SOAR to Health and Wellness for Health Care Providers – March 16, 2017 Webinar >>Beth Pfenning: The Administration for Children and Families and the Office on Women's Health designed an initial training in 2014, which has gone through piloting and enhancements that have been informed by training and evaluation feedback, and the expertise of trafficking survivors, social service providers, and health care professionals through two technical working groups. So, we have four sections for today's training that align with SOAR, which is an acronym that stands for stop, observe, ask, and respond. As Leilani already stated if you guys have any questions throughout today's training please submit them to everyone through the chat box, and we have administrators, both Wendy and Leilani, who will be compiling your questions which our trainers will work to address at the end of each section provided there is time. We will also be offering two short five-minute breaks after the stop and the ask section. So, both Wendy and Leilani will sign on and they'll announce at what time we will resume the training again. As a friendly reminder, we do have continuing education and CMEs available to training participants who stay for the duration of today's training. And successfully complete our online post-training survey form, which will be sent out shortly afterward. So, to get an idea of who is here today I'd like you all to take a look at the map here and identify your region and in the chat box let us know where you are from. Feel free to take a few minutes to do that. That's great. We have got a real diversity of people here, thank you so much. [unintelligible], Minnesota [laughs]. Great. Thank you guys so much. Now, before I turn things over to the presenter they did just want to reference the referral network pre-work handout, which we sent you all as part of your training registration. Don't worry this was homework you did not have to turn in. For anyone who would like a refresher we have included that hand work -- or that handout rather in the download pod, so you guys can reference that. But we hope that you have thought through in your own community who you have as local partners that fall within these categories that can be part of your referral network, and your service delivery system. And with that I will turn it over to Jordan and Holly. Jordan. >>Jordan Greenbaum: I'm very excited to be here, and look forward to the webinar. >>Holly Gibbs: This is Holly Gibbs. I am the grand director for dignity health's human trafficking response program. I am not sure that everyone was able to hear Jordan's introduction because I think she was on mute. Jordan, if you're still there, can you do a quick short introduction for yourself. >>Jordan Greenbaum: Sorry, I thought I was off mute. I am Jordan Greenbaum a Child Abuse Physician from Children's Healthcare of Atlanta, and my particular interest in research and clinical work is human trafficking. Hopefully, that went through okay. >>Holly Gibbs: Yes. Yes, it did. Thanks, Jordan. So, again this is Holly Gibbs director of Dignity Health's Human Trafficking Response Program. And so, the way that I got into this field is that I have a personal background, so when I was 14 years old I was forced into commercial sex by a man I met at my local shopping mall. So, it was the summer after eighth grade middle school graduation, and like most victims of human trafficking I was vulnerable. Like many teenagers are during that timeframe, I was very afraid of going into high school. And, you know, I was struggling with school, I was struggling with the idea of losing my friends and not getting along with my family. And so, this man, this older guy that I met at my local shopping mall befriended me and offered me a glamorous life in Los Angeles if I wanted to run away with him. He said that I could escape high school, and that he could help me find a job as a musician or a model. At 14, you know, I was very gullible and naïve, and I also thought this was my once in a lifetime opportunity. And so, I ran away with him, and within hours of running away I was forced into prostitution in Atlantic City, New Jersey. After two nights, I was recovered by law enforcement, which actually was a pretty negative experience because I was actually arrested by law enforcement. I was not immediately seen as a victim, and the experience of being arrested, and being treated very harshly by the arresting officer was traumatic. Luckily, detectives got involved in my case, and I was recognized as a victim. Ultimately, there were three police districts involved in my case. And the man from the mall was caught and convicted. But I can tell you that even though there were many professionals involved in my case and in my treatment, and trying to help me, they often went about it in a way that made me feel very stigmatized and very isolated. And it was just as traumatic, if not more traumatic than what I had experienced in Atlantic City. So, my personal story is the reason why I'm passionate about this cause, and also the reason why I'm passionate about working with professionals and sharing my story and knowledge in a way that equips professionals to work with victims of human trafficking. But one of the reasons why I'm so passionate about this program is the number of survivors that I have met across the country who were not trafficked for days, but were trafficked for weeks, months, or even years. So, I may mention some of these survivors throughout my presentation, and that's because I think it's so important to engage survivors in your work. There are survivors all across the country that can come and speak with your healthcare staff, sharing their story, sharing their knowledge, and so there you go. Wendy and Barbara Amaya [spelled phonetically] are 2 examples, they are 2 friends of mine who are both survivors of sex trafficking, who were trafficked for over 10 years. Barbara's story is very similar to my own. You can read about it, in her memoir, Nobody's Girl. And instead of being traffics for over 2 nights it was 10 years for her, she lost her entire adolescence to the streets of New York City. And Wendy Barnes [spelled phonetically] was trafficked beginning at the age of 17, she also has a memoir called, And Life Continues. Trafficked for over 10 years by her boyfriend who she ultimately had 3 children with, so both of these women had multiple encounters with healthcare as victims of sex trafficking, in emergency departments, in clinics, and even labor and delivery. So, their stories really underscore the reality that healthcare and other public health facilities belong at the table addressing human trafficking. So, that brings us to our course objectives. So, our objectives today are to describe the types of human trafficking in the United States, recognize possible indicators of human trafficking, demonstrate how to identify, and respond to trafficked persons, respond appropriately to potential human trafficking in your community, and then share the importance and awareness of responsiveness of others in your work environment. So, let's get sort of a pulse check and an idea of everyone's level of knowledge and experience. Has anyone identified a potential victim of trafficking, or could you identify a potential victim of trafficking? And have you ever encountered a potential victim of trafficking? So, if you want to write some thoughts in the chat box. Looks like multiple people are writing. One person says, no I have not encountered anyone. One person says I have, and another person, yes. Another person I would not feel confident in my ability to identify. Others I have worked with victims, yes, direct services, worked with someone who was previously involved in sex trafficking. Three victims. Lots of different thoughts being shared here. So, it looks like there's varying levels of experience which is great and so we're going to kind of cover the basics in today's session so that everyone can get on the same page. In the past, we've typically thought of human trafficking and molded our response to only from the perspective of law enforcement. As a survivor speaker, before I joined Dignity Health, I consulted for numerous organizations across the country, and the audience that I most commonly spoke to was law enforcement which is great. Law enforcement is one of the first responders most likely to encounter a victim of human trafficking, but so is healthcare. So, while the perspective is important, we now realize that human trafficking is also a public health issue that effects individual, families, and communities across entire generations. So, this graphic shows terms that are related to both public health and human trafficking. In the chat box, if you wouldn't mind sharing, which of these public health issues relate to your day to day work. Someone wrote reproductive health. Adolescence, child advocacy center hospitalbased, public health, policy, family planning, prevention, and counseling trauma, lots of terms are speaking to our participants, which is good. One of the primary benefits of looking at human trafficking as a public health issue is the emphasis on prevention. That is looking at systemic issues that cause people to be vulnerable to human trafficking in the first place. So, in my personal experience, going back to 1992, there was so much energy put into the prosecution of my trafficker and that was good, but there wasn't as much energy -- or not that wasn't as much energy, but there wasn't as much understanding or clear direction when it came to after care for me. And unfortunately, I am still seeing that out there, a lacking in community resources and service providers, or a lack of connection between the healthcare facility and staff and connecting the patient or trafficked persons with those resources because we also need much more emphasis placed on prevention. There were -- gosh, I would say a solid 2 years where I was so vulnerable, I was so at risk, I was just likeso clearly struggling, and the first person to notice and respond was the trafficker. The primary, secondary, and tertiary [unintelligible] approach can be applied to human trafficking. So, examples at each level of prevention are provided in this slide the public health prevention of approach does the following, it focuses on prevention, interrupting violence, and changing social norms. It recognizes the social and economic determinants of health and well-being that may lead to trafficking. Focuses on identifying protective and risk factors, encourages culturally specific prevention and intervention efforts, and engages all essential community stakeholders who can play a role in addressing human trafficking. Builds community capacity, and includes community members in the development of policies and practices that's so important in building our own victim response procedures at Dignity Health. We actively engaged with community resources who could provide care outside the hospital setting. Recognizes human trafficking along a spectrum of interrelated violence, and systemic iniquities. So, as we move through each section of this SOAR training, keep these points in mind. So, this training is built on the SOAR framework developed by the Department of Health and Human Services. It provides a quick mental reference for professionals like you to keep in mind the best way to help trafficked persons, or those that are highly vulnerable to human trafficking, so [unintelligible] you need to remember to do four things when interacting with patient who is are clients. The first is to stop, become aware of the nature and scope of human trafficking, and that's what we're doing today. Observe, recognize the verbal and nonverbal indicators of human trafficking. So, the idea is you're going to take what you learn today and you are going to be watching for observable red flags of human trafficking at all times, within and on the grounds of your facility. Ask, identify [unintelligible] with a potentially trafficked person, so we want to engage with people who are highly vulnerable to human trafficking, and those who are expressing red flags, and then respond appropriately to a trafficked person. So, the rest of the training, we will take a closer look at each of these areas. So, these are the objectives for the stop portion. Distinguish between some of the most common misconceptions and realities of human trafficking, recognize the potential for interactions with trafficked persons, and explain the legal definition of human trafficking based on the trafficking victims' protection act, or TVPA. Identify the use of force, fraud, or coercion against trafficked persons, or minor who have signs of abuse or neglect. Identify common risk factors for victims of sex and labor trafficking, and then identify common relationships between traffickers and victims. So again, your role is to understand human trafficking, watch for red flags, and respond appropriately. Including treating, referring, and reporting when mandated by federal and state laws, and tribal ordinances. It's important to know all three. We had a case that involves a tribal ordinance, and luckily, we had set up some of those contact phone numbers and relationships ahead of time. Work with others in your profession to develop protocols for your workplace on how to help potential victims. So, you don't want to -- for those who are on the call who are looking to implement a program within your facility or healthcare system, you don't want to start with education. I recommend starting with protocols because staff will walk away feeling ready to go out and identify these red flags, and they can be quickly sort of turned off if they -- if there are not set procedures in place and community resources identified on how to respond. So, we are going to start with our first case studies, this is Liza, and Leilani is going to read Liza's case study for us. >>Leilani Funaki: Hey, everyone. If you want to follow along as I read the case study, it is available in the file download area, but this is Liza's story. So, it says, as an 11 yearold I was one of six foster kids who were sold to men for sex by my foster mother's boyfriend, my foster mother and boyfriend needed to get money to pay for their addiction to heroin. No one in the foster system knew what was going on. Whenever we ran away, the police would return us to the same abusive foster home. We felt like we had no recourse since no one believed us when we said we were being hurt. By the time I was 12, I left the house for good and was on my own. I met a guy on the street who said he would take care of me and I believed him. In actuality, he was a pimp and sold me to men for money. He had me moving around a circuit, Chicago, Detroit, Indianapolis, and back to Chicago again. At first, he treated me nicely, just long enough to get me to do what he wanted. Then he turned mean. And if I didn't make enough money, he would beat me mercilessly. I learned quickly how to keep my head down and make my daily quota. During this time, I was beaten, burned, raped, insulted -- sometimes by my trafficker and sometimes by the guys who were buying me. Some of those wounds were treated by the grandmother of one of the pimps, who had been a nurse for 30 years. She had a set up in her basement, and the pimps brought us to her place whenever we were seriously injured. Sometimes I went to a local neighborhood health clinic, but no one ever asked what had happened to me. And if they did, I lied because I was afraid of my pimp. I knew he would beat me if I told anyone what's going on. To this day, I have physical, mental, and emotional issues as a result of that time on the street. >>Holly Gibbs: So, that's a lot of information that we're getting from Liza. And probably in our facility setting we're not going to get that information. So, let's say you are working with a patient and she shares some of those elements, my background is foster care, I ran away, I met someone, you know, this older guy who's helping to support me. And maybe there's some signs that indicate she may be involved in commercial sex work. How would you proceed with this patient? You want to write some thoughts in the chat box -- more-depth in -- a more-depth interview. Yes, I think that's important -- it's important to take time with a patient who's expressing red flags, and even ask open ended questions to help them share what they're ready to share. Asking, are you okay? Then pause, and note the non-verbals. I think that's also important. Wendy Barnes, we just had her as a speaker recently at Dignity Health, and she emphasized the importance or impact that's had on her as a victim of sex trafficking. We use this phrase: sometimes people trade sex for things they need to survive; is this happening with you? Yeah, if you're working with someone, and you're not sure if they're a victim of sex or labor trafficking, I think it could be useful to ask questions that get to the heart of discovering whether they may or may not be a victim. I might -- let's see. Communicate to build trust. Building trust is important, and we'll get to that as well. Is she safe? Does he have a safe place to return to? Building a safety plan is also important if the patient is ready. So, what indicators would alert you that she might be a victim of human trafficking? In that story, what jumped out to you as oh, these are definite indicators? Physical trauma and sexual assault. Foster kid. Mother and boyfriends. It's been shown that kids in foster care are highly vulnerable to human trafficking, particularly sex trafficking. The control and history of physical abuse, high ACE score. Yeah, so these are all things that we're going to get to shortly, and so this is a great start. So, what do we mean by human trafficking? How would you know whether or not Liza might be a victim of human trafficking? Let's be clear on exactly what we mean when we say this term. According to the Federal Strategic Action Plan on Services to Victims of Human Trafficking in the United States, human trafficking is a crime involving the exploitation of someone for the purpose of compelled labor, or commercial sex act through the use of force, fraud, or coercion. According to the U.S Department of State, a commercial sex act means any sex act on account of which anything of value is given, or received by any person. And just to be clear that doesn't just mean money it can be drugs, or it