If they ask questions, I was told to lie and say that I bumped my head while in the backyard. When we arrived at the emergency room, the nurse ask what happened, and the husband answered the questions.”  

 

STEP 4 = RESPOND
 

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STEP 4 is to RESPOND.

After identifying signs and symptoms and asking questions, the last vital step for a healthcare professional is to RESPOND in a way that is safe for the patient and provider.

Ask attendees, what are the current ways that healthcare systems respond to victims of abuse? What needs to be taken into consideration?

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Reasons for Protocol Development

• •Refinement of local trafficking identifiers 

• •Coordinate with local law enforcement to improve patient safety 

• •Coordinate with local service providers to enhance victim services 

• •Designate and train of interviewer on trauma informed care 

• •Prior development of separation procedure 

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Just like most hospitals have a protocol in place to respond to a victim of domestic violence or sexual abuse, there are several good reasons to have a protocol in place to respond to a victim of human trafficking.

By connecting with local law enforcement and local service providers, you can learn a great deal about the types of trafficking occurring locally. That will allow you to refine a list of physical identifiers to your specific population. For instance, many traffickers will tattoo their street names onto their girls. It is not uncommon for local vice officers to be aware of the street names of traffickers working in their area. Those names can be given to healthcare personnel to enhance their ability to identify a potential victim of trafficking.

Second, safety for the victim and medical staff is frequently a concern, especially if there is a decision to try and intervene. A safe intervention should only be carried out in coordination with local law enforcement. In addition, if they have adequate knowledge of local traffickers, they may be able to help decide when an intervention is not a good idea, based on the level of danger involved.

Third, victims of trafficking have many needs other than healthcare needs. Once freed from trafficking, they often only have the clothes they are wearing. They will need food, housing, legal assistance and financial aid. Coordination with local service providers in advance will help facilitate getting those services to victims.

Fourth, a safe and effective interview is often critical in allowing a patient to disclose that they are a victim of trafficking. It is very helpful to designate and train the potential interviewer in advance, especially if they have not been trained in trauma informed care.

Finally, to smooth the process of separation, it is very helpful if the entire staff has been trained in advance on the planned procedure that will be used to separate the potential victim from their trafficker.

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Draft for Federal and Technical Working Group Review

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Reasons for Protocol Development

• •Preparation for contacting translators 

• •Preparation for forensic examination 

• •Preparation for reporting procedure 

• •Advanced preparation for certain scenarios: 

• • •Trafficker refuses to separate from patient 

  • •Confirmed victim refuses intervention 

• • • •Critical if the victim is a minor 

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Additional reasons from proceeding with the process of developing a response protocol for trafficking include:

1. 6.Advanced preparation for contacting and educating translators. It will be very helpful if the translator you use is familiar with the concept of human trafficking as well as the general concept of trauma informed care. Translators sensitive to those issues will be more likely to convey the necessary questions to the potential victim. 

2. 7.While not all cases of trafficking within the healthcare setting will require a forensic examination, there are certain cases that might benefit from that specialized exam. Therefore it is helpful to work with local law enforcement as well as local prosecutors to outline cases in which they would recommend forensic evaluation. 

3. 8.Reporting a case of human trafficking is more complicated than you think. First of all, many child protective agencies are untrained when it comes to human trafficking. They may actually be unfamiliar with the term. It is also possible that local law enforcement have not been trained on human trafficking. In general, all federal law enforcement officials have had some training on human trafficking, and most state law enforcement officials as well. However, there are still gaps that exist on the local level when it comes to training on human trafficking. In addition, with foreign victims, it is necessary to report the case to the Department of Homeland security, due to immigration issues. Therefore, it’s very helpful to have the reporting mechanism in place before encountering a victim. 

4. 9.Finally, there are certain scenarios that may arise within the healthcare setting in which it is very helpful to have advanced preparation. For instance, what do you want to do if the trafficker refuses to be separated from the patient? Do you want to push until the trafficker and patient leave the facility? How should you respond when you reach a level of certainty that a patient is a victim of trafficking, but the patient refuses any intervention? Should you still report the case to law enforcement if the patient is an adult? These are questions that are best answered at the local level in consultation with local law enforcement, child protective services and other local government agencies.  

