Human Trafficking
SEMINAL STUDY
15.3
15.2 // Firearm Violence
15.4 // Intimate Partner Violence
15 Violence
Tips For Evaluation & Management in the ED
Objectives
ACTION—MEANS—PURPOSE MODEL
Action
Means
Purpose
Inducing a minor into commercial sex is considered human trafficking regardless of the presence of force, fraud or coercion.
EPIDEMIOLOGY
Over 40,000 reported cases to the National Hotline between 2007-2017
25 % children & 71% women
40 million people world wide
What is the Image of a Survivor?
What Type of Trafficking Do You Image?
Victims and Survivors Seek Health Care!��Up to 88% of survivors sought care during exploitation�
Tip 1:
Put it on the DDX
“If you don’t ever think about it, you will never see it.” ~ Russel
Chief Complaints
Patients may present for conditions not related to their exploitation.
Concerning Features of the History / Exam
Sex Trafficking
Labor Trafficking
May Be Present in Sex or Labor Trafficking
Assault related injuries; repeat visits for injuries
Mental Health
Substance Use
Lacks Identification documents
Long or unusual work hours
Lacks awareness of their surroundings / date
Controlling individual who presents with patient
�Identify Vulnerabilities and Concerning Signs�
Graphic form Polaris Project 2020 Report
What is the Image of a Trafficker?
Tip 2:�Provide Privacy and Use Interpreters
Sex Trafficking & Sex and Labor Combined Recruitment
Graphic form Polaris Project 2020 Report
Labor Trafficking Recruitment
Graphic form Polaris Project 2020 Report
Tip 3�Develop a Framework
Care for All Medical Needs
01
Consider Red Flags and Risk Factors
02
Communicate Concerns
03
Connect to Resources
04
Create Safety Plans
05
The 5 C’s
Tip 4 �Utilize Your Toolbox
TRAUMA INFORMED CARE EX PEARR TOOL
SCREENING QUESTIONS
GROUNDING TECHNIQUES
HYPOTHETICAL / INFORMATION FOR OTHERS
Trauma Informed Care�Back to the Basics of Building Rapport�
Meet comfort needs: Offer blanket, water/food, clean clothes
1
Sit down during the conversation
2
Avoid discussions in hallways
3
Treat pain, nausea, anxiety, etc
4
Medically stable
5
The PEARR Tool
Provide
Privacy
Discuss sensitive topics alone.
Explain need for private exam
Utilize professional interpreters
Explain limits of confidentiality without discouraging disclosure
Educate
Normalizes sharing information about sensitive health information
Use brochure or safety card to review information/resources
Ask
"Is there anything you’d like to share with me? Would you like to speak with a social worker/advocate for information for you or someone you know?”
“I’ve noticed [indicator]. You don’t have to share details with me, but I’d like to connect you with resources if you’re in need of assistance.”
Respect &
Respond
If patient denies victimization or declines assistance, respect their wishes
If patient accepts/requests assistance, arrange personal introduction with local advocate/service provider or assist patient with calling hotline
P
E
A
RR
Rapid Appraisal For Trafficking (RAFT)�Adult Screening Tool
1. It is not uncommon for people to stay in work situations that are risky or even dangerous, simply because they have no other options. Have you ever worked, or done other things, in a place that made you feel scared or unsafe?
2. In thinking back over your past experience, have you ever been tricked or forced into doing any kind of work that you did not want to do?
3. Sometimes people are prevented from leaving an unfair or unsafe work situation by their employers. Have you ever been afraid to leave or quit or work situation due to fear of violence or threats of harm to yourself or your family?
4. Have you ever received anything in exchange for sex (for example, a place to stay, gifts, or food)?
Chisolm-Straker M, Singer E, Strong D, Loo GT, Rothman EF, Clesca C, d'Etienne J, Alanis N, Richardson LD. Validation of a screening tool for labor and sex trafficking among emergency department patients. J Am Coll Emerg Physicians Open. 2021 Oct 12;2(5):e12558. doi: 10.1002/emp2.12558. PMID: 34667976; PMCID: PMC8510141.
Grounding Technique ��5-4-3-2-1
5 THINGS YOU CAN SEE
4 THINGS YOU CAN TOUCH
3 THINGS YOU CAN HEAR
2 THINGS YOU CAN SMELL
1 THING YOU CAN TASTE
�Back to the “E” in the PEARR Tool: �
We know that abuse is common in our community and…
I understand that you feel safe now, would you want to learn what resources are available if your situation changed?
