An introduction to human trafficking for healthcare professionals

Transcription

1 An introduction to human trafficking for healthcare professionals R A C H E L R O B I T Z, M D D I R E C T S E R V I C E C O - C H A I R, H E A L T R A F F I C K I N G A S S I S T A N T C L I N I C A L P R O F E S S O R, U C D A V I S

2 HEAL Trafficking Founded 2013 >2000 multidisciplinary professionals Public health lens

3 public health, international health, academia, government. clinical practice, including physicians, nurses, advance practice clinicians, public health professionals, psychologists, behavioral health professionals, social workers, as well as researchers, attorneys, administrators

4 Edu & Training Research Media & Technology Public Health & Trafficking Protocols Advocacy Direct Services

5 Objectives Define human trafficking Describe the demographics of identified trafficking victims Discuss how a trafficking victim may present in healthcare settings Discuss common physical and mental health problems experienced by trafficked individuals

6 Language Survivor v. victim Sex work Human trafficking Sex and labor trafficking Discussion of gender

7 Definition of human trafficking Trafficking Victims Protection Act of 2000 (TVPA) Labor trafficking Minors and adults induced to perform labor acts through methods of force, fraud, or coercion Sex trafficking A person inducing another to perform a commercial sex act through force, fraud, or coercion or if the person induced to perform such an act is a minor

8 Meet Suzanne

9 Recruitment Coercion boyfriending befriending Threats/blackmail Fraud Promise of a new job Force Rape, kidnap, other violence

10 Copyright Polaris Project, All Rights Reserved.

11 Scope of the Problem Second largest criminal industry in the United States Estimated 40 mil victims worldwide Rarely identified International Labor Organization and Walk Free Foundation. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. 2017;

12 Demographics Data limited because of underground nature In the United States, we tend to over-identify sex trafficking cases Need to focus identification efforts on labor trafficking

13 Who are identified trafficking victims? Labor trafficking Age: More than half (62%) are older than 25yo Race/Ethnicity: 63% Hispanic and 17% Asian Citizenship: 67% undocumented and 28% qualified alien status Sex trafficking Age: Only 13% are older than 25yo Race/ethnicity: 40% black and 26% white Citizenship: 83% are US citizens Banks, Duren, and Tracey Kyckelhahn. Characteristics of Suspected Human Trafficking Incidents, Rep. US Department of Justice, Apr Web. 15 May 2016.

14 Vulnerabilities Protective Homelessness History of abuse or neglect Identify as LGBTQ Kicked out of home due to sexual orientation Lack of social support Special education Foster youth Mental illness More research needed about labor trafficking Immigration Status Disability More research needed Having a supportive adult

15 Meet Suzanne

16 Trafficking victims do seek medical care Treatment Source % Reporting (N=98) Any contact with healthcare 87.8% Any type of clinic 57.1% Hospital/ER 63.3% Planned Parenthood 29.6% Regular doctor 22.5% Urgent care clinic 21.4% Women s health clinic 19.4% Neighborhood clinic 19.4% On-site doctor 5.1% Other 13.3% Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

17 Identifying trafficking survivors: Case studies

18 San Diego is really rape-y 25yo female with h/o heroin dependence presents with a URI Moved to SD to get clean Has had multiple rapes in the past 1-2 months while staying on the street

19 If I leave the hospital I ll kill myself 22yo with h/o depression and anxiety presents to ED with SI after her pimp beat her up Reports?paranoia regarding being followed Endorses hopelessness +SI with vague plan

20 This new necklace gave me a rash 16yo with h/o with h/o PTSD from a rape a year ago presents to discuss birth control and while there asks if you could also look at a rash

21 Red flags Delayed presentation to care Scripted history Inability to produce identification documents Accompanying individual who refuses to leave Tattoos or other marks

22 Red flags Recurrent STIs or pregnancies Frequent relocation Kids with access to material possessions that are more than one would expect Kids who are overly familiar with sexual terms

23 Screening Currently no validated screening tools to cover both labor and sex trafficking Goal Identifying Moving away from checklist screening tools -> creating an open door and providing resources Having a protocol for screening and referral important

24 Screening Safety Ask when patient is alone Patient knows safety better than you do Be careful about handing patients resource sheets If you are screening, have a plan for what to do with positive screens

25 How to ask You are not the detective Goal is not disclosure. Goal is creating a safe environment for disclosure Normalizing language is helpful Photo by Mat Reding on Unsplash

26 How to respond to a disclosure Watch your language and facial expression Reporting obligations Know your resources National Human Trafficking Hotline:

27 Potential Screening Questions Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened or made to feel physical pain for working slowly or trying to leave? Has anyone threatened your family? Does someone else control whether you can leave your house or not? Are you kept from contacting your friends and/or family whenever you would like?

