While Hollywood often sensationalizes human trafficking with kidnapping and car chases, human trafficking victims can be all around us. They might be a lady at the nail salon, a kid at school, or a woman who shows up to the emergency department with a urinary tract infection one too many times. More than ever, we need to start having the right conversations around it! As part of the Social Emergency Medicine Series, Alaina Rajagopal and Victor Cisneros drill down into human trafficking with guests, Dr. Ronnie Rivera and Lisa Murdock. Together, they talk about what human trafficking is, what you should look for to identify victims of human trafficking, and what to do if you ever encounter a victim of human trafficking. This conversation may be sensitive for some listeners, and listener discretion is advised.
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Social EM:Human Trafficking With Dr. Ronnie Rivera, Lisa Murdock And Dr. Victor Cisneros
It is a topic that is not often discussed but is still, unfortunately, more prevalent than it should be. In the emergency department, we are well-positioned to look for signs of human trafficking and provide a safe haven for victims. In this episode, we will discuss what human trafficking is, who the victims commonly are, signs that you can look for, and finally, some stories about actual cases of human trafficking. Some of the topics we will discuss can be difficult to hear and think about, especially for those who may have experienced sexual or interpersonal violence. Joining us is Dr. Victor Cisneros, host of our Social EM Series. Dr. Cisneros, I will let you take it from here.
Thank you. It is a pleasure to be back in another episode of the Social EM Series. I am so excited to have Dr. Ronnie Rivera and Lisa Murdock, with who I have had the pleasure of working with them both. During the fellowship, I had Rivera on my side, who works in the emergency department and Lisa on a couple of projects from food insecurity to talking about human trafficking.
It is a pleasure to be introducing Dr. Rivera, who is an Emergency Medicine Physician and fellow in Multimedia Design Education Technology, MDEdTech at the University of California Irvine. He completed his medical school at UCLA David Geffen School of Medicine, and then went on to do a residency at SUNY Downstate Kings County in Brooklyn, New York.
After being elected to be Chief of Education, he discovered his passion for teaching his peers much in the same way as they advocated for improving bedside patient education as part of patient-centered care. He is completing a Master’s in Education focused on Digital Age Learning and Technology at John Hopkins University with hopes of creating a free public access health literacy education series. His projects include teaching techniques for improving bedside interactions with patients from at-risk patient populations and educating on improving social determinants of health in the emergency department.
Welcome, Dr. Rivera.
Thank you.
Lisa Murdock is an Acute Care Pediatric Nurse at Children’s Hospital Orange County and a Pediatric Clinical Nursing Professor. Over the past years, she has worked in pediatric acute care in several children’s hospitals across the country and in Puerto Rico. Lisa began her journey in anti-trafficking efforts after meeting a survivor in 2014. This meeting inspired her to continue these efforts by expanding healthcare provider education on human trafficking and working to implement evidence-based protocols for inpatient pediatric hospitals.
She believes that as a nurse, it is imperative to actively educate and raise awareness of human trafficking among healthcare providers and to implement a multidisciplinary approach to anti-trafficking efforts, including screening, response, and collaborating without patient service agencies. She serves on the Orange County Human Trafficking Task Force Healthcare Subcommittee and CSCC Resource Committee. Thank you both for joining the episode. Let’s get started. What is human trafficking?
Many people might not be aware of the Trafficking Victims Protection Act of 2000. It was the first comprehensive Federal approach to addressing human trafficking. According to that definition, human trafficking is a crime where a force fraud in coercion is used to exploit somebody for labor services as well as a commercial sex act. I look at it from a pediatric standpoint so I am always looking from eighteen years and under. That also includes youth specifically sex trafficking and youth who perform commercial sex acts in exchange for something of value. For example, survival sex does fall under that umbrella of exploitation.
It is great that you brought in the pediatric portion of it. I typically try to think about the definition of human trafficking from the perspective of action, a purpose, and a means. When you think about an action, this is recruiting, harboring, transporting, providing, obtaining, or advertising the individual that is being trafficked. It has to be done in order to exploit the purpose, capitalize, or force them into labor or sex.
In order for us to educate the public and healthcare providers, we need to have an accurate representation of human trafficking.
When you think about it from the minor’s perspective, they only need action and a purpose because minors do not have a means. For example, for an adult, the means would be by force, starvation, physical abuse, isolation, fraud by false promises of citizenship, money, coercion through threats or blackmail, or deception altogether. For an adult, you need the action, the purpose, and the means, but for a child, you only need action and a purpose because children do not have the means to provide for themselves. It puts children at a much higher risk by the definition of being victims of trafficking.
To add to that, in children eighteen and under, if you are seeing somebody that is exchanging sex for a place to stay, food, or things of value, you do not have to prove force, fraud, and coercion. As mandated reporters, that follow under that responsibility.
That sounds very complex. As a medical provider, I have never been familiarized with a lot of the different characteristics or definitions surrounding human trafficking. A lot of times, when I see a patient that I might have concern for coercion or some inappropriate relationship, it is not as clear or as legal. It is based on a sense of the things that this patient is telling me are not adding up. As medical providers, when we have that sense that something is not right, is there anything that we can do to address some of those specific criteria that you brought up?