can be survival needs like a place to sleep, or transportation, something to eat. Where a person is younger than 18 and they're induced to perform a commercial sex act, it's a crime regardless of whether there is any force, fraud, or coercion. And this distinction is very important because kids are easier to manipulate, they're easier to exploit. So, let's consider some misconceptions and realities related to human trafficking. When I present human trafficking to staff at Dignity Health, I always begin with myths and misconceptions, because there's so many out there, and they're very often perpetuated by the media. So, let's consider trafficking must involve movement across state or national borders. Is this true or false? Yeah, so we're getting an overwhelming response of false. That's correct. Trafficking does not require transportation, a person may be trafficked within his or her own neighborhood, or even within their own home. Although, transportation may be involved as a control mechanism to keep victims in unfamiliar places, it's not a required element of the trafficking definition. Human trafficking is not synonymous with forced migration or smuggling, which involves border crossing. So, something that I often tell staff is to think of human smuggling as a violation of a country's immigration laws, and think of human trafficking as a violation of a person's human rights. So, a person can consent to being smuggled into the country, but if they're able to do what they want upon arrival then they wouldn't be a victim of human trafficking. But if at any point along that process they were induced to produce commercial sex or labor, then they may be a victim of human trafficking. Okay, so let's consider the next one: men, women, boys, and girls of any age, nationality, socioeconomic ability, race, and ethnicity are trafficked; true or false? We're getting an overwhelming response of true, which is correct. Many people associate human trafficking with specific demographics or populations. And while there are trends, human trafficking can cross all racial gender, class, age, ability, and socioeconomic boundaries. Next one: victims will ask for help if they want or need it; true or false? Great. So, overwhelming response of false. And this is important because we cannot depend on that alone, for a victim or a trafficked person to ask for help or to identify as a victim. Even myself, at age 14, when I was taken to a motel room and this man made it clear what he expected me to do, I didn't think, oh my gosh, I'm a victim of a crime. I need to run out of this room and ask for help. What I thought was, oh my gosh, I'm so stupid. I cannot believe I fell for this. I thought about the fact that I gave him my phone number, that I chose to talk to him on the phone, that I chose to run away with him. All I could see were my own choices. I didn't understand -- or I didn't take into consideration his actions. Okay, so the last one: healthcare and social service professionals need to recognize signs of trafficking and respond appropriately. So, there's -- this is a confusing statement actually. There is an overwhelming response of true, and I think that this is true. Healthcare and service professionals need to understand human trafficking, and be on the lookout for signs of trafficking, and then to respond appropriately meaning using established internal procedures that are victim centered and trauma informed. Beyond that, it isn't the responsibility of the healthcare provider to determine whether or not this person is actually a victim of human trafficking as defined by federal or state law. We are not a court of law. You know, we're in the business of helping patients. So, if we're seeing red flags, then we need to respond and empower this person to -- educate this person and empower them to make choices on whether or not they're ready to seek help. Beyond that, whether or not this person was a victim under federal law that would be determined by a court of law. Okay, so identifying potential victims. So, research has shown that trafficked persons are highly likely to come into contact with someone within the healthcare system. A 2011 study interviewed foreign national survivors of sex and labor trafficking to investigate how many had encountered healthcare while they were being trafficked. So, 50 percent had reported an encounter with a healthcare professional during time they were trafficked, but none of them were identified as a victim of these encounters. Another study in 2014, researchers interviewed survivors of domestic sex trafficking, and found that nearly 88 percent had reported an encounter with one or more healthcare professionals sometime during the period of being trafficked, yet none were appropriately identified or assisted. And I want to mention another study that came out just this year. A survey report from the Coalition to Abolish Slavery and Trafficking, or CAST. They surveyed 55 survivors, including sex and labor trafficking survivors, and over half reported at least one encounter with healthcare, while they were being exploited and nearly 97 percent received no information or resources on human trafficking. One respondent said that they were identified as a victim by the healthcare provider, which is a glimmer of hope but I think that the overwhelming reality is that healthcare professionals are still not yet educated or equipped to respond. Trafficked persons encounter a variety of healthcare professionals while actively being exploited. And this graph is based on an anonymous national healthcare survey of survivors in 2014. So, the respondents were either sex or labor trafficking survivors, a total of 117 patients were interviewed, and the percentage total adds up to 108 as some patients saw multiple providers. So, the most common healthcare professionals encountered by trafficked persons were those working within the emergency department, followed by primary care physicians, OBGYNs, and dentists. When we rolled out -- taking this into consideration, when we rolled out our human trafficking response program at Dignity Health, we chose to begin in the emergency department, and then we rolled out next to labor and delivery, and postpartum, and now we're rolling out house-wide all acute care facilities. And now we're rolling out to clinics. So, if you're in a large enough health system that you have to do it in a sort of strategic or systematic way, it may be helpful to take this survey into consideration when you're determining where to start first. So, something that I want to point out is another barrier -- sorry, I will step back here. Another barrier. It isn't just about the fact that -- or reality that healthcare professionals are often uneducated or not equipped to respond to human trafficking, but another barrier is that those who are most often impacted by human trafficking, or most vulnerable to human trafficking are from populations that are often isolated by or stigmatized by society. So, I think it's really important that as you consider implementation of education in your own health system or with your colleagues, bring in survivor speakers. Survivors truly help to shed through their stories humanity on these populations that are often isolated, and ignored, or stigmatized. And so, the next time someone at your facility comes across a so called frequent flyer, or someone who is -- has been a troublesome patient in the past, they can possibly see that survivor speaker before them and see all the potential that's there with the right interventions and support. Okay, so, the Trafficking Victims Protection Act of 2000 is a federal legislation that defines human trafficking in the United States. So, the TVPA provides a framework to identify and respond to trafficked persons. Trafficked persons are victims of a crime. The TVPA says the crime of trafficking has 3 parts an action, a means, and a purpose. In a court of law, one of each of these elements needs to be proven for a successful prosecution. The exception is that when minors, anyone under age 18 who is induced into commercial sex work is considered human trafficking regardless of the means. So, meaning there needs to be no -- there's no need to prove force, fraud, or coercion for someone under the age of 18 induced to produce commercial sex work. This is such an important exception. In my own story, when the man who lured me away from home that I met at the mall -- when he made it clear what he expected me to do, he punched his fist into his open palm in front of my face and told me not to talk to the law enforcement. And that was all the intimidation that I needed at age 14. One of the main reasons I was running away is because I was afraid of getting beat up in high school. So, I have had people say to me that that would not have been enough force, or coercion for them to do what this man wanted me to do. But that exception in the TVPA completely removes that element from the conversation, and that's really important because trafficked persons -- or traffickers are targeting kids who are especially vulnerable, kids from foster care, kids living in group homes, kids who have run away from home. So, it's important that that's been removed. So, while this is the American legal definition, it's important to realize that human trafficking is a global problem. You might also hear it referred to as trafficking in persons, and it occurs in every country in the world, including the United States. The market driven criminal industry fueled by demand for labor services and commercial sex acts. It can affect anyone, but it often effects those who are more vulnerable. And to clarify we want you to understand the legal definition, but we know it's not your role to make legal determinations. As a healthcare or social services professional, you should be able to use this framework to recognize signs of trafficking and connect patients to resources. So, when I'm educating staff at Dignity Health, I say, when you are working with patients, you always want to be on the lookout for red flags of human trafficking. But when you're working with someone who is from an especially vulnerable population, one that's often isolated or stigmatized, keep this framework in the back of your mind. And when you're talking to this person, in general patient care, general assessment, general rapport building and having open ended questions around their history, think about whether or not they're discussing any elements of action, means, or purpose. And I always recommend that staff begin with purpose. If they can determine that this person, this patient who's from an especially vulnerable population is working in some capacity, you may want to ask some questions around the dynamics of that employment to determine if there's any action, or means. So, force, fraud, and coercion, what exactly does that mean? Let's take a closer look. Again, remember that only one of these means is required for a person to be identified as a trafficked person, and in the case of a minor induced to perform commercial sex, there is no requirement for force, fraud, or coercion. So, we have listed the basic definitions here on this slide. Can you offer some examples for each definition? So, throw out some ideas of what would qualify as force. Right, so somebody wrote being beaten, rape, shoving, restraint, threatening to  well, let's see. Harming someone's sister. Okay. Threatened with weapons and physical abuse, restraint. So, I think that'sthat might fall under more of coercion. Threats. So, force includes physical assault, sexual assault, physical confinement, or isolation. So as healthcare providers, we definitely want to be on the lookout for signs of abuse, assault, even torture that's very common with sex trafficking victims. Fraud, involves false promises around work and living conditions. Physical coercion includes physically threatening to hurt someone such as, holding someone at gun point. And then, psychological coercion includes threats to the life or safety of the victim. The victims' family members or others, threats of deportation or arrest, debt-bondage, withholding legal documents, so there's so many different forms of force, fraud, or coercion that it's important to know all the diverse ways it can present. So, we've talked a lot about vulnerable populations, and here's a listing of some examples of vulnerable populations. So again, I encourage you to have these vulnerable populations, this list in mind when you're working with patients. If you are working with someone who falls into one of these categories, know that they're especially vulnerable to human trafficking. So, you want to be on the lookout for observable red flags, and have in the back of your mind the action, means, and purpose model just in gaining general rapport building, and general patient history. So, this is a study, The Adverse Childhood Experiences Study. In the mid90s, the CDC and Kaiser surveyed numerous participants, 17,000, on childhood maltreatment, family dysfunction, and current health status, and behaviors for a study on adverse childhood experiences. The higher the ACE score, the greater likelihood of longterm health consequences, extreme emotional responses, health risk behaviors, serious social issues, adult disease and disability, high healthcare costs, and poor life expectancy. The three types of ACEs include abuse, neglect, and household dysfunction. Abuse can be physical, emotional, or sexual. Neglect can be physical or emotional. House dysfunction can include mental-illness, and incarcerated relative, mother treated violently, substance abuse, divorce. So, the study says that adverse childhood experiences, or aces, are vastly more common than recognized or acknowledged, and they have a powerful relationship to adult health. Childhood trauma has staggering health, social, and economic impacts. Trafficking victims may have already experienced ACEs, which may compound the trauma experienced while being trafficked. In 2014, I actually published a book about my story, and the focus of my book was on so called willing victims. And I focus on that group of victims because that's what I was considered. So, the willing victim is someone who is a victim, but is seen to have complied in their own victimization. So, they may not reach out for help, or they may actively resist help. And so, in my research for this book, I interviewed survivors across the country. Specifically, survivors about sex trafficking who are considered willing victims, and all of these ACEs, all of these different types of abuse, neglect, and dysfunction were a part of their stories. And, whoever had one or more of those was more likely to be identified or considered a socalled willing victim. Okay, so which vulnerable populations are you most likely to encounter during your work day. From that long list, if you want to throw out some thoughts on who are you already seeing in your patient care? Or your client care? So, it looks like it's a -- survey here and everyone's filling in. Lots of different populations are being listed or identified as those commonly worked with. Okay, so the last item that we want to address is the common relationships between victims and traffickers, another stereotype about human trafficking is the nature of the relationship between the trafficker and the victim. The relationship of the trafficker to the trafficked person can vary. Covenant House, a service provider for homeless youth in New York notes that the agency often comes into contact with underage victims of sex trafficking. These youth are also referred to as domestic minor sex trafficking victims, or dmst victims, if they're U.S. Citizens. So, this study by Covenant House collected data on the relationship between the traffickers and the dmst victims, and the most striking finding was that 36 percent were trafficked by parents or immediate family members, while the study was specific to the youth of Covenant House it reminds us not to discount someone as being a potential victim just because they appear to be presenting with a relative. In my own education to staff, I include examples of so-called family controlled sex trafficking. There are -- unfortunately, there have been numerous cases across the country. One even involving a grandmother who sold her granddaughter. Note that boyfriends here could mean any romantic partner and is often used as a euphemism for the trafficker. All right. So, the summary of this section to wrap up some key points, human trafficking is the willful exploitation of another person by force, fraud, or coercion for personal benefit. Healthcare professionals have an opportunity to recognize signs, and become a first line of appropriate response for trafficked person. The TVPA defines human trafficking, trafficking does not require transportation. Trafficked persons do not usually selfidentify as victims, or seek help. The appearance of consent by a victim does not disqualify an occurrence of trafficking. Common atrisk factors include low socioeconomic status, familial and partner violence, childhood neglect, and minority status. Traffickers often have personal relationships with their victims prior to exploitation. And so, with that I believe we are going to take a 5-minute break, unless we want to take any questions? Leilani do you want to throw out questions, or determine if a break >>Leilani Funaki: Actually, we covered any questions that were asked that came up in the chat box, so I think we're good to go ahead and start our break now. So, it is 1:51 here on east coast for a 5-minute break. We are going to switch the screen here, so you all see a timer counting down how much time is left until break, but unless anyone has a question they would like to ask about what we covered so far in the training you can add that in the chat box, but unless something comes in I think we can go ahead and start our break. Okay, looking pretty quiet so a 5-minute break, we will be back to start our next section at 1:57. Thank you. [audio break] >>Leilani Funaki: Okay. Welcome back everybody to our training. We are going to go ahead and move forward with the next section, Jordan will be presenting for us here, and we will turn the time over to her. >>Jordan Greenbaum: Hi, there. I am hoping everyone can hear me okay. And I am not sure that I'm -- I don't think I have control. So, I can't move the slides. I'm doing my -- everything is not moving. So, if