28 Potential screening questions for labor trafficking How many hours per day do you work? What kind of time off do you have? Can you come and go as you please during time off? Can you quit your job or situation if you want to? Has anyone threatened or harmed your family? Where do you live, sleep, and eat?

29 Potential screening questions for sex trafficking Has anyone ever forced you to have sex when you didn t want to? Have you ever exchanged sex for food, shelter, drugs, or money? Have you been required or forced to perform sex acts for work or to pay off a debt? Have you ever run away from home or from a program? What did you do in order to survive during that time?

30 Health Needs

31 Incidence of physical health problems in women who have been trafficked for sex Category Any physical health problem 99.1% Neurological (headaches, dizziness, etc) Diet-related (weight loss, loss of appetite, eating disorders) % of respondents reporting at least one symptoms 91.7% 71.4% Physical injuries 69.2% Cardiovascular/respiratory 68.5% Gastrointestinal 62.0% Dental 54.3% Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

32 Traumatic injuries In a survey of sex trafficked women 92% experienced physical violence 70% reported traumatic injuries Most commonly to head or face 43% had lost teeth Injuries related to poor working conditions/lack of personal protective equipment Photo by Fancycrave on Unsplash Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

33 Reproductive Health 67% had a sexually transmitted infection 70% had pregnancies while being trafficked 55% had an abortion Only 34 respondents answered questions about forced abortions, but 18 of these respondents had a forced abortion in most [of my six abortions] I was under serious pressure from my pimps to abort the babies. Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

34 Other acute symptoms General medical problems Headaches Abdominal discomfort Dizziness Skin conditions Malnutrition Conditions related to poor working conditions

35 Chronic medical conditions Undiagnosed or uncontrolled medical problems High blood pressure Diabetes Cancers Overuse injuries Respiratory disease Photo by Cristian Newman on Unsplash

36 Mental health impacts High prevalence of PTSD and Depression Similar in both sex and labor trafficking survivors 84% of women trafficked for sex report substance use in one study More than ¼ report overdoses Hopper, E. K., & Gonzalez, L. D. (2018). A comparison of psychological symptoms in survivors of sex and labor trafficking. Behavioral medicine, (just-accepted), Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

37 Self Harm Roughly 40% of women trafficked for sex in one study attempted suicide >30% of youth trafficked for sex have engaged in self-harm behavior Ijadi-Maghsoodi, R., Cook, M., Barnert, E. S., Gaboian, S., & Bath, E. (2016). Understanding and Responding to the Needs of Commercially Sexually Exploited Youth: Recommendations for the Mental Health Provider. Child Adolesc Psychiatr Clin N Am, 25(1), doi: /j.chc Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

38 Mental health impacts Mental health symptoms experienced by sex trafficked youth are different than those who have experienced sexual abuse o Higher PTSD o More avoidance and risky behavior such as substance use and running away o More research is needed on mental health impacts of labor trafficking Cole, J., Sprang, G., Lee, R., & Cohen, J. (2016). The trauma of commercial sexual exploitation of youth: a comparison of CSE victims to sexual abuse victims in a clinical sample. Journal of interpersonal violence, 31(1),

39 Complex trauma experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (eg, sexual or physical abuse, war, community violence) and early-life onset. -Dr. Bessel van der Kolk

40 Types of complex trauma Concentration camps Prisoner of war camps Prostitution brothels Long-term domestic violence Long-term child physical abuse Long-term child sexual abuse Organized child exploitation rings Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.

41 Complex Post-traumatic stress disorder Problems with emotional regulation Mood swings, sadness, suicidal thoughts, anger problems Changes in consciousness Reliving traumatic events Feeling detached from your body Poor thoughts of self or feeling different from others Distorted perception of perpetrator Difficulty in relationships with others Loss of meaning Veterans Affairs. Accessed 2018.