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Draft for Federal and Technical Working Group Review

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Respond

Development of a protocol requires someone who has the authority to move the process forward

• •Member of hospital staff 

• •ED Director 

• •Nursing Director 

• •Member of hospital administration 

• •Hospital social worker 

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The first step toward developing a response protocol is identifying someone who will champion the cause. This needs to be a person who has the passion, competence and the authority to move the process forward within your healthcare system. Whether your facility is large or only a small clinic, identifying your champion and empowering them to develop the protocol is critical to accomplishing the task.

This person may be a member of the hospital or clinic staff. It could be a physician, NP, PA or nurse working within your facility. It could be a social worker.

Within a hospital, an ideal candidate would be the Emergency Department Director. However they are often too busy to take on the task and may choose to designate someone else with the task.

Another excellent candidate would be the nursing director of the hospital or clinic.

Alternatively, someone with authority to make decisions regarding the protocol such as a member of hospital/clinic administration can easily function as the champion, consulting with healthcare as needed.

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Draft for Federal and Technical Working Group Review

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Respond
Connect with local partners

• •Law enforcement 

• •Child protective services 

• •Juvenile justice 

• •Municipal Court officials 

• •Social workers 

• •Local Service providers 

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After the champion has been designated, it is important to make contact with all the local partners that will be involved in responding to victims of human trafficking identified in your facility. There local responders include:

1. 10.Local law enforcement- specifically local vice officers from both police and sheriff departments 

2. 11.Child protective services 

3. 12.Juvenile justice officials (Judge or representative) 

4. 13.Municipal Court officials (Court officials that deal with misdemeanor crimes in adults) 

5. 14.Social workers 

6. 15.Local service providers for services such as: 

1. 1. 1.Housing 

   2. 2.Case management 

   3. 3.Legal services 

   4. 4.Refugee and immigrant services 

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Draft for Federal and Technical Working Group Review

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Respond
Connect with local partners

• •State Highway patrol 

• •Truant officers 

• •Mental health professionals 

• •Representatives from local organizations working with troubled youth 

• •Representatives from local organizations working with international populations 

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Especially if you are developing a protocol for a major hospital, it would be helpful to include other local partners in the process such as:

1. 16.State Highway Patrol 

2. 17.Truant officers 

3. 18.Mental health professionals 

4. 19.Representatives from local organizations working with troubled youth such as runaway and homeless youth 

5. 20.Representatives from local organizations working with various international populations in your area. They will be an excellent source of cultural information as well as potential translators. 

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Respond
Connect with local partners

Other local partners to consider:

• •Domestic violence providers 

• •Sexual assault providers 

• •Regional network of trauma-informed service providers  

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Finally, other local partners to consider including:

Domestic violence providers

Sexual assault providers

Regional network of trauma-informed service providers

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Draft for Federal and Technical Working Group Review

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Respond
Connect with federal partners

• •FBI 

• •Homeland Security 

• •Department of Justice  

• •Office of Refugee and Resettlement  

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It is important to also include a couple of federal partners in your response protocol because some cases of local trafficking and most cases of international trafficking will need to include these partners.

These federal partners are the FBI and the Department of Homeland Security. Both federal agencies have representatives that have been assigned to cover your particular geographic region. They will be very helpful to you as you develop your response protocol.

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Draft for Federal and Technical Working Group Review

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Respond
Connecting with partners

National Trafficking Resource Center

Toll-free, 24 hour hotline:

1.888.373.7888

Text: BEFREE

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To connect with the local representative of the Department of Homeland Security, you can call their hotline number at: 866-347-2423.