we could go to the next slide. Great. Back one. The objectives, okay. Okay, so we are going to spend the next part of the time talking about barriers, barriers that patients or clients experience that prevent them from disclosing their trafficking situation. And then, we're also going to look at our own barriers, provider barriers, what keeps us from either screening or not recognizing or acting appropriately. And then finally we will talk about some physical and behavioral health indicators that may suggest a child or an adult is a victim of human trafficking. Next slide, please. Okay, let's start off looking at patientrelated barriers. Why do you think -- and people can type into the chat room -- why you think a child or an adult may not disclose, even if they're brought into a healthcare provider, even if they come in alone? Why they may not tell us what's going on. People are coming up with some great answers fear, shame, scared of repercussions, they're from a different area and don't know where to locate health resources, shame, concerned for the safety for themselves or others, misplaced loyalty, may not recognize themselves as victims. These are all really important barriers, and I think that all of those come into play to some extent. In my own experience, I see a lot of -- I work with kids who don't necessarily recognize themselves as victims. And I think we need to be aware of that: that in many cases people -- adults as well as kids, may be lured and manipulated into a situation in which they think that the trafficker is their lover and is looking out for them. And they may even feel that even if he or she beats me up or forcing me to have sex with people I don't want to have sex with, the life they're providing me is better than the one I had at home. And -- or they may tell themselves that the person loves them anyway, and they're just acting out sometimes, but they're actually in love. So, they don't see themselves as being exploited and in many cases, labor trafficking, the victims may not see themselves as being exploited. They may have sort of normalized very, very, bad work conditions and conditions of exploitation, and feel in some way that they somehow deserve it if they are undocumented, they think well I was smuggled in, so they don't need to treat me like a human being. They can abuse me and that's normal, and not realizing that they have rights. So, I think those things are really important. Next slide, please. So, these are a lot of the factors that you have already identified feelings of shame or guilt. And again, this a lot of manipulation. If you think about the most powerful tool a trafficker may have is the ability to psychologically manipulate a victim into thinking that whatever happens, it's the victim's fault. You were the one who decided to climb out of window and run away with me, you were the one who agreed to stand up on that stage and do exotic dancing. You were the one who came with me across the country. And so, the child or the adult ends up thinking, oh my god, it's my fault. I can't possibly say anything because people will laugh at me, or be angry with me or judge me. So, they feel all sorts of shame or guilt and even in cases where there is no trafficker and we need to really be aware of those cases, cases in which children, for example, are example are living on the street and are engaging in survival sex, exchanging sex in return for things that they need. Shelter, food, clothing, drugs, et cetera. There may be no trafficker around, but those kids often feel a very strong sense of guilt and shame because of the social stigma and also feeling like, whatever they've done ending up out on the streets is their own fault. So -- and they may not feel like they can disclose to anybody. We've talked about fear, in terms of violence and fear of deportation is a huge fear especially in today's world. But even before that, a very good way of manipulating foreign nationals is threatening deportation. And all too often that threat can become a reality if law enforcement does get involved, the child or adult may be deported. So, they may be very distrustful of any person who is in a position of authority including healthcare providers. And then I think also that in some cases, there's a tremendous very deep feeling of helplessness and hopelessness which is partially fostered by traffickers and other people who are manipulating the victim but also a sense that things will never change. So, if a child is living on the street and they've been living on the street for 2 years they've been exchanging sex to get what they absolutely need, they may feel like it's no point that I tell this nurse or doctor or physician's assistance, there's no point in telling them because they can't help Nothing is going to change. This is my life. There's no way out. And many, many of these kids don't see a way out, they don't have the means to get out and so they may don't disclose because they don't feel that there's any option. So, I think a lot of this will come into play when adults and children both of sex and labor trafficking victims, are interacting with authority figures in particular healthcare providers. And many of these threats are significant threats that can be very real, if the child has run away from home to be with a trafficker, that trafficker knows where she lives. If the woman is -- has a child with the trafficker, the trafficker can threaten that child and the woman's not going to leave because she needs the child to remain safe. So, a lot of these threats can be very real as you know. Next slide, please. Okay, let's shift gears and think about ourselves as health care providers, or if you're not a healthcare provider as an adult, in your professional role, what are some of the reasons, that we may not either screen for trafficking or may not recognize it when it's right in front of us. What are some of the barriers for us? Don't know the red flags. It's a lack of knowledge and information on what is trafficking, what are the laws of trafficking, what's my duty? What do I ask? What do I say? What would I -- how would I recognize the victim? Lack of time. Oh man, we know that's a big one. Especially in clinics and emergency departments, things are going, bam, bam, bam, fast, fast, fast. And people are saying, "I don't have time to engage in this patient to find out why they have that penile discharge, I just need that [unintelligible] to discharge and get on to the next patient. So, I think time is a really big factor that no matter how much we ask healthcare providers to take the time and interview people and build rapport, they're slammed up against this barrier --this time barrier and that's a reality. And let's see, lack of resource to refer to you, that is such a good point. Now ethically we don't want to screen for something if we have nothing to give to someone who screens positive. If we have no resources why put a child or adult through the trauma of talking to them about their experience, if we have nothing to offer. If we have no place to go. I think that's a very real perception and many people, here's a relatively new study that looked at healthcare providers and whether they call to the national human trafficking hot line or call their community resources and the majority didn't. They had no idea. So, I think that's a very real one as well. Somebody else wrote victims won't accept help. Absolutely, they -- maybe for all the reasons we just talked about, they may be very reluctant to accept health, very suspicious or feel like they don't need and then somebody else wrote discomfort with the topic. Oh man. I think that's a really big one, too. I mean -- this is just like asking about child abuse or asking about intimate partner violence, you can't just go in there and say, "How long have you been coughing?" Which is a real easy question, have you ask some pretty personal questions, and build rapport and phrase things just the right way and people don't know. And we don't learn that in medical or nursing school so we don't feel comfortable doing it. And it's easier to not think about it and go on. Just -- you know -- ask the questions that we all know how to ask and treat and get on to the next patient rather thanrather than confronting our own tremendous anxiety and fear that we're going to say the wrong thing. I think, and maybe this is just bias, but I think that most healthcare providers really want to do what's best for their patients. They're not intentionally overlooking trafficking and they would be appalled to know that they missed it, but I think that there are people are afraid of what to say because they may cause more harm than good. "Maybe if I say it, I'll say it wrong. I'll traumatize the patient. I don't know what to do. I'll make things worse." So, I think all of those really play into it. Then a lot of what we're talking about, which you mentioned, can be a function of lack of training. The lack of knowledge, the lack of comfort and high anxiety levels, lack of resources may all be in the sense, be addressed by good training that's sort of multidimensional training. Okay, next slide, please. So, the next slide, I think, really covers about everything that we've talked about, lack of knowledge about human trafficking, there are several studies that have shown just how few healthcare providers have been trained on human trafficking and I think, of course, that's changing because a lot of us are really aggressively trying to do training locally and nationally, internationally. But you know it's like spitting in the ocean, there are a tremendous number of healthcare providers out there. I think many people don't understand the federalstatelocaltribal human trafficking laws. And so, they may not really understand what trafficking is and this becomes a really knotty, difficult issue and when you're thinking about labor traffic, is this labor trafficking, is this labor exploitation? Well, I find myself being very confused about that as well so people may feel like "Oh this is too difficult a topic, I don't quite understand this, I'm just going to ignore it." And of course, as healthcare providers we're all a little paranoid, I would say of HIPAA violations. And so, it's easy to sort of fall back and say, "I don't know what HIPAA allows me to say so I'm going to assume I cannot share anything." And I think that's the fall back assumption, and we run into that a lot with child abuse reports that healthcare providers are not aware that they can disclose patient information in cases of child abuse. And so, because they're not aware of that, they fall back on the -- "I better not say anything so I don't violate HIPAA." The lack of trauma informed tiered training is really an important one as well. And you have to ask yourself is it worse not to ask, or is it worse to ask but in a very judgmental, biased, harsh way which might cause more trauma than anything else. So, people may desire to ask an appropriate way but not knowing how to do that. They just decide not to ask at all. I think that we all have to be aware that we all have prejudices and biases built in, that's part of -- I think that's part of our culture and everybody's else's culture. Everybody has biases. So, we have to be aware of them. And be aware of how we may be perceiving things and work not to let those biases play into our ability to recognize human trafficking victims or respond appropriately. And I think that in many cases, there are a lot of biases and social stigma attached to sex trafficking and so people can apply that when they see potential victims and fail to see them as trafficking victims, but instead see them as "bad kids or child prostitutes or an adult prostitute" or somebody who just deserves what they get because they have such a bad attitude. Those kinds of biases can really cloud the issue and prevent us from seeing victimization. And also, I think as healthcare providers and I can include myself in all these conversations about healthcare providers, we tend to train to you and look very closely at signs and symptoms and check off boxes and we ask x questions and you get yanswer and then do z as a test. And so, if a child comes in with a penile discharge, we've been trained to ask certain questions, do testing, get treatment and out the door. And we have to remind ourselves to step back and say, "There's a whole person here not just their penis and the discharge" and you need to step back and think, "Okay, it's a 13 yearold with a penile discharge" maybe we should ask why they have that and find out more answers about that. So, checking off boxes without seeing the full patient I think, is a weakness that is common to a lot of us as healthcare providers. I think that we don't have time and the fact that we don't have time, can be a major issue as well. And then finally I think some people just don't want to get involved. It's a reality but I think that in a lot of cases people will be very upfront in child abuse cases and they don't want to get involved because they don't want to have to go court. And so, they just don't want to see the patients because they don't want to have to go to court. Well human trafficking is a little bit like that, if you get involved, you're will get involved in law enforcement, and you may have to go to court, and it may be much more difficult than treating pneumonia and people may run from that. Next slide please. So, this is a very busy slide, but I think one of the most important slides in this talk. These are red flags that may -- and I want to underline the word may, indicate that a person is being trafficked. And I want to also emphasize that none of these are slam dunks. There are lots of reasons why people may present with these physical problems, or behaviors, or past histories that have nothing to do with human trafficking. But they are common in the identified trafficking victims that we know of and so it would behoove us to be aware of them and ask ourselves, "Maybe we need to ask a couple more questions of this woman or this man just to make sure they're not a trafficking victim." So as somebody who comes in, with treatment for an STI or sounds like an STI, vaginal discharge for example. Especially if they have a history of a prior STI, is a big red flag and this is especially true for younger, younger people. Now we all know that the most common -- the highest prevalence population for chlamydia are the 1825 yearolds so it's not like every 23 yearold with a chlamydia infection is going to be a human trafficking victim, but we do have think about it and especially in younger kids. When we did research on our own population of minors who are coming to our children's hospital, identified victims, about 47 percent of them had an active STI, at the time we evaluated them. And about 30 percent -- 32 percent had a prior history of an STI. So, think about that. These are 14, 15, 16 yearold kids and with the history of an STI prior to their visit. A high number of sexual partners and we only know that if we ask. And so, so often you may have had this experience yourself, you may say you were a girl, you know, "Do you have any -- are you dating or seeing anyone intimately?" "Well, yes." You know, instead of the boy or girl -- do you have a boyfriend? "Well, yes." And we don't ask too many things. We don't ask how old that boyfriend is, and we don't ask about sexual activity, and the number of sexual partners. If we ask about sexual activity, we cannot just say "Well, how many partners have you had?" But of course, that's a big red flag if they say, "Well, eight or 10." Or "I don't know how many it's been a lot." That should raise a number of flags. And multiple pregnancies, especially if you have multiple abortions, is a big one as well. And one thing about abortions that I think is really important is that -- we don't know how often this occurs. But in some cases, kids, and adults -- survivors have told us they have been forced to abortions, or maybe they have decided to have an abortion, but it's not done by somebody who is qualified. So, the trafficker may take them in the middle of the night to some back-alley clinic, that's run by a healthcare professional who may or may not have training in doing abortions. And they may not use the best technique and so we may be seeing women and girls who have complications of abortions. Persistent bleeding, sepsis, et cetera. And that would be big red flags as well. So, keep that in mind. When you think about labor trafficking, in much of the very limited research there is -- over and over, you see, when survivors are questioned about their conditions, they'll say they had no protective safety equipment. And so, they have no gloves, for example, and yet they're dealing with very toxic chemicals so they make a chemical burn. They don't have masks so they have inhalation injuries and irritation, upper and lower airway irritation and inflammation from toxic chemicals or dust or smoke or what have you. So, having exposure to toxic chemicals in the form of burns, or air way inflammation can be a red flag as well. As can be really preventable injuries, because they don't have helmet or they don't have the safety belt, they may fall or have things fall on them and have fractures and closed head injuries that when you ask about it, it becomes really clear that geez, that's a preventable injury, what's going on at that work site so that may be a clue for you as well. And lastly, I want to mention suicide attempts and -- because a number of studies have shown very high rates of major depression and suicide [unintelligible]. There was a recently published study at a child advocacy center, so this was looking at kids who were survivors of sex trafficking. And about 47 percent of them, 47 percent had attempted suicide within the last year. And this is seen as well with an adult populations as well, so if you have a patient who comes in with a suicide attempt and the overdose is coming, when they are stabilized and you talk to them, it really is important to question and try to get a sense of what the living conditions are and the context of the attempt, because it may well be occurring in the context of trafficking and the person is so desperate they have  they see notice other way out. Behavioral issues, and these can be kind of subtle, and there can be a lot of reasons why people act a certain way when they come for medical attention. But