I understand that you feel safe, would you like to take these resources for someone else that you know.
Hypothetical / Information for Others
Tip 5: �Respond Appropriately
When you hear “yes…”
DO
Respond with empathy
Acknowledge the disclosure
Wear your trauma informed care lenses
DON’T
Panic
Move on to next question without acknowledging response
Leave right away/get another staff without speaking to patient about it
Tip 6: �Know Mandatory Reporting Laws
Most states have specific laws on Sex Trafficking in minors:
Many states do NOT have specific Labor Trafficking laws in minors / dependent adults. Nor do they have specific Sex Trafficking in dependent adults.
Tip 7:�Know Local and National Resources
Text HELP to 233733 (BEFREE)
Know your local resources
Do you have statewide crisis line?
Do you have local crisis lines?
Are advocates available?
What are your shelter options?
Are there food banks?
Are there free medical clinics?
What legal services are available?
Are there cultural services available?
Considerations for Documentation
Challenges of balancing continuity of care, documentation requirements, possible legal support, and patient safety
The CURES Act is a federal mandate: effective April 5, 2021
Exceptions are very limited to unshare notes with patients
�Know the Limitation & Safeguards� in the Electronic Medical Record
MARK NOTES AS SENSITIVE
UN-SHARE NOTES
UNDERSTAND WHAT’S ON AVS
& WHERE INFO IS SHARED
UNDERSTAND DOCUMENTATION REQUIREMENTS
Tip 9:�Discuss Documentation With Patient
“We’ve talked about a lot of important things that can affect your health now and in the future. Is there anything we’ve discussed that you do not want documented in your health record?”
Do you have MyChart or do you want MyChart?
Do you think someone might be able to access your medical record?
We can discuss ways to make your information private, are you interested in discussing this?
Tip 10:�Build Hospital Protocols and Strengthen Community Relations
https://healtrafficking.org/
Case �Example
40 yo presents with facial injury. Patient is French speaking and arrived in the United States about 6 months ago.
Injury was sustained at work. Patient unable to give details about how it happened.
Patient presents with employer, who is translating for the patient. Several “family members” arrived as well.
Patient has no insurance and did not bring ID.
How to proceed…
Care Medical Needs
01
Consider Red Flags and Risk Factors
02
Communicate Concerns
03
Connect to Resources
04
Create Safety Plans
05
Red Flags/Risk Factors
Recent Immigration, Unknown documentation
Doesn’t Speak the Local Language
Employer is Speaking for the Patient
Unexplained Injury
No Insurance or ID
Tip 1: Put it on the Ddx
Tip 2: Privacy and Interpreters
Tip 3: Framework
Tip 4: Trauma Informed Care
The PEARR Tool
Provide
Privacy
Discuss sensitive topics alone.
Explain need for private exam
Utilize professional interpreters
Explain limits of confidentiality without discouraging disclosure
Educate
Normalizes sharing information about sensitive health information
Use brochure or safety card to review information/resources
Ask
"Is there anything you’d like to share with me? Would you like to speak with a social worker/advocate for information for you or someone you know?”
“I’ve noticed [indicator]. You don’t have to share details with me, but I’d like to connect you with resources if you’re in need of assistance.”
Respect &
Respond
If patient denies victimization or declines assistance, respect their wishes
If patient accepts/requests assistance, arrange personal introduction with local advocate/service provider or assist patient with calling hotline
P
E
A
RR
1. It is not uncommon for people to stay in work situations that are risky or even dangerous, simply because they have no other options. Have you ever worked, or done other things, in a place that made you feel scared or unsafe?
2. In thinking back over your past experience, have you ever been tricked or forced into doing any kind of work that you did not want to do?
3. Sometimes people are prevented from leaving an unfair or unsafe work situation by their employers. Have you ever been afraid to leave or quit or work situation due to fear of violence or threats of harm to yourself or your family?
4. Have you ever received anything in exchange for sex (for example, a place to stay, gifts, or food)?
RAFT Tool
Case Example Continued
Care Medical Needs
01
Consider Red Flags and Risk Factors
02
Communicate Concerns
03
Connect to Resources
04
Create Safety Plans
05
Knowing patients concerns and needs guides resources and safety plans.
Case Conclusion
Was it a case of human trafficking?
Resources
Polaris. https://polarisproject.org/
Thank You & Any Questions
Please reach out anytime!
Thank you to Brittany McGraw with whom I present frequently with, and we often share slides with each other
SEMINAL STUDY
Intimate Partner Violence
15.4
15.5 // Sexual Assault
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