42 Why is it important to understand complex PTSD? The impact of trafficking is profound and different from some other kinds of trauma When you understand the impact of the trauma, it is easier to understand the feelings and behaviors of the survivor

43 From her voice Cause it s really, like, it s really traumatizing to just tell somebody what s going on with them or what happened to them And it s like, Why should I tell you? Like, if I trust you, then that would be different. But a lot of people just force it, rather than listen. And they judge you before they even know you, just on what they heard. Ulibarri, M.D. (Principal Investigator): Assessment of Risk Factors for Commercial Sexual Exploitation of High Risk Adolescent Girls in San Diego County. UC San Diego Health Sciences, Clinical and Translational Research Institute, Academic-Community Partnership Pilot Grant. Period: 4/01/2013 3/31/2014 Grant #: NIH UL1TR000100

44 Recovery is possible A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential Photo by Anomaly on Unsplash SAMHSA. (2012). SAMHSA s Working Definition of Recovery. Retrieved from RECDEF/PEP12-RECDEF.pdf

45 Assisting in recovery Trauma-informed Survivor informed Culturally responsive Individualized to meet diverse and unique needs Integrated with other medical services Substance use treatment Primary and specialty care Mental health

46 Control over recovery I think so much of their lives are so out of control that trying to also focus in on what do you have control over maybe next week they re gonna decide what group topic they want or what they re gonna decide to disclose or share in group, you know, and then hopefully that expands out into their own life outside of group Ulibarri, M.D. (Principal Investigator): Assessment of Risk Factors for Commercial Sexual Exploitation of High Risk Adolescent Girls in San Diego County. UC San Diego Health Sciences, Clinical and Translational Research Institute, Academic-Community Partnership Pilot Grant. Period: 4/01/2013 3/31/2014 Grant #: NIH UL1TR000100

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48 Bibliography Banks, Duren, and Tracey Kyckelhahn. Characteristics of Suspected Human Trafficking Incidents, Rep. US Department of Justice, Apr Web. 15 May Chisolm-Straker M, Baldwin S, Gaigbe-Togbe B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. J Health Care Poor Underserved. 2016;27(3): Chisolm-Straker, M., Sze, J., Einbond, J., White, J., & Stoklosa, H. (2018). A supportive adult may be the difference in homeless youth not being trafficked. Children and Youth Services Review. Cole, J., Sprang, G., Lee, R., & Cohen, J. (2016). The trauma of commercial sexual exploitation of youth: a comparison of CSE victims to sexual abuse victims in a clinical sample. Journal of interpersonal violence, 31(1), Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books. Hopper, E. K., & Gonzalez, L. D. (2018). A comparison of psychological symptoms in survivors of sex and labor trafficking. Behavioral medicine, (just-accepted), Ijadi-Maghsoodi, R., Cook, M., Barnert, E. S., Gaboian, S., & Bath, E. (2016). Understanding and Responding to the Needs of Commercially Sexually Exploited Youth: Recommendations for the Mental Health Provider. Child Adolesc Psychiatr Clin N Am, 25(1), doi: /j.chc International Labor Organization and Walk Free Foundation. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. 2017; Lederer, L., Wetzel, C. (2014). The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Annals of Health and Law, 23,

49 Bibliography Ottisova, L., Hemmings, S., Howard, L. M., Zimmerman, C., & Oram, S. (2016). Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiology and psychiatric sciences, 25(4), Roe-Sepowitz, D., Bracy, K., Hogan, K., Brockie, M. (2017) Youth Experiences Survey. Retrieved from Tucson, AZ: SAMHSA. (2012). SAMHSA s Working Definition of Recovery. Retrieved from Ulibarri, M.D. (Principal Investigator): Assessment of Risk Factors for Commercial Sexual Exploitation of High Risk Adolescent Girls in San Diego County. UC San Diego Health Sciences, Clinical and Translational Research Institute, Academic-Community Partnership Pilot Grant. Period: 4/01/2013 3/31/2014 Grant #: NIH UL1TR US State Department. Trafficking in Persons Report Veterans Affairs. Accessed 2018.