if they are giving very inconsistent stories, or they sound like they're rehearsed stories about what happened, how did you break your jaw? "Well, I -- you know -- I fell off the bus and I hit the curb." And a few minutes later, "Oh I actually fell down the stairs." It's a [unintelligible] pretty obvious. But if there's not a consistency, ask yourself, "Maybe I need to talk a little bit more about this and dig a little deeper." If -- I think that Holly mentioned, that in many cases, it's -- victims are a part of trafficking network. They may be moved from place to place to place. And so, it's not unusual to be in Atlanta today, and Miami next week, and Los Angeles two weeks from now and all over the country. And let's say that the woman gets to -- she's taken to Atlanta and lands here last night, and is forced to work that night and gets beaten up badly by a customer. Well, the trafficker may take her to the nearest hospital, but she has no idea where she is, she may not even know she's in Atlanta much less which hospital she is in. And may not be able to tell you where she is staying, so that may be a clue as well. If they are very timid and somebody is with them who is acting very -- a little bit aggressive and some in your face answering all the questions when you try to talk to the victim -- your patient -- rather, the person who is accompanying them answers all the questions and doesn't allow the patient to talk. That should raise concerns about some troubling relationship between them -- whether it involves trafficking or not, it is worth pursuing some questions. In terms of social history, and one reason why we encourage getting a social history -- this is where you pick up a lot your risk factors. So, for kids, the runaway history is a big one, foster care, and being in foster care because of child abuse is really a major risk factor. A history of sexual abuse or sexual assault. They're very, very common among identified victims. Sudden increase in substance use. A lot of trafficking victims may use drugs before they became victims of trafficking and that may be what put them at risk. But a lot -- well, that's not necessarily a problem, but once they start being trafficked, they may use alcohol and drugs as a way of self-medicating to be able to handle the extreme stress and anxiety that they're feeling and so they may have substance abuse issues. If she is -- or the trafficker may try to get them hooked on drugs as a way of controlling them. So, drug related issues, depression, withdrawals, especially if this is a sudden onset. If you are a health care provider and one of your patients keeps coming in to you with complaints of stomach pain that doesn't seem to have an organic cause, and then next week it's a headache, and the next week it's a backache, and next week it's abdominal pain again, and you can't find organic causes for this. Think about sematics [spelled phonetically] symptoms of stress and trauma, and that may be your clue. And in terms of public health, think about [unintelligible] sexual abuse, we've talked about if you are asking about, let's say this guy who comes in with a head injury and something fell on him at the construction site, and you realize "Well he didn't even have access to a helmet." And you start -- and you think, "Well, maybe we need to ask some more questions." So, you ask a few more questions and you find out that the working conditions are pretty bad. He doesn't have much time on breaks, he works very long hours, et cetera, et cetera. That may be a clue that there is at least exploitation going on, if not flat out trafficking. And then also, think about people who have a lot of behavioral issues, especially if they are related to post traumatic stress disorder, anxiety, nightmares, et cetera. That that may be your clue. So, there are a lot of potential red flags that are related to the way people act when they come for medical care, the way they present, the things they present for, and the histories you obtained in their background, social, history and past medical history. Next slide, please. And this is just to drive it home that while we are doing our exam, we may find more evidence that may raise the question in our minds that a person may be being trafficked. And these are, again, nonspecific but if you have somebody who is complaining of constant headaches that especially if it's headaches, back aches, stomach aches, et cetera, like I was mentioning before, that may be your first clue. If there is pelvic pain in a woman, that may be PID and you need to think about that as well. If you see injuries that are suspicious, and we're thinking, "Well what is suspicious?" Suspicious injuries would be those that are noted in places that are ordinarily protected from accidental trauma and tends to be things like your neck for example, it's really unusual to get bruising on a neck in an accidental way. Bruising, abrasions, lacerations to the torso, the breasts, the buttocks, back, are pretty unusual, they certainly can happen but they are unusual. So, that may be worth pursuing if you see a mark whether it has a pattern to it that looks like a folded over belt, or it looks like a cigarette burn, you might just say while you're, you know, listening to the lungs, you see something on the back, you can say, you know, "I see there's a kind of a bruise here near your right shoulder, do you remember how you got that?" And so, if you're introducing it very informal way, not interrogating and that may be your clue. And many times, people will say that in punishment for not meeting their quota or not doing what the trafficker wants them to do, or not doing what the buyer wants, they may get beaten, or choked, or thrown down, or pistol whipped, or burned. And so, it's not unusual to have cigarette burns or [unintelligible] marks, like you see with children who have been beaten with an extension cord. You can see that with trafficking victims as well. So, you may see old injuries and that's really, really important to carefully document those and I like to use an example on this on just how important it is to document. Let's say -- let's say a 14 yearold boy and he is a victim of human trafficking, and he is also a run away, and she's got some petty crime history, and he's got a bit of an attitude that's related to his trauma so he can be kind of be in your face. And he's not going to make the most sympathetic witness in two years when this whole case goes to trial. And so, the jury may tend to say, "Oh God, I can't believe whatever this kid is saying." But if your documentation can corroborate that, that can make a huge different. So, if you see, for example on the back of this child, a cluster of three round scars that are about one centimeter each, and you say, "Hmm, you know, I can see some scars on your back here, do you remember what happened?" And he says, "Yeah, those are cigarette burns. My trafficker got pissed off at me and burned me with a cigarette." And you write that down and take photos of that. That can corroborate a statement later on in court which can be very, very helpful. So, I don't want to in any way down play the importance of really doing a good exam in documenting any injuries that you see. Tattoos are also things that you can see. And I don't want too much of this because a lot of kids -- most of our patients -- don't have tattoos. But some of them do, and they may actually have been branded by a trafficker. Literally like branding an animal, sort of saying, "You are mine." And the brand may be a street name of the trafficker, it may be a sexually explicit tattoo that the child may or may not have agreed to have put on them. And so, if you see a tattoo that is of a street name, or somebody's name, or has a sexual innuendo to it, it's helpful to ask, "Hey, you know, I see you have a tattoo that says, 'Mr. T.' Who's Mr. T? And when did you get that tattoo. Oh, okay, okay, do you remember was it your idea to get that tattoo, or somebody else's idea?" So, you're getting information that may open the door. What else to say? Have I left anything else out here? Dental issues. Oh, that's a good one. Dental issues are very common. You know, in our own experience we haven't seen a whole lot with kids, but in some of the studies that have been done, dental issues are prominent. And that may be dental trauma being socked in the mouth, and so you lose a tooth, for example, but it may also be from decay, et cetera. So, looking in the mouth and following up on the things that don't look quite right is very helpful. Let's see. Selfmutilation, I do want to say one thing about that. Remember that there is a huge population of trafficked persons who have major depression and just unbearable PTSD. So. selfharm, cutting behavior, selfburning, is fairly common and we see this a lot with the kids so if you say a lot of parallel lines on the [unintelligible] forearm, or on their thighs, or their legs, it really helps to ask about that. And that will open the door to you asking about sadness, depression, suicide attempts, and that can help steer you in one direction or another in terms of treatment and referrals. So, that's really important. Next slide, please. Okay, and then I think we talked a little bit about this, but reproductive issues and sexual issues that may be indicators of trafficking -- sex trafficking, kids and adults coming in with pelvic inflammatory disease, or signs of pelvic inflammatory disease that they complain of pain with intercourse, if they have a lot of petechiae in their throat or palate, that may be related to oral sex; vaginal and penile discharge, et cetera. We've talked about these a lot. No prenatal care is another one to think about. Miscarriages, et cetera. A couple that we haven't discussed are vaginal or anal foreign bodies. People may get raped with foreign bodies, and bits of the foreign body may be retained. And so, you may see bits of a bottle for example, in the vagina or -- causing an infection. In some cases, there may be things inserted in the vagina to try to stem the menstrual blood, and so that may be what you see. So, keep that in mind as either a source of vaginitis, or if you just come upon that when you're doing your exam. And then, the other thing to think about is hormone therapy for transgender patients. There's a recent study done that looked at medical service access among transgender youths and adults. And it showed in this particular study in the U.S. that the majority of transgender youth and adults, did not get -- have good access to medical care. Because of a number of reasons. One is they didn't -- they couldn't find somebody who -- a specialist who could really address their needs. Cost was another issue. So, there are a lot of barriers but the point is, if you have someone who is taking hormones, they may or may not be taking them under the supervision of a healthcare provider. So, it really helps if you can gently ask about that. Ask about hormone treatment and say, "Well, you know, what are your doses? Is anyone following you for this? Who's prescribing this? Where do you get your hormones? Tell me about that. Do you have any questions?" Et cetera. Because that may be your first indicator. "Well I'm getting the hormones on the street. I live on the street. I'm buying them on the street." That may be extremely -- it makes that child extremely vulnerable, or the adult extremely vulnerable, because they need money for their hormones. And that can force them into engaging in survival sex to get the money for that. So, keep that in mind as a possible indicator as well. Next slide, please. Okay, let's do a quick case study. So, Leilani are you going to read that please? >>Female Speaker: Yeah, I will. And once again if you guys would like to download the word document detailing the case study, it's available in the files to download section of the screen here on the right side. Just below the chat box. So, this case study is for Jesse. Right? "I grew up in Colorado. I was born a male but always identified as a female. My mom allowed me to express myself any way I wanted, so I wore dresses and played dolls. But she still referred to me as a boy. My mom was an addict, mostly cocaine. I don't even know the name of my father. I was never taken away from my mom, even though we were in and out of homelessness, sometimes living in shelters, and sometimes with a man she called a boyfriend. "I often saw her being sexually exploited by these men. As I started maturing physically, people started using sexual innuendos around me. I was being group groomed to think that selling my body for sex was normal and expected. I wasn't getting my basic needs met, so I started selling myself for sex as a 12 yearold. "At some point, I started work -- excuse me. At some point, I started working on becoming a woman by taking hormones. Like many transgender people on the streets, I didn't seek treatment through a doctor, but got hormones off of the street. The initial hormone pills were provided by a bar owner. Once you start hormone therapy, you can't stop. At around 15, I ended up being trafficked by the bar owner. "Most people assumed I was working for the bar, and could come and go like a normal employee. However, I couldn't leave, and everything I made at the bar went towards the debt to pay for my hormones, which had incredibly high interest rates that made it impossible to pay off. "At some point, I left the bar and was sold to several other traffickers. I sometimes felt like the traffickers were my boyfriends and often didn't try to get away. I was eventually forced in a dangerous trafficking situation in New York City that was eventually forced to shut down, leaving me and the other LGBTQ kids homeless. "While homeless, I was introduced to my first trusted advocate, who helped me realize I had been trafficked, and helped me contact an anti-trafficking organization. They tried to find me a place to go for help, but could only found the shelter for homeless men, since there aren't many that cater to LGBTQ, or male victims of abuse. "I was apprehensive about going to the shelter, but was willing to try it because my advocate wanted me to find a better way to live. I ended up leaving after two weeks and going back to my old life. "I eventually learned I was HIV positive and developed AIDS. Since I had been using the wrong dosage of hormones for such a long time by body started breaking down. I went to clinics regularly for AIDS treatment, and no one ever asked me questions about my sexual history, or my hormone usage." And then a note to follow up on Jesse's story. Jesse died at 26 years of age, one year after diagnosed with AIDS. Her heart finally gave out. >>Jordan Greenbaum: You know a really tragic history. Let's think about this. It sounds like, Jesse, for much of the time that she was trafficked, was a child. So, when -- the first issue is identify force, fraud, or coercion. Do we need to do that if the child -- if the victim is a child? No absolutely not, you're right. We don't. So, that is not a legal requirement. You will see it a lot, force, fraud, and coercion is awfully common. And a lot of times it's through the sort of psychological manipulation. What do you think were some of the issues of force, fraud and coercion that are relevant in this case? Pretend that she is an adult and we would have to show that. Do you see any bearers of coercion or force, fraud? Debt to the bar owner for the hormones, yep. Trying to get those hormones. That debt, an economic debt is a huge way of coercing people and a really important one that we understand, I think. This whole  the issue of debt bondage. So, for Jesse, Jesse was saying she can't afford the hormone. And that person knows it. And so, they're charging her and saying  charging exorbitant prices which she can't possibly pay back. So, it becomes a downward spiral of these incredible interest rates. And that's a form of debt bondage. Essentially there's -- it's unreasonable payments that are being required. Jesse doesn't know that or doesn't have any way of objecting to it. So, there's force to keep  to comply with the trafficker in order to start to pay back their debt which can never be paid back because the interest rates are so high. And so, this debt bondage, they're really in bondage, is very common especially among transnational victims as well. So that's, I think, a really critical one. Homelessness. Yeah, there's no -- there's no choice for Jesse at some point. At some point, she sort of turned out, and what are you going to do? And I think this is really important, there may not be a trafficker there, but they're still being trafficked in the United States. If a child is engaging in survival sex, they're being trafficked and so -- homelessness and the need to get resources. Psychological abuse, yes, that's a part of coercion and manipulation. There is something else, I was thinking about that psychological. It just left my mind. Mother was sexually exploited and seen as a way to survive. And so, there's these sort of normalized. I think Jesse talked about it being normalized. This is part of the culture in this particular family. That this is what is expected and that is affecting it as well. So what kind of barriers do you think prevented Jesse from saying anything to her service providers and prevented the service providers from asking? Does anyone have any -- yes, let's see. Mother -- transgender issues not understood by all providers. I think that's a big one, yes. And people don't want to ask questions if they don't know the answers and they don't know what they should ask. I think that's a big one, yep. Issues of privacy. [affirmative] Absolutely. So not knowing whether the healthcare provider is going to keep it private and confidential. They may not trust people. So, they may not want to tell us about it. Time and focusing on treating AIDS, yes. I think there's sort of that tunnel vision, again, exactly. People get very caught up in signs and symptoms of the infections related to AIDS, absolutely. They need to be caught up in that, but it's sort of at the expense of looking at the bigger picture. What else to do we have here? People are typing that's why I'm talking. Okay. Taking a sexual history is difficult for some providers. Let's -- absolutely. That's a big one. So, I think on both sides, there may be a lot of distrust on Jesse's part. She's been betrayed by adults all her life, so why