I do not want to tell physicians what to do. I have been in this situation before where a lot of things need to be peer-to-peer. From a nursing perspective, there are things to do, especially using a trauma-informed approach, and building a rapport with the patient before you ask the questions in a trauma-informed way, which a lot of survivors might not use trauma-informed.
For example, in a qualitative study I completed, they said, “If someone asked me questions in a gentle way, that would have helped disclose.” In addition to that, as you are building a rapport and creating a safe space for them to disclose is being transparent, especially with youth under eighteen. Many of them fear healthcare providers because they have been manipulated into thinking, “Trafficking is a crime. You are going to get in trouble.”
As healthcare providers as mandated reporters, we have to call CPS and law enforcement. We are confirming what they have been taught is true. Being transparent with them like, “We do have to call, but it is to protect you. You are not committing the crime. We are calling to ensure you are safe because the other person is committing the crime against you.” It is important to be transparent and explain that is going to happen and also not leave them alone if we do have to call law enforcement. If they want somebody to ensure them who someone they trust and build a rapport with, it is at the bedside with them during that process.
You bring up an important point about trauma-informed care. This is something we hear frequently in the emergency department. It is a term that is not always well-defined in our minds as to what exactly is trauma-informed care. Trauma-informed care is trying to get into the head and perspective of the person who has experienced the trauma so that we understand that the person’s behaviors and responses to what we say or do may not seem appropriate. It may be angry, violent, or emotional.
We have to be okay with that because we understand that they have been through a traumatic experience and they are unlikely to respond as we might expect them to or want them to because of that trauma. We have to respect that, especially when someone says that they have hesitancy about reporting because this is an agency they may not have been given during the period that they were being trafficked. This may be the first time they have ever been able to exercise their right to say no to somebody.
If they say no to us, we do have to respect that. We also have to normalize the behavior, let them know how common this is, and that there is nothing wrong with being a victim of this. We can show empathy and avoid judgment in all of our statements. That is the trauma-informed approach. It is using our own empathy, avoiding judgment, and accepting that somebody may have maladaptive behaviors in response to this trauma that we can maneuver around in order to help them.
To also add to that, if you, as a healthcare provider, screen for your own adverse childhood experiences, you can even evaluate your own triggers when you are dealing with somebody who has been through a lot of trauma. In order to implement trauma-informed care, it is great to assess your own triggers as well. There are some tools to help providers out implementing trauma-informed care because it is so complex.
The PEARR Tool is created by a common spirit in collaboration with yield trafficking. It walks you through each step like Provide Privacy, Educate, Ask, Respect, and Respond. It is a tool for everyone to use because maybe everybody does not have training on the neurobiology of trauma and how to implement it as a skill. If you have that little tool, we can do that on a more comprehensive approach.
You bring up a great point. A lot of our readers are not trained in medicine and may not encounter somebody in the emergency department or in a clinic. Is there a way that people from non-medical backgrounds can also provide appropriate assistance to victims of human trafficking?
If you are not in a healthcare facility, there is a national hotline that you can call. It is tricky with human trafficking because many times people are basing it on the media presentation of what human trafficking looks like. That creates misconceptions about human trafficking based on sensationalized imaging or the taken movie where many victims are kidnapped.
That is important to point out that in order for us to educate the public and healthcare providers, we need to have an accurate representation. It is not just limited to sex trafficking. It also includes labor trafficking, which can be done through domestic servitude, agriculture, even healthcare providers, and nursing homes. This is pervasive even in youth as well. It is not as easy as what you might see in the media.
Lisa, you bring up a good point. In order to understand human trafficking, we have to have a sense of some of the statistics and what do the victims of human trafficking look like. If we look at the US citizenship and immigration services reports on human trafficking, about 21 million people in the world are forced to live in conditions of forced labor or sexual servitude. There are about 14,000 to 17,000 foreign nationals that are trafficked through the United States each year, not including US citizens who are trafficked.
About 100,000 to 300,000 children are at risk each year for the commercial sex trade. If you think about it globally, about 124 out of 195 countries have reported cases of human trafficking. Sixty-seven percent of trafficking is sex trafficking. Thirteen percent is believed to be for undocumented citizens. 49% are women, 21% are girls, 18% are men, and 12% are boys. That is expected to be underreported because of societal expectations about men and boys and their ability to be sex trafficked. It is important for us to know that 63% of victims have reported being visiting an ER and seeing a physician in ER at some point during their sex trafficking.
You talked about the most common categories in sex and labor trafficking. When we talk about sex trafficking, we always think about sex in exchange for money are goods, like sex for drugs or money. We have to remember that stripping and prostitution are also forms of sex trafficking. Pornography is also one if someone is being forced to perform either for live video shows or for photographs. Mail-order brides are another form of international trafficking. Sex tourism where people are traveling and looking to have sex with people in or from different countries is also trafficking.
