Multi-Disciplinary Care for the Trafficked Victim

1. Multi-Disciplinary Care for the Trafficked Victim Clydette Powell, MD, MPH, FAAP Nov 2012

2. Learning Objectives Identify the key personnel with whom health care professionals (HCP) will interface in the process of care for a TIP victim - including law enforcement Develop an approach to referral services and the short- and long-term needs of trafficked victims. List the key forms of immigration relief available to victims, including T and U visas. Apply key lessons as an expert witness (as a health care professional) and how to use affidavits

3. Your team…. You will have to work with many different professionals when you work with trafficking victims. Although you are not expected to perform their functions, you are expected to understand how your role can complement theirs.

4. Who is on your team?

5. Preparedness…. before the need… trusted support persons range of assistance

6. Map out your potential partners

7. Community referrals • Know your local resources • Make a list of name and phone numbers to call. • Shelters and safe houses • Hotlines • Local clergy and other organizations

9. Hotline (USA) 1-888-3737-888

10. Referral scenarios

11. Four referral scenarios…. • urgent or imminent danger • referral possible • none, butpatient may come back • refused or unsafe

12. Emergency referral for… Altered consciousness Dehydration Recent fractures and lacerations Vaginal or rectal bleeding Abdominal pain Fever

13. Imminent danger • Ensure your own safety first! • Focus on the health of the patient; you may need to convince him/her AND the person with them that emergency care is essential

14. Take responsibility for your safety

15. If serious security threat…. Prepare in advance an alert system

16. When referral is possible… Priority needs of your patient Effects of referral Optionsand benefits

17. Inform patient and obtain consent • A voice in this decision • Help them make the best decision for themselves.

18. If no referral possible at the time but patient may come back… Maintain your professional role…. On the next visit, the patient may develop trust and request different assistance..

19. What if referral is not possible? Maximize the encounter to make as positive an impact on their health as possible.

20. When communicating information, be careful…. • Documents may be traced back • Put the information on a small piece of paper that can be hidden

21. Some words of wisdom regarding… Security risks Links to the protection system Contact with authorities and patient’s permission.

22. Short and long term needs

23. What are some of these?

24. Basic personal hygiene needs include… Abuse in custody and lack of clean facilities means that the female victims will need basic items – underwear, clothing, tampons, personal hygiene items. You can help provide some of these.

25. Long term needs of victims Mental and spiritual health counseling Assistance accessing documents Life skills training Financial management assistance and skills Job training Legal services and help navigating systems Permanent housing Childcare - victims may have children of their own Reunification with families or repatriation

26. Other services • Juvenile justice and detention centers • Child welfare and child protection services • Children of victims • Mental health and substance abuse programs

27. Part of the caring also includes… Helping the healing process through self-expression – through art, music, movement or dance, sports, picnics, celebrations, creative writing such poems and stories

28. What law enforcement wants you to know….

29. If you suspect a felony, you must report it to your local law enforcement agency International TIP victims should be reported to the Department of Homeland Security Domestic TIP victims should be reported to either local police or the FBI

30. Working with law enforcement • Investigating and building a case is a challenge • Victim’s willingness to cooperate • Victim mistrust • Witness testimony is crucial in prosecution as a criminal case.

31. What are the steps to follow? National and State Protocols for Sexual Assault Medical Forensic Examination Coordinate with other professionals to minimize repetitive questions (and re-traumatization)

32. Sexual Assault Response Team(SART ) Law enforcement Prosecutor Advocate Crime lab Children’s Service

33. A word of caution…. The patient can decline any or the entire exam, and we must support their decisions. Giving control back during the exam is vital for the healing to begin. Exams and evidence collection can be difficult, but done in a compassionate and respectful manner, they can help with the healing process.

34. Remember….. The body is the crime scene

35. What is court evidence? Patient’s history Written documentation Photo-documentation Clothing Photos of wounds (sharp/blunt/strangled) Foreign bodies Findings from blood/urine/emesis Vaginal and penile swabs; pubic hair

36. Documenting abuse Get the patient’s statement in their own words Don’t sanitize it Be able to paint a vivid picture for the jury if a trial ensues. These statement will demonstrate the actual severity if the patient recants or minimizes.

37. Photography tips • Get consent • A picture is worth a 1000 words • Photograph before cleaning or suturing • With and without a ruler • 90 degree angle • Indirect lighting

38. Legal protections for TIP victims

39. Forms of USA immigration relief for victims • Continued presence (CP) • T- non immigrant status • U non-immigrant status • Lawful permanent resident status

40. Benefits with Immigration Relief Legal status in the US Public benefits (food stamps, cash assistance, Medicaid, SSI) – only for those with T non-immigrant or CP status Work authorization T and U non-immigrants can bring some family members into the US

41. T and U Non-immigrant visas

42. You as the expert witness

43. Your new role You are not the doctor and the person is not your patient, unless you are providing care and treatment, with medical record support.

44. Testifying for a client (1) • Before the court date: • Discuss testimony with client’s attorney • Review your affidavit • During questioning: • Answer hostile questions courteously • Be clear about limits of expertise • If you don’t know the answer, say so

45. Testifying for a client (2) • Via telephone (most common): • Speak clearly and coherently • In court • Dress professionally • Don’t get ruffled

46. Proposed terms to use in the assessment • “Not consistent” • “Consistent” • “Highly consistent” • “Typical” • “Diagnostic”

47. What makes for a good witness or affidavit? Comments that don’t extend beyond strict facts No statements on the client’s credibility, unless appropriately contextualized Evidence that you tested for malingering Factual, non-emotional assessments (let the client be the drama in the case, not you) Diagrams, photos when appropriate No statements that say the life of the client will be endangered if they have to return to their country (up to the judge to decide that)

48. Some realities….

49. Systems are not perfect … Support services - staffing, experience, paper work Law enforcement - criminal justice outcomes versus protecting the victim (re-trauma) Bureaucracies and details Reality is much “messier”

50. Victims are not perfect either .…. “Imprisonment” by shelter systems and rules Fights Mental health states - cloud perspective Victims may still be working out issues (TBI, guilt, drugs, etc)