should she trust any physician or nurse or PA. And may feel that there's nothing these people can do because they're not specialists in transgender issues. And feel like there's not an ability to communicate or may fear that they are going to be judged and -- harshly because of their transgender. Okay, how could we overcome some of these barriers? Well, somebody wrote access to resources which would be a really good way of overcoming the barriers. If we know like -- if you get off this webinar and you click on to google and you try to look for LGBTQ resources around the country, you'd be surprised at how many great web sites there are that provide help, Crisis lines for people, so just knowing that, and being able to provide some resources is a huge trust builder. And may, actually, really change the life of the -- of your patient. Cultural sensitivity training and capacity going, oh, you are so right. Absolutely. So that we all know how to work with transgender youth, how to think about the vulnerabilities of transgender youth. They're not just youth and vulnerable just because of their young age. They're really vulnerable to trafficking because of their transgender status. That really puts them -- makes them very vulnerable. So, knowing about that, having a better medical assessment tool, absolutely. And having protocols, I think all of those are extremely important. Okay, last slide please, for this section. We're winding up on the observe section. Can we go to the next slide? Yeah, thank you. So, we just covered the barriers that prevent recognizing human trafficking, both from the perspective of the patient/victim and the provider. And some of these include fear, distrust, shame, et cetera, on the part of the patient as well as provider barriers related to lack of knowledge, lack of training, discomfort, anxiety, bias, et cetera, judgment. And we've also talked about some of the common indicators of human trafficking. Which can help alert us that we need to ask some more questions. Okay. Do we have a break now? Or do we go right on to -- I think we go on to -- so we go on to -- back to Holly. Who's going to cover the third section, which is the ask. So, take it away, Holly. >>Holly Gibbs: Thanks, Jordan. So, I am going to move ahead to step three, which is the ask. These are the objectives for the ask portion of the SOAR framework. Commit to treat, identify, interact with a trafficked person, or vulnerable person, using victim-centered treatment best practices. Such as the trauma informed care approach. Identify the elements needed to establish a safe environment. Apply victim-centered interview techniques, such as those described in the trafficking-victim identification tool and other interviewing tools. So, the first thing I want to talk about, is the -- oh, where's that? The objectives. Is a victim-centered approach. So, this approach is defined as they systematic focus on the victim's needs, and concerns to ensure compassionate and sensitive delivery of services in a non-judgmental manner, so the top priorities are a victim's wishes, safety, and well-being. So, the idea is for a victim centered approach, you want to actively seek and maximize input from your patient or client. We don't want to just make decisions around this person without involving them and you know, I want to point out that this is called a victim centered approach, but I think that this should be practiced in all patient encounters and client encounters, so we often use the term patientcentered approach at Dignity Health. So, if you are working with the patient who's just been through an experience of human trafficking victimization, then they've just been through an experience where someone took away all of their agency. Someone made decisions for them about what they were going to do for work. How long they were going to work, when they were going to sleep, when they were going to eat, if they were going to eat and sleep. So, we want to begin to empower this person as early as possible and that's how we can gain trust with this person by not taking another role of someone who's making decisions on their behalf, without including them. One thing I want to point out that's very important to a victimcentered approach is knowing when you have to contact authorities against your patient's wishes. So again, this is about seeking and maximizing input from your patient in all decisions regarding care including, if and when to contact law enforcement. But we're all mandated reporters, well, I mean, I guess it depends on your role as healthcare practitioners and according to your state law, you may be mandated to report against your patient's wishes. [audio break] So, this is Holly. Can everyone hear me? Is it just me that -- >>Female Speaker: Oh, yep, Holly, we can hear you. >>Holly Gibbs: You can hear me? Okay, all right. So, everyone's back on, great. So, what I was trying to say was victim-centered care, a victim-centered approach -- you need to know when it's necessary to call CPS, APS, or law enforcement against your patient's wishes. And you want to be upfront with your patient about this. So that they know the limits to confidentiality and if you have to contact authorities against your patient's wishes, the key to continuing to offer a victim-centered approach is to continue to advocate on behalf of your patient's wishes. One more point I want to make is -- you know, state law, at least, the state laws that I've read through in California, Nevada, and Arizona -- can you guys still hear me? It says -- Leilani, you hear me? Okay we can hear you. Okay, sorry my -- I don't know why it seems to keep showing a concern. I lost my train -- Oh, the state law, that I've reviewed actually specifies what you're required to share with law enforcement. So just because you're required to contact law enforcement or another  well, specifically law enforcement may not mean you have to disclose everything about this person. Especially if they don't want you to contact law enforcement, we only want to share what's required by law, outside of that, would be a violation of HIPAA. And I think Jordan is going to get into this a little more, in the respond section. All right, so what do we mean by trauma. So, we want to provide both a victim-centered approach and trauma informed care. So, in short, trauma is any experience that overwhelms one's ability to cope. Anyone can be effected by trauma, individuals, families, or communities. Vulnerable populations, especially children, girls and women, youth, LGBTQ persons, persons with disabilities, and older adults disproportionately affected by trauma. And keep in mind that trauma can occur along a spectrum, right? So, you can have a healthy active adult who's in a serious car accident, that presents its own set of issues related to trauma, and then you may have another person who has been -- who has experienced abuse, neglect, and violence over a number of years by family members, by people she was -- or he -- was supposed to trust so these can both present different sets of concerns. Okay, a trauma informed approach. I want to spend a minute on this slide and kind of describe it in a way that makes the most sense to me. So, a trauma informed approach, to me, is -- it's a complex concept. And I think it has layers to its definition. So, let's kind of go through some of these layers. So, the first one realizes that wide spread impact of trauma and understands potential paths for recovery. So, violence is so prevalent in our society, right? And whether it's intentional or unintentional. Every time you turn on the news, there's a story about violence or there's a story of some other experience that caused trauma like car accidents or train accidents. So, recognizing that anyone walking through the door of your healthcare facility could be a victim of trauma or could have experienced some kind of traumatic event, last night, last week or last year. Another important aspect is realizing that your colleague, your coworker, the person working next to you, they may have experienced trauma last night, last week or last year. And understanding potential paths for recovery, so let me share an example from my own story to give an idea of different paths that I  coped with my own trauma. So, and again, a lot of the trauma I experienced in my victimization in middle school was more from the professionals who were in a position to help me. So, when I was arrested by law enforcement, that was a very negative experience. I was arrested on Pacific Avenue in Atlantic City, and by the time I got from Pacific Avenue to the police station, I was mentally and emotionally shut down, the officer called me all kinds of names. And I won't repeat those but they were terrible names. And so, I was shut down, not talking to anyone. And on that car ride, I actually thought that I had betrayed the people who were trying to help me. Meaning the traffickers. So, the man who lured me away from home, and the woman who was sort of overseeing me, under his control. Yes, I understood that they tricked me into running away, and that they had intimidated me into doing something I didn't want to do, but once I was doing what they wanted me to do, they actually praised me. And they, you know, I recognize now that he was using tactics to bond me to him and make me for this positive reinforcement. Where this arresting officer just berated me and so I thought that I had just betrayed the people who were on my side. So, when detectives got involved in my case, I was slow, very slow to open up like I said, I was crying and just not communicating on that first night. From there, I went through an emergency department, I had to be assessed by an OBGYN physician, and then ultimately, I was placed in a group home, and then placed in a mental health facility. Because I had actually attempted suicide soon after I was recovered by law enforcement. The way that I was treated by everyone from healthcare professionals to the detectives to my family and to my friends, was people treated me like I was an adult. Like I had agency and what happened to me, like I chose to become a prostitute and just to show that this wasn't totally in my head, I mentioned I published a book, well in my book I include my case files, my medical files and in one of the evaluations by the psychiatrist he wrote that the presenting problem was that I chose to run away and become a prostitute. So that was before this person even talked to me. And so, it gives you an idea that I just was constantly feeling like everyone looked at me differently. Like I was dirty, like I was damaged goods. I just felt awful. And so, after a few weeks of this, I became extremely angry and resentful. And I thought, "If everyone sees me as a prostitute, I'm going to show them a prostitute." And I became very, very aggressive, even sexually aggressive when I was placed in the mental health facility after the suicide attempt, I decided no longer was I going to be made to feel this way. So, I was very open about what happened to me in Atlantic City. I would openly and graphically describe commercial sex acts, I committed in Atlantic City, or that were committed on me. And then I would like proposition male nurses and, you know, even men in the adult ward if we were down in the cafeteria so my whole goal was to make all of you uncomfortable. I was tired of feeling bad about myself. So, realizing that there are so many different potential paths for recovery, know that if you're working with a victim of human trafficking, they can present as an emotionally shut down crying person, or they can present cussing and not wanting anyone's help. Recognizing the signs and symptoms of trauma in patients or client's families, staff, and others involves the system. Another, sort of, layer to the definition of trauma informed care is watching for signs of a patient or person being triggered or having a sudden negative encounter -- a negative response to a healthcare encounter. And this can happen with patients, it can happen with family members, it can happen with other staff. And so, I'll share -- there's a friend of mine, her name is Anika Mac [spelled phonetically]. She's survivor of sex trafficking, she is a speaker and I encourage anyone interested in bringing education to staff, please hire survivor speakers. And I recommend Anika. So, Anika was trafficked for, I believe, four and a half months by a very violent man who used forms of torture on her. And when she managed to escape this person, she walked to an emergency department and was immediately hospitalized. She spent a month in the hospital system, and underwent 12 different surgeries. So, she has a wealth of experiences, in which trauma informed care was and was not practiced. And so, one of these examples is, she was working with staff, she was very pleasant, very thankful, for their help. And at one point, the nurse took the oxygen mask off of her face. Which took her back to the feeling of being waterboarded, which is what her trafficker did to her. Which is one of the forms of torture that he imposed on her. So, she immediately lashed out at this nurse, her whole demeanor changed and so, the other layer of this definition is to watch for signs of your patient's being suddenly triggered and then sort of taking a step back and thinking, "All right, what's happening in this dynamic to cause this person to react to me in this way instead of assuming that there's something wrong with this person or that they're -- you know, it's -- or by taking is personal. Another bit of advice is for trauma informed care, is when you're working with someone and you suspect they're a victim of a crime like human trafficking, explain everything you're about to do in a procedure. This helps a person to know everything that's about to happen. So, seeks to actively resist re-traumatization. So, you want to actively take steps to prevent re-traumatization. And so, for patients this means creating a nonjudgmental space, it means providing options, and empowering your patient to make his or her own choices. For staff, it may be debriefings. And then the last step is to respond by fully integrating knowledge about trauma and to policies, procedures, and practices. You want to implement that into all policies, procedures, not just one where you're writing procedures up to responding and trafficking. Trauma informed practices can and should be used in an organization. Here are a few ways organizations and providers can implement a trauma informed care approach, reflect the principles of a trauma informed approach throughout the organizations policies, program designs, services, and spatial environment. Foster the core principles of safety, voice, and choice. Establish trusting, respectful, and collaborative relationships. Establish and maintain transparency and actions and interactions. Share information in an ongoing consistent manner. Six principles of a trauma-informed approach. This approach to care, maximizes healing and recovering while minimizing the risk of re-traumatization by safety, trustworthiness and transparency, peer support and I really appreciate the mention of peer support. I encourage you whenever possible, wherever possible, check your local communities for survivor led and survivorinformed organizations that provide mentorship or onsite peer support. Collaboration, and mutuality, empowerment, voice, and choice. Meaning shared decision making. And cultural historical and gender considerations. So, from here, we're going to watch a video. A short video of a survivor describing her experiences interacting with healthcare and social services. [audio break. Video restarts] I was trafficked beginning as a very young child. It was pretty much almost a part of my life, all of my life up until I escaped when I was 18. My trafficker was somebody that had my complete trust and the complete trust of my family and therefore made it very easy to gain access to me, to exploit me. There were quite a few moments at time when I was trafficked that, you know, the opportunity for intervention arose. When I was a young child, I had chronic reoccurring vaginal infections that was treated by my pediatrician. Then in middle school, I contracted oral sexually transmitted disease in which I was treated by an ears, nose, and throat doctor. Both physicians were wonderful and very caring but not one physician or healthcare worker ever asked whether I was being sexually exploited. Not once. Both doctors knew my family, and so I think that they may have dismissed that thinking, "No way could a child from a middle-class home be being exploited." Another case where I see an opportunity that was missed for intervention was -- I was in middle school, somebody reported that I was being sexually abused. I had to go down to child protective services. Prior to going to my interview, I was coached by my trafficker on what to say, and how to deny the abuse. He told me not to talk too much, and to know that the CPS was not my friend. I distinctively remember him saying, "Do you know what they want to do?" And I said, "No." And he said that, "They want to take you away if you say anything for good. You will be locked up, taken away from your family, your friends, and your pets. You will go to jail and everybody will know what you did." By the time I got there and walking into the office in which I was interviewed by a CPS worker, I walked into there feeling guilty, feeling ashamed and not at all seeing the social worker who was interviewing me as somebody that could help me, who was there to rescue me and bring me to safety. I saw her as the enemy. And I answered her questions, denying that I was being abused and left there with no -- there was no follow up. >>Holly Gibbs: This is a tough story to take in. And so, there were a lot of missed opportunities to help this person. What red flags should the providers have seen? Anyone want to share in the chat box? Multiple infections? STD in a middle schooler, absolutely. Multiple UTI's, vaginal discharge in a young child. Also, STI in a child. What questions could the providers or the social worker have asked her? Any thoughts on that? Looks like multiple folks are typing. Are you sexually active? That's a good question. Are you having consensual sex. Depending on her age, I don't know, you know -- we may have to ask in a few different ways to help this child understand what sexually active means and what