Commercial phone sex lines are one we do not think about but people can be forced to work on these lines. You brought up a couple of great categories for labor trafficking as well as those are the two most common categories. I try to think about domestic work as another one that we do not think about too often. People who are being brought over to work in hotels or restaurants as chefs or cleaning services for large companies. Peddling and begging people can be brought over and put on street corners and asked to beg for money.
Trafficking also includes agricultural and admirable husbandry, like bringing people over to work on farms and to pick fruit here in California especially. Construction jobs are also labor trafficked as well. Somebody may be working construction, but not necessarily getting paid and the person who brought all of the workers over is getting paid. We talked about hotels and hospitality, and health and beauty services as well. Carnivals are another one I never thought about, but that seems to be a common one as well.
What about social media or the use of the internet? Has that increased sex trafficking or contributed to any changes in the market?
When you look at the impact that COVID had on both trafficking and anti-trafficking efforts, that impacted because many traffickers then transition to online means and residential brothels. That is an excellent point to bring up. When you are thinking about prevention, that is why it is so important, especially in pediatrics from the prevention standpoint to teach about online safety.
When it comes to human trafficking, keep an open mind that it's not a cookie-cutter definition. It includes a lot of different populations.
I love this team approach having both perspectives from you guys. To summarize for our readers, it is important to define human trafficking and keeping an open mind that it is not a cookie-cutter definition. It includes a lot of different populations. This might be underreported because a lot of these populations might not be reporting true statistics like undocumented people that are being trafficked. It is a complex issue. Keeping an open mind and that little spider-sense in the back of us as healthcare providers and realizing that is a team approach as we have a physician and an RN.
A lot of times, the RNs are the ones at the bedside spending more time with patients and giving us those signs. We spend a couple of minutes here and there, especially in the emergency department. From your guys’ point of view, Lisa from pediatrics and Dr. Rivera from the adult world, what would be the most common patient population that we could potentially encounter in the emergency department? It could be all of the above, but is there one that we keep reencountering or that we should keep an eye out for most?
I do not want people to focus on one population because that is what happens with having things be so missed or under-documented. We are not asking sensitive questions. If you look at barriers to disclosure or challenges with identification, there are both provider-related as well as survivor-related. If you screen for ACEs, many of the youth had a history of foster care being independency situations, experiencing homelessness, and being contacted within 48 hours of experiencing homelessness that a trafficker had approached them with either lucrative job offers that were fraudulent.
It is hard for me to pinpoint which population because I do not want to exclude other vulnerable populations within that vulnerable population. Male patients and LGBTQ+ community are even more under-documented because people are so focused on female victims of sex trafficking and missing out on labor trafficking and other more vulnerable populations.
It is interesting because we see a big focus in our political context on trafficking at the border for immigrants. Trafficking of illegal immigrants around the border probably makes up close to 13% of trafficking in general. It is important for all of us to understand who in our particular areas could be trafficked and what the most common areas are for the places that we live and work.
When you think about some of the main statistics about trafficking, 36% of traffickers are immediate family members, another 27% are boyfriends, 14% are friends of the family leaving 15% as employers and 9% as strangers. When you are thinking about the actual statistics of who gets trafficked, it is vulnerable populations. Anybody who is at risk is going to have their risk of trafficking amplified infinitely.
These are members of the LGBT, people who have drug addictions or who need substances, and people who are in unstable relationships or have a history of unstable or abusive relationships in the past. People who are victims of interpersonal violence are often more likely to end up in trafficking situations because of the relationships that they are in.
These are things that we should know about our own individual areas. If you live in California, you should understand those places. If you live on the East Coast, you should understand what is the most common. Most city and state websites will have statistics that allow you to review what the most common forms are so that you can become more familiar and hone your approach to tracking them down.
What’s shocking to me about the statistics that you read is that only 9% are trafficked by strangers. That leaves the other 91% as people that the patient or the victim knows. It is baffling when I think about it. What we are looking for in a lot of these situations is someone who has an unusual relationship with a family member, a friend, or a significant other.
That is why it is so important as well as healthcare providers that when we are creating a safe space, building a rapport, and asking sensitive questions is to try to interview that patient alone because many times, they are with somebody. In the study that I finished, multiple people were trafficked by family members. Similar to that research, in Orange County alone, 71 were recruited by people they knew. That is why it is important to use a professional interpreter. If you do need an interpreter and to get that patient alone, that is going to be key in assisting with the disclosure process.
I often get asked like, “When you are worried that there is something going on, how do you get the patient alone?” A couple of things came up. I do not know if you have been to an airport but a lot of airport bathrooms or ports of service have signs in the bathroom stalls that have a phone number that you can call or text. If you text “Be Free” to this phone number, it connects you 24/7 to somebody who can text back and forth with you about resources and get you help for trafficking. Having signs in the bathrooms, in your clinic, or in your hospital where people will go in the places you expect them to be alone or private are great ways to provide resources or pamphlets.