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Draft for Federal and Technical Working Group Review

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Respond
Protocol Components

1. 5.List of local indicators 

2. 6.Separation procedure 

3. 7.Interview procedures 

4. 8.Safety planning 

5. 9.Mandatory Reporting 

6. 10.Referral Network 

7. 11.Resources 

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Draft for Federal and Technical Working Group Review

A good protocol to respond to victims of trafficking within the healthcare system will have the following components:

1. 21.A list of local indicators of trafficking 

2. 22.Separation procedure 

3. 23.Interview procedures 

4. 24.Safety planning 

5. 25.Mandatory Reporting 

6. 26.Referral network 

7. 27.Resources 

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Respond
Local Indicators

• •Names of local pimps 

• •Specific types of local labor trafficking 

• •Specific types of transnational trafficking 

• •Suggested local identifiers for the populations within these types of trafficking 

• •Local trends in trafficking 

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Draft for Federal and Technical Working Group Review

Your list of local indicators should include:

1. 28.Names of local pimps which may be found as tattoos on victims 

2. 29.Specific types of local labor trafficking 

3. 30.Specific types of international trafficking, including the specific international population that may be involved 

4. 31.Suggested local identifiers for the populations within these types of trafficking 

5. 32.Local trends in trafficking 

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Respond
Local Indicators

Develop a list of local indicators with input from:

• •Local law enforcement 

• •FBI 

• •Homeland Security agents 

• •Local service providers,  

• •Outreach worker 

• •Youth workers 

• •Organizations that work with refugees 

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Draft for Federal and Technical Working Group Review

The data necessary to put together this list of local indicators is usually available from the following sources:

1. 33.Local law enforcement, specifically vice officers from both local police and if applicable, local sheriff departments 

2. 34.FBI  

3. 35.Homeland Security agents 

4. 36.Local service providers 

5. 37.Local outreach workers 

6. 38.Local youth workers 

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Respond
Separation Procedure

1. • •When to Separate the patient  

   • •What reason to give  

   • •Who is to do the separating  

   • •What to do if you are unable to separate patient 

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Draft for Federal and Technical Working Group Review

If the patient that is suspected of being a victim of trafficking is accompanied by another person, it will be important to separate the patient from that accompanying person…no matter what the purported relationship is. If the patient truly is being trafficked by the person accompanying them, or by a co-worker of the person with them, they will not likely reveal that fact while the person is in the room.

The protocol should address the following items:

1. 39.When to separate the patient from the accompanying person 

2. 40.What reason to give for the separation 

1. 1. 5.Hospital/clinic protocol 

   2. 6.Urinalysis 

   3. 7.X-ray 

2. 2.Who is to do the separating 

3. 3.What to do if the person accompanying the patient refuses to be separated from the patient.  

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Respond
Interview Procedure

The  interview procedures should include:

• •Qualifications of the interviewer 

• •Trauma informed care techniques 

• •Translators to use as necessary 

• •Questions to ask 

• •Procedure if patient confirmed as probable victim of trafficking 

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Draft for Federal and Technical Working Group Review

One the patient is separated or ready to be interviewed, the protocol should address the following items:

1. 41.Qualifications of the interviewer 

1. 1. 1.Who the designated interviewer will be 

2. 3.How to train the interviewer on trauma informed care techniques to utilize during the interview 

3. 4.What translators to use and how to contact them 

4. 5.The specific questions to be asked and the order to ask them 

5. 6.The procedure to follow if the patient is confirmed as a probable victim of trafficking 

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Respond
Safety Planning

• •The protocol must address the safety of: 

• • •Patient/victim 

  • •Staff of the hospital/clinic 

• •To do this, input is required from: 

  • •Local and federal law enforcement 

  • •Hospital security if applicable 

• •Criteria should be established for: 

  • •When and when not to intervene 

• • • •Informed consent of victim 

  • •Exact procedure for intervention 

  • •Notification of internal and external security officials 

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Draft for Federal and Technical Working Group Review

Because of the fact that human trafficking is a criminal activity, there is inherent danger involved. Most of the danger involves the patient who has now been identified as a victim of trafficking. If an intervention is planned but fails, the victim will suffer additional abuse and possible trauma. In addition, the staff of the hospital or clinic will possibly be exposed to some level of danger, especially if dealing with a sophisticated international trafficking ring. Therefore, it is critical to carefully work through the safety component of your protocol with input from the following:

1. 42.Local and federal law enforcement 

2. 43.Hospital security if the protocol is for a hospital 

Strict criteria should be set for when and when not to intervene. This should include obtaining informed consent from the victim if they are an adult. Even with a minor, criteria for intervention should include input from local child protective services.