consensual means. Ask if she's okay. Is anyone hurting her? Who does she live with? Has anyone asked or made you do something you didn't want to do? Do you feel safe? These are all great suggestions. So, what should the social worker have done differently? Explain their role and they were there to help, build rapport, follow up again later. Absolutely, follow up again later. Share types of help available. Absolutely. What happens after it is reported to the health department and wouldn't this be reported to CPS? You know, I certainly hope that there are better procedures in place to respond to potential reports and potential suspicions. I think that and a lot of areas where children are still being failed. So, I think these are all great suggestions. Building trust. Trust is a key component in helping to identify a trafficked person. And it requires patience. You want to see the potential victim as an individual and treat him or her with dignity and respect. Foster honestly, trust, and respect with the suspected victim of any kind of abuse, neglect, or violence. Understand that incremental disclosure is how most cases unfold. You know a lot of times, a person is vulnerable to being trafficked because of the number of times they were let down or not supported in the past, or the number of times maybe they reported something and it only turned into a situation where they got into trouble by the abuser or by family. Using open ended questions is important. Practice reflective listening. Trust can help the trafficked person, or vulnerable person, open up to you or come back at a later time. Wendy Barnes is such a great speaker about planting seeds. If you do your due diligence of creating a nonjudgmental space and communicating with dignity and respect, you planted a seed in which it's sort of a counter narrative. So, what they're hearing in their abusive situation. So, in Wendy's case she had a trafficker telling her that nobody wanted her in the real world. And so, every positive encounter that she had, which there were a few, it planted a seed. And so, as health care professionals that may be all that we can do in -- for this particular encounter. But it may be the best that we can do for this person. Cultivating trust and creating a safe space, establish an inviting physical environment. You know, I want to point out, when you're -- when you're working on procedures on how to respond to not just a trafficked person but any person that you suspect to be a victim of abuse, neglect, or violence, you want to -- you want to -- I think respond in a similar way. And in our program, at Dignity Health, we encourage staff that this program wasn't designed or these procedures weren't designed for staff to rescue this person or gain a disclosure from this person. It's about knowing what common red flags are, or knowing human trafficking well enough that you can recognize red flags or concerns. Watching red flags or concerns. And if you see a red flag or concern, getting this person in a private space, creating that nonjudgmental space, and establishing trust, building rapport. Conduct the interview in a safe and comfortable environment. You know when you design procedures for your facility, I recommend creating procedures for the most ideal approach. But for those of you working in hospital settings, you know that that's not always possible. In an emergency department, we have worked to identify rooms that are the best rooms to interview a person who may be a victim of abuse, neglect, or violence, including human trafficking. But the day or time or night or case or case load, may be such that we cannot use that room. So, we want to create the most inviting, and safe and comfortable environment as possible. Trust is compromised when an interviewer appears judgmental, presses too hard for disclosure, fails to promote informed consent, and meets infrequently with the potential victim. So, I want to call out this presses too hard for disclosure. Again, we don't put the responsibility on staff to rescue this person or gain a disclosure from this person, or you know, to determine -- to ask enough questions to determine whether or not this person is actually a victim of human trafficking under the federal definition. That's not our job, that would be the job of law enforcement and those involved in a court proceeding. If we see red flags, we determine concerns we want to get this person in a private space and build rapport with them and then from there, we want to educate them on what resources are available to them. Trust is promoted when an interviewer clarifies his or her role in supporting the potential victim. For example, I'm not a cop, and what you tell me is confidential, unless I feel that you are in immediate danger. Also, you want to mention any other restrictions around confidentiality per state law. Define what he or she can do for the potential victim without making unrealistic promises. And it's important when you create your procedures to identify resources in the community and to vet those resources in the community. Identify which ones are truly viable options for your patient and educating your patient on what's available to them. Ask simple questions. Listen to the potential victims' answers. And emphasize that he or she is not guilty or at fault. Demonstrate cultural competency. So, say you set up these procedures, you've identified rooms where you're going to take a person that has red flags of human trafficking, or any kind of abuse or neglect. If the person is accompanied by a controlling companion, then you will need to separate them at some point to -- you want to question this person in private. And so, we've had numerous cases in our health system that have provided so many opportunities for learnings. And one of those learnings was not to become focused on separating the companion from the room if you don't have a social worker or a person who's going to assess this patient ready to walk in and assess them, because it may be that you wind up only having five minutes with this person. Or if the controlling companion is pushing back on leaving, then if you spend all this energy on getting this person out of the room, and you don't have anyone ready to go in and talk to the patient, well then you may have, you know, created more conflict than what was necessary. What reasons to give? Our staff have been pretty creative in trying to separate patients from companions. Anything from requesting a urinalysis to an X-ray or some other kind of lab test, but also pulling the companion out to complete some kind of paperwork at -- with registration. That has been an effective strategy. For one facility, they actually created a form -- they call it the purple form; it's purple-colored -- and this is what they have the companion fill out if they have any suspicions. And it's sort of an alert to everyone of what's happening. Who will do the separating? I think that it's going to depend. Again, you want to create procedures that define everyone's roles in the most ideal situation. But in our hospital settings, we don't have social work 24/7. So, for some steps in the procedure, including separating a companion from a patient, it may be a nurse or a physician or a social worker or even security if it gets to that level. What safety measures are needed? So, I just mentioned security. If you suspect this -- what we've learned in our procedures and refining of our procedures with each case -- we've learned that if we suspect a patient to be a recent or current victim of human trafficking, we notify security, so that security can be on the lookout for dangerous persons. I mean, they're already on the lookout for dangerous persons in and out of the ED lobby or parking lot. But we want to make them aware that we have this concern in-house. And especially if there's a controlling companion that we're looking to separate, we involve security. If there's a controlling companion who refuses to leave, then we will notify security and we may notify law enforcement. You know, if you're working with a patient and you suspect that they may be a victim of any kind of abuse, neglect, or violence, this may be their only opportunity to get help. And it may be that they won't disclose anything in front of this person as long as they're in the room. And if we cannot separate them, then calling law enforcement may be their only chance. And we've had to do this in cases. Okay, I want to make sure I'm not missing anything. Tools for action: ask specific questions about human trafficking if red flags are raised. So, let's say you've taken steps to get this person in a private room. First, conduct a safety check with the patient or client. When conducting a safety check in person, you should ask questions like, is it safe for you to talk with me right now? Do you feel like you are in any kind of danger while speaking with me at this location? Is there anything that will help you to feel safer while we talk? When conducting a safety checkin by phone, remind the individual that he or she is free to hang up at any point during the conversation. If he or she believes that someone may be listening in, then ask questions like, "How can we communicate if we get disconnected?" "How -- or would I be able to call you back or leave a message?" "If someone comes on the line, what would you like for me to do: hang up, identify myself as someone else, a certain person?" "Are you in a safe place?" "Can you tell me where you are?" "Would you prefer to call me back when you are in a safe place?" "Are you injured?" "Would you like for me to call 911 or an ambulance?" Something else to keep in mind if you're working, if you are seeing a patient in person, know that if that person has a phone or any kind of electronics, there may be a person listening in. So, the safe place may be compromised and a trafficker could be listening in on the other end. Trafficking victim identification tool. So, there's this trafficking victim identification tool -- it was created by the Vera Institute of Justice. So, they recently completed studies in which they created, field-tested, and validated the first screening tool that can reliably identify both adult and minor victims of sex and labor trafficking. Including both U.S. and foreign-born victims. The tool was validated in victim-service agencies but not in healthcare settings. So, I did have an opportunity to look through this tool, and I didn't incorporate it to our initial rollout at Dignity Health because we were working -- we rolled out first in hospital settings. And in emergency department settings, it just wasn't reasonable to include such a long list of assessment questions. I knew that most cases would be such that we couldn't do this full-on assessment. So, something that we focus on in -- especially the acute-care facilities is to create this nonjudgmental space, this private space, and then talk to the patient after you've gone through a safety check. Educate the person on what resources are available to them. So, the most ideal approach is that you're going to take the time to build -- you're going to identify yourself. You're going to build rapport. Then you're going to discuss with the patients your safety concerns, what resources are available to them, potentially educate them on their rights and what resources are available to them in the community. And then ask the patient if they would like assistance in contacting these resources. Ask if they want help. but in some of the cases we've had, we only had five minutes with this person while a pimp was walking through the emergency department looking for this person in one of the back rooms. So, it may be that you identify yourself, express concerns for their safety, and ask if they want help. Or if you have more time, you may be walking in, identifying yourself, expressing concerns for their safety and really educating them on what resources are available to them. Jordan emphasized the importance of this. Know what resources are available, and then know -- educate the patient on those resources. Anticipatory guidance for healthcare providers: prepare a patient before a potential harm arises. Information can save lives. Don't assume the patient has knowledge about health and safety. So, again, there's a focus on the education and meet this person where they're at and educate them on resources that are available to their -- that meet their current needs. It's not about saving them, it's about empowering, educating them, and empowering them to choose which direction they'd like to go. When appropriate educate the patient about human trafficking and their rights. I think a lot of this is going to depend on how much time you have with this person. One example, we had a case in Southern California where a patient presented with dehydration and exhaustion. And so, the nurse is talking with her, and she discloses that she's been working so many hours and hasn't had a break in such an amount of time. And so, the nurse starts asking questions about how much the patient makes. And she disclosed, I believe it was $50 a day. And she asked does your employer have, you know, do they dictate when you can rest. And then she began to cry and say, that they did in fact dictate when she could rest. It was some time in the middle of the night whether or not she could stop and sleep. So, the nurse had enough information to stop asking questions to determine if this person was a victim, a truly victim of human trafficking under federal law. She saw enough red flags to see at least labor exploitation if not labor trafficking. She got this person in a private space, asked if she wanted help, and the nurse was able to contact CAST the Coalition to Abolish Slavery and Trafficking. And they responded onsite, with an advocate and an attorney who was able to explain to this person, what their rights were here as a temporary worker. She was a foreign national. So, that's an example of what I would call a success story. To me, it doesn't even depend on what the patient said, whether or not she wanted help. Because in fact, she didn't. She chose to leave. But she left educated on what was available to her, and we empowered her to make that choice for herself. So, if she wanted help, she could return to us, and she may have already gone to CAST for assistance. Depends on whether or in the wants help. So, what would you do? What would you do if you see that a patient or client has bruises on her face and arms, and an unusual tattoo or brand at the top of her breast? So, if anyone has some thoughts they want to write in the chat box. Lots of people are writing. Build rapport, then ask broad questions and see how she answers. While folks are writing I want to point pit that if you see bruises on her face and arms and you suspect those bruises are connected to some kind of abuse, then you may be required to contact law enforce in certain states. It depends on the state law and how it is written. And if the person is underage, you may be required to contact CPS. If the person is elderly, you may be asked to contact APS. Ask open ended questions, not just yes or no answers. Build a relationship, tell me what happened. Definitely explain role. Let her know that you're there to help her, and be gentle with any questions. I think these are all great suggestions. What would you do or ask next? Let me think -- let's try the next one. What would you do if she tries to leave the room in the middle of a meeting? So, you're talking with the person, she starts answering questions, and she leaves. What are we going to do? Let provider know to separate the two parties. So that was, I think, what would you do or ask next. Depends on her age. That's right. Like I said, if the person is under age, you may need to contact -- well if you suspect abuse, whether this person leaves or not, you're going to contact CPS. If she's overage, you still -- like I said, you still may need to contact law enforcement. But if this person wants to leave, we can't stop her from leaving. You know, when I educate staff, it's very hard for staff to consider this idea of letting this person leave. But that's the -- that's the idea behind victim-centered care, and trauma-informed care. We're empowering this person to make his or her own choices. But we are always following through with mandated reporting. Mandated reporting is there for a reason. It's to protect patients or persons who aren't able to protect themselves. Assure her, she's welcome to return. Absolutely. You want to create an experience where this person feels that they would be welcomed back and assisted. And if she's accompanied by another person, how would you separate them? Has anyone on the call had to do this and what were your strategies? Someone wrote, to the last question, reiterate the need for care, and but allow her to go and give her a number to call if she changes her mind. At Dignity Health, we use a resource from the Blue Campaign which is like a resource center from the Department of Homeland Security. And it's a small plastic shoe card that you can provide to someone with the national hot line printed on it. We have made that available to staff, and staff have made that available to patients. Especially to those who declined assistance. It's been a great tool, and Jordan's going to talk more about the national hot line next. Take her to the bathroom, close the door ask her questions. Urine specimen. Yep, these are all great. So, I think that I am out of time. And, Leilani, next are we doing a bit of Q&A or a break? >>Female Speaker: Why don't we see. Does anybody have any questions they'd like us to address right now about the ask and the observe sections we just covered? If you do, you can go ahead and enter them in the chat box, as you've been doing. But we didn't have any questions that were gathered prior there, Holly. >>Holly Gibbs: Okay. Well just to summarize then, let's see. We've got -- applying trauma-informed techniques can improve your ability to work with a potential victim of human trafficking. Building trust is essential when working with trafficked persons. Conduct a safety check with the patient prior to starting the interview. And use the trafficking victim identification tool. If it's appropriate for your setting, and I think that HEAL trafficking has also come out with a tool. Someone mentioned in the chat box. So, Leilani, do you want to start the five-minute