Other things you can do is if you need imaging on your patient, you can meet your patient alone in the imaging area and then discuss when whoever’s company with them is not around. A lot of times, the person who is with them is going to be the person who is doing the trafficking and that person is not going to want you to separate the patient from them. That is one of the key signs that you should be looking for when somebody is potentially being trafficked. If you do talk to somebody and provide resources to them, you can give them hospital socks and put the information in it. Fold it up in the bottom of their sock in the shoe.
With working with pediatric populations, I always set out from the beginning with the parents saying, “I interview one part with all of us together, one part with the patient alone, and one part with the parents alone and then we will all come back together and make a plan.” You are setting that up in advance so that they understand how the interview is going to go and they are expecting that they are going to get separated at some point. Those are the great ways to start to be able to address it.
Are there particular brands, marks, or signs that clinicians or the public can look for in human trafficking?
From the medical perspective, let’s look at some of the most common things that you can see in a medical setting. These brands and marks come with this also. I try to separate it into categories, responses, companions, medical issues, appearances, and others. When you think about response-based red flags, these are things like rehearsed or scripted responses from the individual. They are unwilling to speak even though they are able to speak and someone does a lot of speaking for them.
Their history is inconsistent or vague. They seem to be unaware of the location or the time. They do not have personal information such as their home address, their home phone number, or information about how they could get home if they were discharged. Companion-based things are someone who might be over-controlling or someone who is completing the paperwork for the patient, speaks for the patient has control of their ID or passport, does not give that back to the patient when they are done, or refuses to leave the patient alone.
For medical history, these are inconsistent or vague histories, histories that are inconsistent with the exam or the injury that they are being evaluated for. For appearance issues, we talk about inappropriate or ill-fitting clothing. An unexpected demeanor is somebody who seems irritable, anxious, or has a flat affect in a situation where you would not expect that. Lack of eye contact that is not culturally related can also be a red flag. Some may have large amounts of cash, condoms, or hotel keys on themselves and on their person. They may not have many personal items or the person may be controlling their cellphone and not letting them have their cellphone back.
When we talk about skin, tattoos, or brands, we think about tattoos in the inner lip area, on the neck, or on the back of the neck. There have been brands that have been reported on several websites that will show you brands that are considered consistent with human trafficking. There is a tattoo that is common. It has a crown with the name of the person who is the handler. It is a crown on their name that is associated with trafficking often.
On the physical exam, we should be looking for things like malnutrition, dehydration, and physical exhaustion from possible labor as well. On skin examination, we talk about bites, burns, ligament marks, ligature wounds, bruises, traumatic alopecia, where somebody may have had their hair pulled and had chunks of hair pulled out, scars, unhealed wounds, or wounds in various stages of healing. For tattoos, we talked about the neck inner thigh and lip. Under hair is another one that I try to think about as well.
I am going to add to that as well is cutting or self-harm. A lot of times, it is in inconspicuous areas. That is why the assessment is so important. When you are using a trauma-informed approach to give some element of control, you are not just asking them to take their gown off, for example. There have been survivors whose trafficker has made them undressed to make sure they are not hiding money anywhere. By you asking to see skin and have them take their clothes off to put the gown on could be re-traumatizing.
As medical providers, one of the things that are so important that we can do is provide resources and a safe place for victims of human trafficking.
Entering that exam using a trauma-informed approach, but being aware that a lot of these things might not be apparent. In addition to having somebody with them, a lot of survivors are dropped off by themselves at the emergency department, especially youth under eighteen. It is not limited to injuries, STIs, or some other high-risk categories but chronic diseases, like asthmatics, diabetics, and people in DKA.
It might be other regular chronic illnesses that we are seeing but you are seeing inconsistencies in the story like they do not know how they got there. There are other things that we should be looking for, just not based on those high-risk categories. Asking the questions and using a screening tool is going to be helpful for us.
You bring up a good point about framing everything that we do in the emergency room. That is a huge approach to Trauma-Informed Care. When we examine or touch any patient, it is so helpful for us to frame what we are asking in the context of why we are asking it and explain what we are going to do and where we are going to touch before we do that. Patients give us a lot of leeway with their bodies. We want to be as respectful as possible as we can with that.
For most of my patients who come in with lower abdominal pain, I think about things like sexually transmitted infections, etc. Have you been having any unprotected sex? Not letting them know why you are asking the question before asking the question allows them to have a context within which to respond to understand that it is not a random question or you are not trying to get information out of them that is not important.
It is understanding complex trauma as well. With a single episode of trauma, you have time to recover. Survivors of human trafficking, they have repeated events of trauma over sometimes a long period of time. A lot of times they are coming in terrified, even though they might not come off as being terrified. Could I read a quote from a survivor about this? She says, “We are terrified. Every person that walks through the door, we do think is either a client, a pimp, or a friend of a pimp. We do not know.”
“It gets to the point that we are sitting there for so long. We get up and leave. Sometimes we do not even make it past the front desk because it is terrifying. We do not want to sit there. You do not want to be seen and exposed. It is one of the scariest, especially when you are a child.” It is important for healthcare providers to know that they are terrified. They are coming into this emergency room with a different power dynamic. Sometimes, we forget about that power dynamic.
