Human Trafficking

1. Human Trafficking “It ought to concern every person, because it’s a debasement of our common humanity. It ought to concern every community, because it tears at the social fabric. It ought to concern every business, because it distorts markets. It ought to concern every nation, because it endangers public health and fuels violence and organized crime. I’m talking about the injustice, the outrage, of human trafficking, which must be called by its true name—modern slavery.” “Our fight against human trafficking is one of the great human rights causes of our time, and the United States will continue to lead it…” --President Barack Obama, September 25, 2012

2. Human Trafficking – Identification in a Health Care Setting October 18, 2012 Role of the Health Care Setting in Identifying and Helping Victims of Human Trafficking SF Department of Public Health

3. Learning Objectives What is human trafficking Identifying human trafficking victims Health & medical issues associated with trafficking victims Communicating with trafficking victims Role of health care provider Resources

4. Prostitution Child prostitute What is Human Trafficking? Sexually Exploited Minor Slavery Modern-day slavery human trafficking Human smuggling Human trafficking

5. Human Trafficking vs. Smuggling Smuggling: Individual voluntarily crosses international border for a fee Trafficking: Individual forced or deceived into involuntary service or labor even if voluntarily crossed borders Domestic trafficking: U.S. -American youth or adult forced into commercial sexual exploitation and / or labor

7. Human Trafficking Under Age 18 Action + Means + Purpose Recruits Force Sex Harbors Fraud Labor Transports Coercion Provides Obtains OR

8. Forms of Human Trafficking Sex Trafficking: • Commercial sex • Anyone under the 18 years of age in the sex industry • Massage parlors, brothels, strip clubs, escort services, internet Labor Trafficking: • Recruit, harbor, transport, obtain or employ a person for labor or services in involuntary servitude, peonage, debt bondage or slavery • Nannies, maids, sweatshop factories, janitorial jobs, construction sites, farm work, restaurants, hotels

9. Who is Trafficked? Up to30 Million people are exploited worldwide for forced labor and sexual exploitation. (United Nations, ILO, International Labor Organization, Not For Sale Campaign) Each Year: Approximately 800,000 to 900,000 victims are trafficked across international borders.(DHHS) Between 17,500 - 20,000victims are trafficked into the U.S.(ICE, DHHS) Global Human Trafficking

10. Local Human Trafficking Cases have been reported in all 50 US states. California is a major trafficking entry point. 43% of California trafficking incidences occur in the Bay Area*. *South Bay Coalition to End Human Trafficking www.sbcteht.com

11. Labor and Sex Traffickingin the Bay Area Sex work (commercial and non-commercial) Domestic service Nannies Marriage Factories Agriculture Restaurant work Manufacturing work Home/Residential care facilities • Criminal activity (including drug trafficking) • Construction • Hotel/motel • Housekeeping • Daycare teacher • Cleaning business • Candy/trinket sales

12. Who are the Traffickers? • 42% are women * • 46% of cases the recruiter was known to the victim* *International Organization for Migration 1999. Mabelle de la Rosa Dann Home of Giuseppe & Kesia Penzato Lakireddy Bali Reddy Walnut Creek San Francisco Berkeley

13. Victim Profile Isolated (physically and linguistically) Lack Information Intimidated, Monitored Physically Threatened and Abused Emotionally Manipulated Vulnerable populations

14. What are the Signs? Being Controlled Lack of knowledge of the local community Health Issues Work Conditions

16. Frontline health providers play an important role in identifying and helping trafficking victims

17. Health Risk Factors Inhumane living conditions Dangerous workplace conditions Poor sanitation& personal hygiene Physical and emotional abuse Inadequate nutrition Lack of quality medical care

18. Health Issues Associated with Victims of Human Trafficking STDs, botched or unsafe abortions Infections or mutilations caused by “home” medical procedures Chronic back, hearing, cardiovascular or respiratory problems Weak eyes and other eye problems Malnourishment and serious dental problems

19. Health Issues Associated with Victims of Human Trafficking Infectious diseases like tuberculosis Undetected or untreated diseases, such as diabetes or cancer Bruises, scars, “branding” and other signs of physical abuse and torture Substance abuse problems or addictions Psychological trauma

20. Video

21. Child Sex Trafficking • Many terms used to define the problem • Child/adolescent prostitution • Child sex trafficking • Commercial sexual exploitation of children (CSEC) = commercial sexual exploitation in which the exploited individual is a minor <18yo, and includes survival sex.

22. CSEC includes: Commercial • Street prostitution • Pornography • Stripping • Erotic/nude massage • Escort Services • Phone sex lines • Private parties • Gang-based prostitution • Interfamilial pimping • Forms of Internet-based exploitation SURVIVAL SEX

23. Epidemiology • Global—1.2 million children are trafficked worldwide year (UNICEF) • US- estimated 300,000 children are at risk for commercial sexual exploitation (US DOJ) • Estimated 200,000 incidents of sexual exploitation of minors occur each year in the US (Shared Hope International)

24. Epidemiology • Multiple studies estimate that 70-90% of sexually exploited youth have a history of sexual abuse

25. Cycles of Violence and Child Trafficking

27. Pathways to CSEC

28. Pathways to Entry • Parents selling children • Violence or forced by family • Kidnapping • Seduction/coercion • False advertising for “modeling” “acting” and “dancing” • Peer recruitment • Internet enticement through chat rooms/profile sharing