Finally, if a decision is made to proceed with intervention, a clear procedure for intervention should be laid out as part of the protocol.

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1. 4.State laws lack specificity related to human trafficking but state laws on suspected child abuse or domestic abuse may apply even if you are not sure this is a HT case 

1. 2.Requirements vary from state to state 

1. 3.Investigate protocols from community resources: 

1. 4.Work within HIPAA guidelines         

2. 5.Document, document, document 

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Respond
Mandatory Reporting

Draft for Federal and Technical Working Group Review

1. 44.While there are no mandatory reporting laws specifically for human trafficking, there are laws concerning the abuse and sexual exploitation of minors and vulnerable adult populations, child welfare laws, and domestic violence reports (Clayton et al. 2013; SOAR Jan 13 mtg 2014). 

1. 45.These reporting requirements may vary from state to state, so it is important to know the mandatory reporting requirements in your state and even include them in the response protocol 

3. In the development of your protocol, when it comes to the issue of mandatory reporting, it may be helpful to investigate mandatory reporting within community resources that are already working with children and adults being abused. These resources include:

1. 1. 1.Child protective services 

   2. 2.Child abuse agencies 

   3. 3.Domestic violence agencies 

   4. 4.Sexual assault agencies 

4. Of course, your reporting requirements in the protocol must work within HIPAA guidelines

 

5. Finally, the protocol should address the importance of documenting everything you do!

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1. 5.Original HIPAA law written with the following under Sec. 1178 Effect on State Law: 

"(b) PUBLIC HEALTH.--Nothing in this part shall be construed to invalidate or limit the authority, power, or procedures established under any law providing for the reporting of disease or injury, child abuse, birth, or death, public health surveillance, or public health investigation or intervention.”1

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Respond
Mandatory Reporting HIPAA

Draft for Federal and Technical Working Group Review

In the original legislation that created the HIPAA regulations, the paragraph quoted above specifically addresses the issue of reporting of disease or injury and child abuse and its relation to state laws addressing those concerns. In essence, it means that nothing within the original HIPAA regulations is meant to contradict a state law enacted to protect public health.

Therefore, healthcare professionals can safely follow their state laws regarding mandatory reporting without fear of violating HIPAA regulations. (I believe this is the case, but would like confirmation from an official HHS source).

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• •A privacy rule update of HIPAA by HHS in 2002 contains the following quotes:1 

• • •“The December 2000 Privacy Rule…allows a covered health care provider to choose not to treat a parent as a personal representative of the minor when the provider is concerned about abuse or harm to the child.”  

  • •“Of course, a covered provider may disclose health information about a minor to a parent in the most critical situations, even if one of the limited exceptions discussed above apply. Disclosure of such information is always permitted as necessary to avert a serious and imminent threat to the health or safety of the minor.”  

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Respond
Mandatory Reporting HIPAA

Draft for Federal and Technical Working Group Review

In the updated Standards of Privacy document released by HHS in 2002, the above quotes reinforce the ability of a healthcare professional to ignore rights of the parents if he or she is concerned that the minor is being abused. The report references: § 164.502(g)(5)

For the second quote- the report references: § 164.512(j)

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“A lot of healthcare professionals don’t want to ask [about issues  related to human trafficking] because they don’t know what to do next.”

                                                                  -  SOAR Technical Working Group, 2014                                                                       

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Respond
Referral Network

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 Referral Network
Immediate Needs

1. 6.Safety 

1. 2.Housing 

2. 3.Medical care 

3. 4.Food & clothing 

4. 5.Psychological needs 

5. 6.Community needs 

6. 7.Translation services 

7. 8.Case management 

8. 9.Legal immigration assistance 

9. 10.Legal guardianship (under 18) 

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Draft for Federal and Technical Working Group Review

This slide contains a list of the immediate needs of a victim of trafficking once they are identified. We’ve already addressed the issue of safety. Immediately after that are the following needs:

Housing

Medical care

Food and clothing

Psychological needs

Community needs

Translation services

Legal immigration assistance

Legal guardianship

Note:

Psychological needs are important for both domestic and foreign victims, how to deal with talking to a lot of strangers, being in a strange land, worrying about deportation, worrying about threats being acted upon, how to get comfort, and dealing with suicidal ideation.  However, keep in mind that a trafficked foreign national may have a distrustful view of western medicine and the idea of talking to a psychologist/psychiatrist is a very alien concept (Chuang 2014).