That is the most important part. We can give the power back to the individual. It is also important when we talk about this trauma-informed approach to care is understanding why might someone be afraid and not want to report that they have been a victim or a survivor of human trafficking. There are a couple of reasons why to help put us in their perspective or in their heads a little bit.
One is there is a need for safety. This person who is holding them or trafficking them may instill a need, fear of authorities, or immigration saying like, “If you report this, you are going to be deported or arrested.” They may create a stigma or a shame about them being a victim saying, “This is your fault. You did this.” Other things we talk about are the need for chemicals. Someone might have a forced dependency on drugs or might be using drugs as a means of coping with the experience. They rely on that person to provide the drugs that allow them to cope with this experience that they are going through.
We talk about intimate partners, boyfriends, or spouses being some of the primary perpetrators of trafficking. Sometimes there is a need for love or connectedness where someone has Stockholm Syndrome or forms some trauma bond with the person that is trafficking them. That may be a reason why they are not willing, able to report, or want to report that person.
Sometimes it is down to survival needs. Somebody might be threatening their children or their family back home, or their fellow victims who are with them. They are saying that if they do not go to the doctor or do what they are being told to do, someone is going to get hurt who is not them. They may be isolated, deprived of food and water, or emotionally or physically abused. They may not have their identification. These people can sometimes take IDs, passports, and take away their options for escape or to get away because they do not have any way of living or identifying after they leave.
There is also the need for food, water, and shelter. We talk about labor trafficking. A lot of these people have to live in certain conditions. They are only allowed a certain amount of food or water in these conditions. They are afraid that if they leave, they will be in a remote part of the world where they won’t be able to survive. There is the personal part of it, which is the shame. Someone who might feel shame that they were coerced into this by a loved one or a family member. They feel shame that they were complicit in what has been going on. They may be to blame for this.
A lot of these reasons combined together to make someone not want to seek out care from a healthcare clinician, healthcare system, or even from law enforcement, because they may have these fears. It is important for us to get into that frame of reference and understand those things when we are trying to help an individual.
You have outlined so many different barriers to these patients coming in and getting care. By the time someone sees you as a medical provider, they have already overcome so many of those barriers. I love that you highlighted how important it is for us to be empathetic and cognizant of their perspective and where they are coming from in this situation.
If they are abrasive in their conversation with us, it does not necessarily mean that they do not want help or do not need help. It has to do with a lot of those power dynamics and the background of where they are coming from and what they have been through. I appreciate that you highlighted all of those things that we should be remembering and keeping in perspective when we are interviewing and talking to these patients.
I agree 100%. It is so important that you guys highlighted at least some tangible signs and things that we can identify. The tattoo was a thing that I encountered at a community hospital where I work part-time. There was a female that was dropped off early in the morning, after supposedly partying. Her boyfriend allegedly dropped her in the emergency. She was altered. One of the things that I teach our residents is that you have to undress the patient automatically because she was not completely undressed.
We undressed her. She had marks finger marks in areas she should not have. I looked in the back of her neck and she had a tattoo which is a barcode. I learn that a lot of times, that is common, especially in Europe. The numbers do not necessarily read anything but sometimes it means the amount of debt that they owe. She was refractive and intoxicated. She was put on a bunch of drugs and pretty much altered most of the time. We found out that she was living in a house with five other girls.
The question is, “What do we do?” The nurses did not know. They wanted to call the authorities. I was like, “Let’s not call authorities right away because she is going to probably be afraid of the cops.” The cops had been multiple times to this household but they never did anything. There were some suspicions but they never had anything tangible. Long story short, it is like, “Is there anything from you guys’ perspective in place? Now we have this victim here that we identified in the emergency department. What do we do next?”
Out of the healthcare providers and nurses in this community, it is a small hospital, single coverage, I was the only ER doc with 30-bed. I am not going to disclose it is one of the number one counties of human trafficking in Southern California, which I did not even know. What do we do next? They did not even have any guidelines. They did not have policies. Luckily, I was there, to mitigate the team and stop them from contacting the authorities in protecting her.
I said, “Nobody can come in and be allowed in. She does not exist. She is not in the emergency department. Change her name. Boyfriend is not allowed.” We said she was positive for COVID so nobody can come near her until we got more information. Are there any guidelines in place, anything that we do or providers can do?
I have my five-pillar approach. Number one is ensuring that you have an accredited educational program that provides accurate education on human trafficking and trauma-informed care for all your employees. Whether that is in your new hires or your annual ACEs, that is going to be important. For nurses and physicians, you might need a higher level of what that looks like and having an educational program for all your employees.
Be aware that in any at-risk patient population that you see, you have a possibility of trafficking.