30. Recruiters (pimps) • Come from families, “friends” others in group homes, criminal networks (gangs, drug dealers) • Online from social networking

31. Recruiters pattern of behaviors • Manipulation • Create and illusion of family structure • Becomes role model/parent figure • Different types • Boyfriend • Business man • Guerilla (severe abuse usually associated w/ this type)

32. Red Flags for CSEC • Truancy of stops going to school • Sudden changes in appearance (nails, hair, clothing) • Has access to cash (taking friends shopping, out to eat) • h/o arrest for drug possession or sale, theft, possession of weapons, or prostitution • Older boyfriend

33. Red Flags for CSEC • Mental Health Symptoms • Severe PTSD, anxiety, other traumatic sxs e.g. disassociation • AWOL from group homes • h/o sexual abuse and/or DV • Early sexual initiation and/or knowing a great deal about sex • Acting more mature than age

34. Symptoms of CSEC • New definition of self/self worth • Emotional attachments to perpetrators, desire to protect perps • Addicted to the “life” and often takes several times to leave (estimates are average of 6 times) • Ego boosts from tricks/customers • Relates to all men in a sexual way and as potential tricks.

35. Stockholm Syndrome/Trauma Bonds • Criteria for Stockholm Syndrome • The presence of a perceived threat to one’s physical or psychological survival and the belief that the abuser would carry out the threat. • The presence of a perceived small kindness from the abuser to the victim • Isolation for perspectives other than those of the abuser • The perceived inability to escape the situation

36. Stockholm Syndrome/Trauma Bonds • How is it displayed • Positive feeling by the victim towards the abuser • Negative feelings by the victim toward family, friends, or authorities trying to help/rescue the victim • Support of the abuser’s reasons and behaviors • Positive feelings by the abuser toward the • Supportive behaviors by the victim at time HELPING the abuser

37. Health Implications • High rates exposure to STI’s and acquisition to STI’s including Hep C and HIV • High rates abnl PAP • High rates UTI • Pregnancy/infertility • Physical injuries of abuse (fractures, lacerations, head trauma, organ trauma etc) • Homicide

38. Behavior/ Substance Abuse Implications • Severe Depression • De-sensitized to violence • Self-sabotage drops out of programs helping and returns to pimp • Lack of trust in adults • High levels of shame • High levels of substance use esp. addictive drugs (can switch from exchanging sex for money to sex for drugs)

42. How CSEC interfaces w/ health care providers • Will use cases to demonstrate: • Type of visits for medical care/evaluation • Disclosure how it occurs • Issues/Successes • Common Themes • Signs and symptoms • Areas for prevention/intervention

43. Different Venues for Health Care Provider Interactions • Can occur in ANY HEALTH CARE SETTING! • 3 COMMON settings • Urgent Care/ED and Family Planning • Primary Care • Sexual Assault Examiner

44. Populations at “RISK” • The “underserved” populations • Foster care youth • Institutionalized youth • Incarcerated youth • Immigrant youth • Homeless/runway youth • GLBT Youth • Disabled, developmental delay

45. ED/Urgent Care/Reproductive Health Provider • CSEC often will come in to address acute medical or reproductive health needs • Trafficker will want victim to be medically treated in urgent/quick manner • many commercial sex workers including <18yo need FP services

46. Urgent/ED Reproductive Care Case 19 you woman presenting for 1st visit for STI evaluation. • Discloses on intake form she works as an “escort” • Admitted to sex work since 16yo after her mother died and didn’t want to live w/ father who was an alcoholic • Dx’d w/ HSV and later Chlamydia • h/o alcoholism (how she “coped” w/ being an escort) • h/o Family DV

47. Urgent/ED/Reproductive Care Issues • Fear of leaving sex work due to sex trafficker (pimp) • Missed opportunities (? CPS involvement/school involvement) when victims first enter into sex work • STI’s difficult to f/u and treat (esp. partners) and high risk for HIV and other STI’s • Lack of protocols in how to help these patients particularly in leaving sex work in this setting. • Lack of primary care knowledge and ability to refer to primary care counseling (e.g. therapy and alcohol abuse)

48. Urgent /ED/Reproductive Care Success • Sexual History/forms can facilitate disclosure • “how many partner have you had sex with in the last year?” • “have you ever exchanged sex for money, drugs, housing, or food” • STI counseling and contraception discussed. • Drug and Alcohol treatment counseling resources given. • Confidentiality maintained (pt was trusting of clinical setting and followed up for future care)

49. PCP Case 16yo female for routine health evaluation • 16 y.o. first time seeing a PCP in >4 years. • Was in drug treatment program for methamphetamines, alcohol • Disclosed >100 sexual partners • Sex trafficking since 11yo • +h/o STI’s • +h/o child pornography • +h/o various living situations • +h/o family DV • Currently in foster care

50. PCP Issues in providing care: • Lack of protocols for the health care provider in caring for CSEC • Difficulty in gaining the trust in order to establish care for CSEC for both providers/and their clinical settings. • Barriers in disclosure due to reporting laws (pt aware of mandating reporting so didn’t disclose) • Communication w/ many agencies and coordinating care (foster care, drug treatment, therapists) especially for survivors of CSEC