break? >>Leilani Funaki: Yeah, let's go ahead and do that. It's 3:30 so we'll take a five-minute break and we'll get ready to start our last section, the response section, at 3:35 p.m. Thanks everyone. [program is on a short break] Okay welcome back, everyone. It's 3:35 now here, Eastern Time. We're going to go ahead and begin the final section of our webinar today, which is respond. Jordan will be taking it from here. We'll turn the time over to you, Jordan. >>Jordan Greenbaum: Thanks so very much. Can I have the next slide, please? So, the last section is going to be talking about responding when we have suspicion that a person is being trafficked. So, the objectives are to discuss how to refer a potential victim based on our local resources and what we have accessible. We're going to talk a little bit about the Culturally and Linguistically Appropriate Services Standards, which you may or may not have heard of before. We’re going to define the role the governmental NGO organizations play in the whole world of combatting human trafficking. We'll apply the model of SOAR -- stop, observe, ask, and respond -- to real world case study. And then talk about creating a trafficking protocol that you can use in your medical setting. Next slide, please. So, when you're -- let's say you're at the point where you have been talking to a -- an adult or a child long enough and you have real concerns that this person may have been trafficked. Well, I think that Holly has emphasized that we need to follow our mandated reporter laws and whatever laws that are relevant. But we also need to think about referrals. And I like to stress to healthcare providers that we are the people who are going to be really in charge of making referrals related to the child's, the adult's physical and mental well-being. Police, child protective services, adult protected services are not necessarily thinking about the health needs of people. They're not thinking, "Well this person needs the HPV vaccine." So, we need to be thinking about that. And so hopefully, the questions you've asked, if you've had the ability to really talk to your patient and they've given you some information, hopefully the questions you've asked have given you information that'll help guide the referral. this person So, you may have asked hopefully, about drug and alcohol use. Maybe you've got the sense that this is a real problem for this person. And they really need a formal drug assessment. So, that might be one of your referrals. And hopefully, you're thinking along the lines of getting a behavioral health assessment. It might have to be emergent if the person is actively suicidal. But you're thinking, "Okay, I need to make a behavioral health assessment" because 99.9 percent of trafficked persons are going to need at least a behavioral health assessment and likely some sort of trauma therapy because of the extreme trauma they've experienced. So, we're thinking along those lines. If the woman is pregnant, she's going to need an obstetrician. They're going to need a primary care person who is easily accessible. So, for example, I was talking to a girl a couple of weeks ago. And she had run away from home on a number of occasions. Well, she's not running -- she's not a runaway right now. She's living at home. But chances are she's going to run again. So, one of the things I wanted to do was to talk to her about where she could go if she does run away. So, I wanted to provide her with some resources that would help her minimize the likelihood that she might have to resort to survival sex or become vulnerable to traffickers. One of the things that I would suggest when you're thinking about referrals, before you're actually standing in there with a patient is to find out as much as you can about some of your local resources. So, finding out things like, does this shelter takes kids of all ages? Does this homeless shelter take both women and men? Does the homeless shelter allow women who have kids with them? What are the hours of calling people? Can you call this shelter in the middle of the night? And if so, what would the experience be like? You almost want to put yourself in the shoes of a trafficked person and say, "If this person reached out, what could they expect and what would their experience be?" So that you could help explain that to the -- to your patient because you may or may not make the referral from your office. But if you give them information and they decide to take you up on it, and they make the phone call, we kind of want to know what they can expect. And we don't want to make referrals at places that are going to say no. So, for example, my child who needed a homeless shelter, most of the shelters on our little list of resources don't take kids her age because she's too young. So I had to be -- I had to know enough about these resources to know whether they would be able to serve the child or not. So, knowing as much as you can about individual resources, is really helpful. Are there particular anti-trafficking organizations in your neck of the woods? If not are there domestic violence shelters? Are there homeless shelters? Where are the food pantries? Those kinds of things that we can help with. And if the person is willing to accept these referrals, you might want to make the call yourself. Make it sort of a warm hand off, as we call it, so that you're not just saying, here's the number to call when you get home or something. We want to help them as much as we can so that we can make the transition as easy as possible. And help as much as we can while still at the same time empowering the patient to make decisions and do as much as they can themselves. One of the things that would be really important, and you all know this, is to empower the patient to think about what resources might be helpful for them so that we're not just telling them. You've got to do this, that, and the other, but just asking what they think would be helpful. And is it helpful if we call now, or would you rather take the information with you? If it's information, would you like this pamphlet or is that not safe for you? What would you -- how could you best remember this information? So, getting the person involved and really thinking about what they might need in terms of physical health and behavioral health follow-up is really important. And then, I think that it would also be very helpful to follow up, if we can -- and you all had mentioned this in some of your comments before that it's important to follow up, have them come back or at least know they can come back. Extremely important. I think Holly also mentioned talking about the need for peer support. So, if you know of trafficking organizations, NGOs in your area that provide drop-in services or group services where trafficked persons can talk to each other and give each other support, that's enormously helpful. Or if you have access to victim advocates who might be survivors themselves -- enormously helpful. So, it really kind of depends on what's in your neck of the woods. But many of these things can be -- if you know about them ahead of time, you can sort of plug them in when you need them. And you're starting from scratch in the middle of the night when you find yourself needing to have resources. I think it's also important to have an idea of what law enforcement's response is going to be. If you are working with children and you are a mandated reporter, it helps to know. If I make a call to this law enforcement office, what is it that they're likely going to do? Because you want to know how you can make it as easy as possible for the trafficked person. Next slide, please. You may have concerns about HIPAA. I know I have concerns about HIPAA. I think all of us have concerns about HIPPA. As you know, HIPAA stands for the Health Insurance Portability and Accountability Act Privacy Rule. That's a mouthful, isn't it? But basically, it ensures that healthcare providers are health care facilities take adequate measures to protect patient privacy and the confidentiality. And ordinarily, we can't go gabbing about somebody's case to just anybody there are very strict rules about who can learn information about patients and who cannot. And in most cases, we're not allowed to share information. But there are some critical exceptions that allow us to share information with outsiders: police for example. And child protective or adult protective services. So, here's some of the examples of exceptions to the HIPAA rule. For example, if you have allegations of child abuse or neglect, you are able to disclose information about the child to authorities, and that's expected. And it's important -- I think Holly mentioned that we only give them the information that's relevant to them. We don't yak on and on about all the different things that we know about this child or this adult. But we can certainly give the information that's relevant to the investigation. If you know that the law requires you to report certain crimes, for example, then that also absolves you. It's in the HIPAA exemptions as well. But to be sure, you know, it's always helpful with adults and really necessary to get their consent. So, if you have an adult, and you want to make a referral to, say, the Human Trafficking Hotline, which we're going to talk about in a minute, you need to get consent on that. And that will allow us to provide patient-related information. So be aware that there are certain really important exceptions to HIPAA. And there are times when we can share private patient information that override HIPAA. Next slide, please. So, ask yourself, "Do I know what our state reporting requirements are?" Every child -- every state has child abuse reporting requirements but whether all these states consider child trafficking as necessarily a type of child abuse, is not necessarily true. So, states vary and they vary with the mandatory reporting requirement. So, it's important that you are aware of what they are for your particular state, and that you are able to follow those mandated policies. I think we've talked a little bit about this. What happens if a child or an adult threatens to leave. Let's say you have a child who is a homeless child, and you talk to them about their homelessness, and you realize that they are being trafficked by another person. And so, as a child, you’re in a state where it's mandatory to report. So, you say, "Well, you know, I'm really concerned about your health and your wellbeing. I'm concerned that someone is using you. And because of my concerns, I'm going to need to call the police. Because I'm required by law and because I'm really concerned about your safety." So, you're explaining what you are going to do. And the child says, "Are you kidding? Are you kidding? I'm out of here. I am -- you leave the room to call the police and I'm gone." What do you do then? And you just chat right in the chat box. What did you respond? He's in your face saying, "I'm out of here." And we can certainly understand why he might want to leave. If he's experienced foster care and other things, or problems with the police, he has no reason to trust that that's going to help him at all. And may feel very much -- very vulnerable. So, it looks like multiple people are typing. They're threatened and scared, so it'd be hard to choose the right words. It would be very hard to choose the right words. Would we be able to grab him by the shirt collar and say, "Sit down, kid. You're not going anywhere," and lock the door? No. So, in his written -- you need to be calm and let them vent. Absolutely, absolutely. And I think a good response to that would be, "Can you tell me more about -- you seem like you're really angry right now. And that you don't want me to call the police. Can you tell me more about that? Can we just sit down and talk about that?" So that you're giving them time to vent and you're understanding more what their point of view is, because it may be that they're under some misperception that you can correct. But at least it's allowing them to fell respected, and feel that you're really listening and you really care about them. So being calm, letting them cent, and reiterating your concerns for your safety. I'm concerned about your safety, I'm not the bad guy here. I'm concerned about your safety. So, you're empathizing and saying, "The reason why I'm doing this is not just because it's the law. But I'm really worried about you." And I think that's all very validating, and it shows compassion and empathy. The other thing is, as one person said is you ultimately have to let them leave. You can't grab them by the shirt collar. And so, if they're going to leave, they're going to leave. But I would make sure that you make it very clear, you know, before you leave, there are a couple things I just want to mention. I know you don't want me to call the police, I know you're going to leave and I can't stop you. I'm not going to stop you. But please know that I still have to call the police, because that's what -- I need to do that. So, I'm still going to call the police. I understand you're going to be leaving. Before you go, the second thing is -- before you go, can we talk about any resources? Is there anything I can do before you leave? Can I give you some numbers to call for a shelter or a food pantry or whatever? Suicide hotline or crisis hotline? Do you need these numbers? Can I help you? And that way, you're validating and you're also potentially helping them in a way that may not -- they may not get otherwise. So, offering them services and being very open to that is very important. And then trying to follow up and say, if you know that your organization is going hem with open arms, I would make sure that you say, you know, "This is a good place to come. If you change your mind, please come back here" And if you are operating in your own clinic or something, you can say, "Well, can we make an appointment for you to follow up and I'll see you in a week?" They may not come back but at least you reached out and made it very clear you're concerned about them and this is not a one-off deal. I think that's really good. Let's go to the next one. And adult is -- oh I'm sorry. If we can go back to the last slide, to the second example. An adult is badly injured, but they're an adult. And you realize they've been trafficked and they're injured. But they don't want you to call authorities. What do you do? Okay these are some really good points. Okay so one person is saying, "I understand and whether or not I call the police is up to you. My concern is for your safety. I can give you resources in case they help. You will make the right decision for you." I love that. You will make the right decision for you. And I think a corollary to that is, only you can know what is safe and what is not. And you know yourself best. You're empowering them and saying I respect you, and you know yourself better than anyone else. So, I think that's really important. You will make the right decision. However, if the injury is a felony, I must call, if that's the law in your state. Offer assistance, other than authorities, yes absolutely. I worry about your safety and welfare, yes, you're being empathic, you're being compassionate, you're validating their concerns. And if they absolutely don't want you to call the police, again, asking them, "Can you tell me why? What are your concerns?" And so, you can validate their concerns or gentle challenge their concerns. Well, actually, you know, it may not work out that way. It may be something different, you know. I can give you more information. That kind of thing is very helpful. Next slide, please. Okay. There's something called the Culturally and Linguistically Appropriate Services, or CLAS Standards. And these are basically standards that are -- that guide healthcare facilities so that they can provide culturally and linguistically appropriate services. They're basically saying these are the things you need to do to be culturally competent and, linguistically appropriately. And so, they address cultural health beliefs and practices, language issues, health-literacy levels and they give standards about what facilities need to do to make sure that people who have very low health-literacy can still understand what is being done and participate actively in their own care. So, for an example, the class standards might say something along the lines of ensure the competence of individuals providing language assistance. Provide easy-to-understand print, multimedia, materials, and signs in the language that's commonly used in your service area. So, it's not being really specific and saying put Spanish-speaking posters up. It's more general, saying these are the ways that you can meet these standards, that you need to provide easy-to-understand materials for example. You need to have adequate interpreter services available. So, just be aware of those standards. Next slide, please. If you don't remember anything else about this three-hour webinar, I hope can you remember this slide, because it's hard to remember everything we said. So, three weeks from now when you get a trafficking victim in your clinic or emergency department, wherever you are, and you're thinking "Oh man, I can't remember what was said in that SOAR -- oh, jeez. I can't remember what she said to say, think about this: this National Human Trafficking Resource Center is a goldmine. This is a 24/7 hot line that has a very easy to remember number. 