There have been many times when environmental services and patient care techs have been the ones to see some inconsistencies or red flags to notify us. Having a screening tool validated for your patient population because of the challenges and barriers to disclosure, they are not going to come up and disclose to you that they have been trafficked. Many youths do not even identify as a victim. A lot of times, when they say boyfriend, they think that person is their boyfriend. They might be manipulated into thinking, “He is my boyfriend. We need to do this because we need to save money for our future. “
That is why it is so important to have a screening tool. Once you have educated and identified, it is having a patient response algorithm based on your department in your population. My algorithm on pediatrics might look different from an adult ER. As mandated reporters, we do have to call CPS to do a call report and have to call law enforcement wherein in the adult world, you are not going to do that. You are going to want to get consent from that person to see if you want to call victim services or law enforcement, have an institutional policy, and then resource provision so you are connecting that person with outpatient resources upon discharge.
That is important as well because you want to plant the seed. It is not one and done. Many people think once you identify people, you are all set. That is not the situation, especially with youth that is being discharged to foster care or a group home. There have been youth that is recruited through foster care and group homes. They can run away.
It is important to link up. For example, in Orange County, we have a drop-in center for commercially sexually exploited youth. We have victim services and transitional programs. It is important to give them some resources. In the hospital, if we can create a safe space then they will be more apt to come back to us when they need the help instead of looking at it like, “I am not going back there.” I have survivors that are like, “I do not trust healthcare. I had a bad experience.”
A youth that was pregnant during focus group interviews through this qualitative study was like, “Sometimes, even with my first child, I just Wikipedia things and only go if it is critical.” Creating that safe space is important so they know they can come to us no matter how many times. That is called the Frequent Flyer or Non-compliant. I have another youth that has diabetes that was considered non-compliant so they would not give her an insulin pump. It is engaging with them, meeting them where they are at, planting the seed, and ensuring that they are getting services all along the way.
As you pointed out, so many of these patients do not recognize that they are victims. They do not even recognize that this is something that is not normal because of the narrative that they have been given over whatever period of time. As medical providers, one of the things that are so important that we can do is provide resources and a safe place. If they do recognize that situation that they are in is not ideal or not appropriate, they know where they can go, who they can call, who they can text, and what they can do.
Lisa, you brought up a great part about screening in the emergency room. There are four questions that have been pretty well-validated. When you can use all four, it is the best. If you can even use a couple of them with your patients when you have suspicions or you can set up a policy in your triaging that asks these questions like you might do a depression screening in the emergency room on all patients that come through.
These four questions can also be good screens for interpersonal violence and trafficking. Question one is, “Do you currently feel unsafe?” It is a yes or no question. Have you ever been slapped, kicked, hit, or physically hurt by someone in the past? Are you currently in or have you been in an abusive relationship? Have you ever been pressured or forced to have sex?
Those four questions can be done as a screening and can help to identify potential cases where we need to dig deeper and give people an opportunity to disclose if they are a survivor of trafficking. Those are four screening ones I have been validated in the emergency room for use. They can be used in clinics as well. You also brought up a great point about the team.
Victor, your story highlights this the most because as one single physician or individual, you can’t do all of this alone. You can’t screen the patients, fix the situation, and get all the paperwork done so you have got to get help. You have to have a team approach to this. You have got to work with your social workers, your hospital, and medical legal representatives, and put the team together.
Whether you need SART, Sexual Assault Response Team, for instances with sexual assault. Another thing is with our documentation as well. We have to be careful with how we document these patients, making sure that we only put in medically relevant facts and supporting details. We have to avoid words like, consistent with, possibly this, or make our own assumptions about what if could put a potentially gone on instead of reporting only the facts.
If we need more detailed accounts of things, there are medical legal representatives who work with state and local officials. They can help with the proper documentation, photography, and those kinds of things. We have to also take pictures if possible or use drawings with scales in them so that we can say how large the tattoos or marks were and then asking the patient for consent before any of these things are done.
We talked about consent before exam but also consent before taking photos. We make sure that at each step in this, we get some consent from the patient. Those are some of the things that we can do from the medical perspective. We talked about the National Human Trafficking Resource Center Hotline, which is a free number (888) 373-7888, which people can call 24/7. We also talked about texting “Be Free” to 233733, which is numeric for Be Free. These are things that people should know about as well for patients who are non-immigrants who are victims of trafficking.
There are two kinds of visas in the United States. There is a T visa and a U visa that allows someone who has non-immigrant status to obtain status while they are working with law enforcement. It is a way for people who are concerned that they are going to be deported or arrested to have a pathway to citizenship by helping to bring down the trafficking ring.
The US Citizen and Immigration Services Department has something through the US Department of Health Human Services called the Blue Campaign which is great to look into. They have a lot of training resources for medical professionals so that you can take courses. There is an hour course online that you can take as well. There is a group called the Polaris Project and then there is SOAR which is Stop, Observe, Ask, Respond to human trafficking. Lisa, you brought up CAST earlier, the Correlation to Abolish Slavery and Trafficking, which is another group that you can refer to as well for resources.
There is a few others. HEAL Trafficking, which is Health, Education, Advocacy, and Linkage. They also have a source for education research. They also have a Hospital Protocol Toolkit. You can go through their protocol toolkit in building policy. They also have an educational assessment tool. As you are rolling out your own education, you can go through the checklist to ensure that you are being responsible, and then also comprehensive on your training. In addition to that, they have a Train the Trainers program between HEAL Trafficking and mass general hospitals.