Community needs – victim needs to feel less alone during this time, how do they reconnect with loved ones.

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 Referral Network
Short & Long-term Needs

1. 7.Continued medical care 

        • Mental health assistance

        • Counseling

        • Follow-up for physical issues

1. 2.Legal assistance 

        • Family reunification/repatriation

        • Advocacy

        • T-visa applications (foreign victims)

        • Immigration assistance (foreign         victim)

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Draft for Federal and Technical Working Group Review

1. 1.Most victims will require additional health and illness screening – i.e. for tuberculosis, sexually transmitted diseases, pregnancy, etc.; vaccinations/immunizations; medical treatment for physical injuries; and dental care (Clawson & Dutch 2008, p.2).  

1. 2.Under the Trafficking Victims Protection Act of 2000, victims of human trafficking in the U.S. who are non-citizens may be eligible for a special T-visa (Trafficking visa) that allows them to live, work, and receive comprehensive benefits and services in the United States for up to 4 years on a non-immigrant visa.  Victims who are U.S. citizens are already eligible to receive many of these benefits (HHS 2008; Crane & Moreno 2011).   

“Services such as a sheltered place to live, immediate physical or mental health care, translation needs and cultural considerations, income assistance, intensive case-management, legal and immigration assistance, and determination of legal and criminal culpability and confidentiality issues, may be covered by the TVPA” (Crane & Moreno 2011).

3.  “Other service needs include child care (for both adults and minors with children), education (GED assistance, enrollment in school, technical  training/certification), life skills training (including assisting some international victims with operation of basic household appliances, using public transportation, using a telephone, mailing a letter, etc.), job training, finding employment, and financial management” (Clawson & Dutch 2008, p.2).

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National Resource

National Trafficking Resource Center

Toll-free, 24 hour hotline

1.888.3737.888

Text: BEFREE (233733) www.traffickingresourcecenter.org 

                       

               

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If you think you have come in contact with a victim of human trafficking and you do not have local partners or a local hotline in place, then call the National Human Trafficking Resource Center. This hotline will help you determine if you have encountered a victim of human trafficking, will identify local resources available in your community to help victims, and will help you coordinate with local social service organizations to help protect and serve victims so they can begin the process of restoring their lives.

Ref: (HHS 2008).

 

Federal Resources

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Draft for Federal and Technical Working Group Review

PANEL Discussion:

Ideally this is where we would bring in local resources/survivor for a brief panel discussion.

To continue educating yourself on the topic of human trafficking, educational modules can be found on the CMDA website, DHHS – Rescue & Restore Campaign website, Blue Campaign website, etc.

If you encounter a victim of human trafficking prior to setting up a protocol at your location, you can also call the National Trafficking Resource Center  1-888-373-7888

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Local Resources

• •State Domestic Violence Coalitions 

• • •www.nnedv.org/resources/coalitions.html  

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Draft for Federal and Technical Working Group Review

This slide will include local resources.

If you think you have encountered a victim of human trafficking, it is important for you to collaborate among key service providers, including the Department of Health and Human Services, local law enforcement and others at the local, state and Federal levels, to help the victim get the protection and services they need (HHS 2008).

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Review: Learning Objectives

1. 12.Describe the scope, severity, and diversity of human trafficking in the United States. 

2. 13.Recognize the common indicators and high-risk factors for human trafficking. 

3. 14.Recognize the importance of trauma-informed techniques when interviewing a potential victim of human trafficking. 

4. 15.Identify and engage local, state and national service referral options for trafficking victims 

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Let’s review.

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References

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