8883737888. I feel like repeating that a million times, like one of those late-night commercials. But it's a really good hotline and it's for trafficking victims and survivors. It's also for people who are taking care of suspected victims. And so, you can call and say, "I have this situation. I'm not sure if this man is being trafficked or not. I'm not sure, I can't remember what I'm supposed to ask. Can you give me tips?" And that person can guide you through and say, "Well what are your concerns? These are some questions that will help you clarify." And they may even talk to you for the patient for you. They can if you know that the child or the adult is a victim or they need services. They can click, click, click, click, and figure out where you are. You're in Omaha, Nebraska. Well, there are three shelters in your area. And these are the numbers to call. So, they can look up resources for you in your catchment area. They can even, in some cases, help you make a police referral. So, they are just a gold mine of information, and you know you may be thinking, "Well, I can't share that information if the adult won't let me." But you can still call and get information from them if you don't release protected health information. So, you may be able to say, "I have this woman in my clinic now, these are the general concerns. I'm not sure what to do. You're not saying the patient's name, you're not giving the birthdate or anything like that. You're saying, "I have these concerns. Can you help me?" And that way you're complying with HIPAA, and you're getting the information you need. And as I mentioned, they're willing and very good at talking to patients as well. So, they can be a really good referral source for you. Especially -- and also ahead of time, if you're trying to figure out what services are in your area, give them a call and find out what services are in your area. Next slide, please. So final group exercise, we're going to have one final case study. And while we're talking about this, Leilani is going to read it. But please think about some of the things that we've talked about. The stop-step, when you're thinking about risk factors for human trafficking, and you're saying, "Okay, so what risk factors does this case illustrate; and then observe what are the physical and mental indicators that maybe this person is a trafficking victim. What questions would you ask, and how would you apply the victim-centered, trauma-informed approach in your questions. And how would you respond? Who would you refer the child to, what -- or the adult to? What does this man, or does this woman need in terms of health, and mental health resources. So, Leilani, you want to take over? >>Female Speaker: Sure. Our final case study is about Barbara. And once again the file is available for download if you'd like to read along with me. So, I grew up in the suburb in Northern Virginia. I was molested in my home for the first time by my father when I was eight years old. I started running away from home to get away from the abuse. The first time was when I was 12 years old. The police were always catching me and bringing me back. And my parents didn't seem to know what to do with me. I spent time in a detention center, and reform schools, and in hospital centers for children with problems. My mother was in complete denial. I tried to tell her once what was happening, but she couldn't believe me or didn't want to. They put me into the juvenile justice system and into the child welfare system. And eventually my parents' rights to me were taken away. I kept running away to Washington, D.C. And before long, people noticed me there. One day a woman picked me up. I was around 13 years old. She took me back to her apartment and told me I could stay there with her. She began to groom me for prostitution and told me the man was her boyfriend. Now I believe he was a trafficker. One day when I was 13 or 14, they sold me to another pimp, named Moses. He was vicious but smart and had many women under his control. He sold me to anyone and everyone. He had a quota which was hard to make, and if I didn't make it, he would take out a wire coat hanger and whip me mercilessly. I did whatever he wanted me to do, for fear that he would beat me again. I walked the tracks around certain hotels. I was arrested many times, but my pimp never bailed me out. He didn't want to spend the money. So, I would just sit in jail until they let me out. Around that time, I also started using drugs that were given to me. At first, I used them to numb the pain but I quickly became addicted to heroin. With all the beatings, violence, and abuse, I became tough. But somewhere inside me I was able to protect a small little space, a place that loves life, and loves animals. And years later, when I helped to leave the life, I told someone what happened to me. She couldn't believe it. And she kept saying, "You don't seem like all that happened to you." The emergency department was my doctor during the years I was on the street. Even though I was obviously a minor during the years, no one asked me what happened to me, or what was wrong. Ultimately, one caring and concerned person in the drug rehab center where I went for methadone saw I was sick and addicted and realize it there was something more going on. She saw I needed help and took the time to ask some questions and get me to tell my story. She was the one who found me the right set of services for what happened to me. It wasn't until years later that I really understood that I was a trafficking victim. >>Jordan Greenbaum: Okay. Okay, so let's just think back on this. What are some of the risk factors that Barbara had that made her especially vulnerable to being trafficked? Let's see. Early child abuse, victim of childhood sexual abuse, abuse in the home, running away, molested, high ACE score, absolutely. Taken from her home and put into the system. A lot of kids we see have been in the system for either abuse and neglect, or some other family dysfunction and are in foster care. So absolutely being in the system is a big risk factor. What about some physical and mental indicators of human trafficking in this scenario? People are typing. Drug abuse, yes. Substance abuse, absolutely. Physical injuries, yeah. Absolutely. Beaten with a wire, so she probably has some scars, probably marks on her if you did an exam, you'd probably see those. Yeah, absolutely. Frequent ED visits, only using the ED. Without a primary care provider. How would you apply some victim-centered interview techniques to this case? Do you think this person is going to be challenging to your interview? Perhaps because of all that trauma they maybe will have trauma-associated stress? Looks like multiple people are typing. Building rapport, taking your time, absolutely. Looking through the trauma informed lens, absolutely. This person has a lot of trauma and so we have to assume that whatever their attitude is, whatever they're saying, whatever they're hearing me say, or you say, is all being processed through their own trauma. And so, their withdrawal and they're very sullenness, aggression, whatever it is, their behavior is probably influenced by the tremendous amount of trauma they have had. And they are looking to protect themselves or are in survival mode. You always have to look for the function of their behavior. And the way they are interpreting what you say is also going to be through their own trauma lens. And so, they may misinterpret things and may misinterpret your facial expressions. And think you are threatening when perhaps you don't need to be. So, we always need to keep that in our minds as well, and assume that the things that they're saying may also be reflecting some of their trauma. So, the trauma informed approach is really hugely important, and building trust by building rapport, using open ended questions, absolutely. Open ended questions are the best thing in the world. "Tell me more about -- tell me everything else about this night. Then what happened? What happened next." Those kinds of things are really helpful because you're not -- it's very nonthreatening. And you're not leading and introducing any material. Really helpful. So, somebody said, "Avoid crossing your arms because that may be portrayed as not caring and feeling bored, absolutely. And it also may be portraying being kind of defensive or judgmental. So that's absolutely -- very open posture is very helpful. Look at the speaker straight in the eyes, so they know you're listening to them. I think eye contact is one of the best ways to build trust, to convey compassion and empathy if you can't look somebody in the eye, they may think you -- that you're bored, you're not listening, you're thinking about your grocery list. You don't believe them, you don't like them. There's lots of things they can misinterpret. What other things? Avoid re-traumatization. Absolutely. I don't know that -- I guess I don't have time for that. But I was going to give an example. What service providers do you think this person may need? Gather this information, we know about the drug abuse, we know about their prior abuse, we know about the trafficking. What kind of referrals, health referrals, do you think would be necessary? Oh good, somebody said their coalition has case managers that will provide resources. Wow, that's great. Behavioral health, yes, yes, yes. One, two, and three on my referral list are behavioral health. Because there's been so much trauma. Support groups, a community advocate, addiction support, substance abuse, crisis housing, absolutely. All of these are going to be really important because we ask those questions about substance abuse and mental health issues, because we want to know what their needs are so we want to do something with that information. So, we use the information. If we're going to ask the questions, we have to use the information for the answers, absolutely. I think we're getting close on time. Could we have  the next slide, please? I think we did -- yeah okay. You may or may not be in a position to be writing the protocol for your institution, but let's say you're working in your own clinic, or your own practice. You may want to have a protocol. Or if you're in the hospital, you may want to be on the team that creates a protocol. And the good things about protocols is that they set everything out for you so you don't have to be in crisis mode when you finally have to use them. There's nothing worse than not knowing what the heck you need to do in middle of the night when you have a young man come in who you feel is labor trafficked, and you have no protocol in place, no idea who to call. Then everything is a crisis. But if you have a protocol in place, it's spells out exactly what you should be doing. What you should be looking for, some indicators or risk factors, and then how to do certain things. Like how would you separate the patient from whoever is accompanying them? It's really good to have that in place and say, "Well, you know, so you know, that when you want to get somebody separated, your tactic is going to be -- you know it's our policy in this clinic to interview all of our patients alone. So, I'm going to need to ask you to step out and go to the waiting room for a few minutes." And you open the door and lead them out. That's what is' in the protocol. You know that's going to be your first line of trying to separate. And then you have Plan B and C if that doesn't work. You need to have some reminders in place on the interview process, like who's going to do the interview. When are they going to do it? Where are they going to do it? Where's a safe, warm, quiet place? What types of questions are going to be used? All of this goes into the protocol, because in the middle of the night you may not remember all that trauma-informed care stuff. So, we need to go -- have someplace to go that you can remind yourself. Safety-planning gives you ideas on what kinds of questions to ask and what to do. How do you use security on your premises? What is their role, and when do I call on them? The mandatory reporting process: you don't want to be scratching your head in the middle of the night saying, "Do I need to report this or not?" You need to be able to go somewhere -- boom -- protocol that says this is what you report and this is what you don't. And then finally, having a referral process so that you can have reminders in your protocol. These are the things we typically need to think about. And these are the numbers we suggest to call. You have some behavioral health referrals in place. You have an obstetrician that you can refer to, for example. And then the protocol also gives you guidance on follow-up and follow through procedures, so the warm handoff to your referral agency, for example. Protocols are really, really helpful. Next slide, please. And then develop that protocol. Lord knows we need help doing it. Nobody is going to be able to develop a protocol on their own and have anyone else follow it. So, you're going to need at least one person who has some authority to move the process forward. The executive director, the CEO, the program manager, whoever it is who's got some clout in your institution needs to have buyin and they need to be able to say, "This is moving forward and they need to be able to champion it. And you also need somebody at the lower levels, somebody in the trenches with you who can champion its real implementation. Because it's very hard to get a protocol off the ground. You need people constantly reminding. And so, I think that's really important. Excuse me, next slide, please. So just to wind us up, there's strong advocacy for victims of trafficking, and it begins by using the SOAR techniques that'll help us ask the right questions, recognize indicators, and respond appropriately. We can't emphasize enough to know your local referral networks so that you are not alone and you have something to provide the patient at the end. Not the screening, you've got referrals in place to help. And this can involve NGOs, law enforcement agencies, legal providers, especially those who can help with immigration issues. And it's important to identify -- [clears throat] -- sorry -- elements needed for protocols. [coughs] -- excuse me to assist victims of trafficking. And before I choke on myself, I think I'm going to end and open it up for questions. Thank you. Okay, let me see, I'm back. HEAL Trafficking offers a Protocol ToolKit for healthcare agencies. And it is really good. So, I would suggest that and they also have, on their website, sample protocols for different hospitals as well. HEAL has many resources, why is it so high in Ohio? I'm not sure what -- why is trafficking such a problem in Ohio, maybe? It -- so one person said, "In Ohio we've pulled together resources and a multi-disciplinary response." Ohio has done a lot of really good work. So, has New Jersey, California, New York -- a lot of really good resources to reach out to. Leilani and Holly and others, do you want to jump in at all? I don't want to dominate the question-answering period. I know it looks like we're just about out of time as well. >>Leilani Funaki: Also, just so that everybody knows, in the download area there are a couple of resources that could be helpful in helping you to identify how to create protocols or resources that can you use as you're looking to do that in your own organizations. >>Holly Gibbs: Hey, Jordan can you hear me? >>Jordan Greenbaum: Yeah, I can. >>Holly Gibbs: So, in response to the Ohio question, I actually get that question a lot in certain service areas where we have facilities. And I think it's less about that trafficking is happening more there, and it's more about that there's additional awareness. And resources with resources comes healthcare and other responders, feeling confident in responding if they see red flags. So, -- so I think Ohio has done a lot of great work and so they are just recognizing more cases. I think also that any place that has a big city is going to have trafficking because big cities will pullin people on business and conventions, and sports events and stuff. So that helps sort of create the demand but also rural areas can be very high risk as well. Places where there's an interstate going through and there are truck stops. So, when it comes down to it, I think most places are fairly high risk but especially major cities. Looks like there's a question here that asks, "I understand the need to give a patient agency, but what if the person is severely depressed? How can he or she make the best decisions? I think that's a great question. Another thing that we've run into is -- we've had patients who weren't necessarily depressed but possibly in a psychosis. And reporting concerns of being trafficked but also exhibiting behavior that indicated they may be at risk or -- what's the term, a hazard to themselves or others. So, I think that taking mental health concerns into consideration is important. Jordan did you want to offer anything there? >>Jordan Greenbaum: Yes, that's a good point as well. That if they are blatantly psychotic they need to be hospitalized. And if they're extremely, extremely depressed you might be able to make an argument for hospitalization at that point. And then, you know, that can buy you some time to work with that person as well or at least other people can work with that person because that is very hard to make a decision when a person is very depressed. On the other hand, they may still know better than we do about their own safety. And if the reporting is going to jeopardize the health of the lives of somebody else, they may only be the ones who know that. So, it's a real dilemma and if there is the right answer, but we need to think about their immediate safety and the safety of others. Do you have referral resources for all areas? So, one person asked, do you have a referral for all areas? I'm not sure if it's part of the greater conversation about Ohio or not. But I would suggest calling the human trafficking resource center and asking about referral sources in your area. And that's a good start. And whether or not you're in Ohio, that -- Ohio probably has a lot of resources on top of the Human Trafficking Hotline. But that's a good place to start if you don't have local knowledge. Let's see. I think we're out of time, it looks like. I just want to say I really appreciate everybody hanging in there and listening and having such great participation. Because it's so nice when there's a lot of participation. I learn a lot. Leilani Funaki: We'd also like to give a big thank you to Jordan and Holly for their expertise today and sharing their knowledge with us. We really appreciate that. And just so all of you know who are on the call, we'll be sending out a follow-up email from NHTTAC. It will include an evaluation and a link to an online evaluation for this training. If you want to earn continuing education credits, you do need to complete the evaluation. So, please be on the lookout for that in your email boxes tomorrow. And we appreciate your time and are so happy that you joined us today for this webinar. And one more reminder, the recording will be posted on the NHTTAC website (https://www.acf.hhs.gov/otip/training/nhttac) within the next few days. Thank you. >>Jordan Greenbaum: Thanks, everyone. Bye-bye. >>Holly Gibbs: Thanks all. [end of transcript]