If you have somebody within your facility that is going to be responsible for training others on human trafficking, that is a great resource. It is a two-day workshop that they have annually. They also have the National Human Trafficking Training and the Technical Assistance Center, which does SOAR, but they also have core competencies as well. There are multiple resources out there for healthcare providers, as well as dignity, health, and common spirit have the pair tool. They also have a shared learning manual and a sample policy. As people are starting to build their policy and response, it gives an example of what that might look like.
I appreciate when there is a specific list of things that people can do, and places they can go to get resources and training. Lisa, you have been working in stopping human trafficking for some time. Dr. Rivera, I am sure you also have some stories. I was wondering if either of you can tell us some stories about victims and how they ended up being trafficked and then maybe after that, some stories about how people were finally able to get out.
I am careful. I feel responsible for sharing these experiences. I want to make sure I am doing it in a responsible way because I do not want to sensationalize other experiences from someone who has had this lived experience. Survivors that I have met that were part of a qualitative study expressed being trafficked by a family member and then not being identified through their healthcare experiences. It was not until they were in the recovery process.
I had a youth that was shot. She was not identified in the hospital but then was assigned to a visiting nurse because she needed wound care. She was telling her visiting nurse different places she could meet her like, “Meet me at the Jack in the Box. Meet me at this fast-food restaurant.” The visiting nurse is like, “We cannot be doing wound care and dressing changes in the bathroom at Jack in the Box. I know you are homeless. Where is your stuff?”
She drove her to the park, picked her stuff up, and brought her to the shelter. A lot of times, being recruited or trafficked by a family member and then not having that picked up through their healthcare experiences changed their perception. It is never too late to identify somebody and then ask the questions. Sometimes, you have to bring up the fact that, “I know there is something going on. I can get you services. You can trust me.” You are taking it to the next level and not just saying okay. You need to have to ask more questions.
The more we talk about human trafficking, the more we're aware of it, and the more we're prepared to deal with it when it happens.
A lot of times, victims are not necessarily in school and that removes a place for finding help. Is there something maybe people who work in education can look for signs at schools that might be helpful?
Some are in schools. I do not have statistics on it. It is difficult with human trafficking because it is so under-documented. We do not have a centralized database to track all these occurrences or identification. There is youth that is going to school. This one particular youth that I am speaking about went to school. There are prevention programs. There are different school systems that have Curriculum K to 12. San Diego county is one of them and they do it from a developmentally appropriate approach.
For example, in kindergarten, it might be, “My body, my choice,” in talking about safe touch all the way up to 12th grade. They run them through life scenarios and give them different options they can choose. If somebody is disclosing that they met somebody online and they are meeting at some undisclosed place, they have two choices, either report that to an adult, a teacher, or a parent or not say anything. It lets them work through that curriculum, It is called The Cool Aunt Series. That was built by a survivor. That also gives a series of twelve videos in a curriculum that parents can talk to their children about trafficking.
With this particular victim, she was not found in the medical community, within her schooling, or educational community. It seems those are both great places where she could have been identified and gotten resources. You guys have given us a lot of different ways that we can potentially close some of those loopholes for future victims.
Remember that it is not always sex trafficking depending on where you are. In California especially, we have a lot of labor trafficking situations in which someone might be presenting to the ER multiple times for standard medical care or even non-standard medical care.
One that I remember is a patient who presented to the ED for a urinary tract infection. This was hypertension. These were non-descript medical complaints like headaches, abdominal pain, those kinds of things. It was a middle-aged to a slightly older patient. They were always accompanied by their boss who they worked for who maintained all of their IDs and everything in a nice little organized folder. The boss also offered to translate. It was Vietnamese. They would always translate and say, “We do not need a translator. Let me translate for you. I speak Vietnamese. I am worried about my employee.”
It turned out this was a person who was brought over on a temporary visa from Vietnam and was working in someone’s nail salon for free on the promise that they would bring over their other family members. They were living in unclean conditions without having proper access to food and water. This person maintained all their immigration documents so that they could not getaway. It was found out to be a pretty large human trafficking room for labor.
The person who was running the nail salon was collecting all of the income and using these people and immigrants on the promise that they would get their family members to come. In some cases, the threat of violence that their family members would be hurt back home if they did not stay, work and continue to provide services in the United States. It does not always look like a relationship. Sometimes, it looks like someone whose boss brought them in and not feeling well on the job at work.
We have to be aware that based on where we are, it is a snowflake. Every situation is going to be slightly different. Every survivor is going to have a slightly different response. Every single time, you have to customize your approach to this person based on their individual trauma and their willingness to work with you. That is the crux of it. The hardest part for us is we have to customize our approach every single time. There is no formula that works perfectly. It is understanding the background and then being able to respond accordingly.
What you guys have highlighted is how much it is all around us. It can be at school, at the hospital, or at the nail salon. It could be any number of places that you go to every day and these people are not being seen. This would encourage a healthy amount of awareness and look around you at situations where something might not seem quite right. Once you identify a victim, having that sense of empathy and respect for what they are going through and providing resources, but not forcing things are some of the lessons that I have heard from you guys throughout this episode.
What are a couple of pearls, maybe 1 or 2 that we can impose on our learners in terms of improving education or awareness? Sometimes, our residents, RN students, and medical students are so busy. There is so much material that they are learning. Education is an interest of mine and all of us here. What are ways that we can establish this? In places that do not have a curriculum established, how do we start? What are a couple of pearls that we can initiate the spark?
I went through this a few years ago in starting to implement evidence-based practice. First of all, you need a multidisciplinary approach. As a nurse, I can do evidence-based practice, translate, and research into recommendations, education, and screening. I can screen because that is not diagnostic but I am not a physician. I am not billing, coding, and diagnosing either. We need to work together, especially when it comes to documentation as well. There are some challenges, especially with ICD-10 codes. Since I am not a physician, I can’t use those.
However, when getting buy-in or doing other studies, they will ask me, “How many have we seen?” I am like, “If I pull codes, I can check all the asthmatics and the appendectomies. It is hard to see how many exploitation situations we have seen.” It is working together to see what that looks like for your organization, finding ways to document correctly, working together on pulling data, and then working towards building a comprehensive approach for all disciplines within your facility.
You bring up a good point. You have to have a plan. This show is a great start to it. You start the process by learning and finding resources to learn more. In UC Irvine where I work, we have a human trafficking and sex trafficking training program that we have to go through every so many year. If you do not have that, access the Department of Health and Human Services or resources and take their training program to make sure that you are aware.
This brings me to my second pro. Be aware that in any at-risk patient population that you see, you have a possibility of trafficking. Have it in the back of your mind when the history does not make sense, when the patient seems they are not responding properly, or when you see or hear some of these red flags. Be prepared to address it and then have a team approach. Be able to bring in someone besides yourself who can help with it like a social worker, a care manager, a legal aid, or even hospital police if you are in a hospital setting who might be able to transition easily from hospital police to local law enforcement.
Being able to have discussions about it in practice is another important pearl. The more we talk about it, the more we are aware of it, and the more we are prepared to deal with it when it happens. We are not keeping this as a taboo subject but talking about it and breaking the stereotypes that we see in media and television so that we know what is going on in our local areas and be prepared for it.
Thank you guys so much for all of that incredible information. Before we wrap this up, do you guys have any final thoughts or anything else that you would like to share with our readers?
I want to say thank you for providing a platform to talk about these topics. Some people in other communities can’t even talk about human trafficking. It is a taboo subject and maybe not be brought to the forefront.
Thank you all so much. It is difficult to talk about this. It is a wide and encompassing topic and impossible to cover in 30 minutes, 40 minutes, or an hour. It is something that you have to constantly work at. I am glad for the opportunity to try to break down the most important things for you. There is more to learn and more to hear about. I encourage everyone out there to access some of the resources that we have suggested and dive in because there is a lot more to learn.
Thank you both again so much for sharing your expertise and your willingness to fight against this under-discussed topic. That is it for this episode. Thank you as always for reading. Our guests were Dr. Ronnie Rivera and Lisa Murdock. This episode was sponsored by the National Geographic Society’s Emergency Fund for Journalists. If you liked this episode, please give us a like, rating, or comment. This is our second to the last episode of season two. Please consider subscribing or follow us on Instagram if you would like to be notified when we start season three. Until next time.
Important Links
Dr. Victor Cisneros - LinkedIn
https://www.DignityHealth.org/Hello-Humankindness/Human-Trafficking
Instagram – The Emergency Docs
About Dr. Ronnie Rivera
Dr. Rivera is an emergency medicine physician and fellow in Multimedia Design and Education Technology (MDEdTech) at the University of California, Irvine. He completed medical school at UCLA’s David Geffen School of Medicine and went on to complete his residency at SUNY Downstate / Kings County in Brooklyn, New York. After being elected to Chief of Education, he discovered a passion for teaching his peers much in the same way he advocates for improving bedside patient education as part of patient centered care. He is currently completing a masters in education focused on Digital Age Learning and Technology at Johns Hopkins University with hopes of creating a free, public-access, health literacy education series. His current projects include teaching techniques for improved bedside interactions with patients from at-risk populations and educating on improving social determinants of health from the Emergency Department.
About Lisa Murdock
Lisa Murdock is an acute care pediatric nurse at Children's Hospital Orange County and a pediatric clinical nursing professor. Over the past 22 years she has worked in pediatric acute care in several children’s hospitals across the country and Puerto Rico. Lisa began her journey in anti-trafficking efforts after meeting a survivor in 2014. This meeting inspired her to continue these efforts by expanding healthcare provider education on human trafficking and working to implement evidence-based protocols for inpatient pediatric hospitals. She believes that as a nurse it is imperative to actively educate and raise awareness on human trafficking among healthcare providers and to implement a multidisciplinary approach to anti-trafficking efforts, including screening, response, and collaborating with outpatient service agencies. Currently she serves on the Orange County Human Trafficking Task Force Healthcare Subcommittee and CSEC resource committee.
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