Recognizing Human Trafficking: Guidelines for Health Care Providers by Safe Horizon

This training tool was developed for and in collaboration with the New York City Mayor’s Office Survivors of Human Exploitation Working Group.

Note to the Audience Human Trafficking is modern day slavery. The impact on the health and wellbeing of the men, women and children who are the victims of this crime is serious and long lasting. Developing a public health response to this issue is a critical step to ensure that survivors are identified and receive proper care and support. “Recognizing Human Trafficking: Guidelines for Health Care Providers” is a power point presentation intended to be used as an introduction for medical professionals who may come into contact with victims of human trafficking in the context of their daily practice. The slides describe numerous trafficking indicators which will help the professional both to identify and appropriately respond to the victims they may encounter. Victims of human trafficking have often been subjected to severe and complex forms of interpersonal trauma that can have an effect on the way that victims interact with medical professionals. The trafficking information set out in this presentation has been put together with the health professional in mind. However it is by no means exhaustive. To make the best use of this presentation, we recommend that health care providers meet with an anti-trafficking service provider or expert to tailor and facilitate trainings that address the specialized needs of the staff.

Human Trafficking Trafficking is the practice of exploiting adults and children for use as commodities in conditions of sexual and labor servitude. Tactics used by recruiters, traffickers and their associates are often the same tactics used by batterers and can mirror dynamics of domestic violence. Trafficking is not limited to formal work sectors. It can occur wherever there is work.

People are trafficked for many kinds of work and sexual exploitation Debt Bondage Sex Industry Domestic Labor Agricultural Work Restaurant Work Factory Labor Commercial Sex Acts Construction

Photo: Kay Chernush for U.S. State Department Traffickers often accompany victims at all times and can be: Friends/Family/Romantic partners Sex industry managers and “Pimps” US and International government employers –e.g. Diplomats Legitimate employers –e.g. Households with domestic workers

Trafficked persons are: Labor Trafficked Adults US Citizens Transgender MaleSex Trafficked Foreign nationals Youth/minors Female

Source: Freedom Network Training Institute Elements of human trafficking Recruiting OR Harboring OR Moving OR Obtaining 1 PROCESS by Force OR Fraud OR Coercion* 2 MEANS For the purposes of Involuntary Servitude OR Debt Bondage OR Slavery OR Commercial Sex Acts 3 END *Minors involved in commercial sex do not need to prove force, fraud, or coercion.

Common red flags in health care settings Environmental/ Situational Suspicious employment situation Dependence on “friend” or co-worker to answer questions Abusive relationships Verbal/Emotional/ Psychological Providing health provider with contradictory information Suicidality, depression Fearfulness, anxiety, trauma symptoms Physical Untreated injuries, explanations inconsistent with injuries Multiple STIs or abortions Evidence of sexual abuse

Common red flags in health care settings (continued…) Medical Indicators: Delayed medical care Headaches Fatigue Abdominal Pain Back pain Severe/untreated dental problems High blood pressure Malnourishment Drug or alcohol addiction

Common red flags in health care settings (continued…) Trauma Indicators: Unusual reactions to gynecological or breast exam (appearing fearful, screaming, sobbing, tensing up as if expecting intense pain, hyper-ventilating, fainting, going totally limp) Unusual reactions to disrobing in doctor’s office (trembling, sweating, stomach upset) Sexualized behavior or seductiveness, particularly in a child (seeking inappropriate proximity to nurse or doctor)

Common red flags in health care settings (continued…) Trauma Indicators: Flinching or jerking away from contact Lack of responsiveness (appearing checked out as if in another place, not responding to verbal prompts or name) Confused, having difficulty paying attention

Common red flags (continued…) Special Considerations for Minors: Involved in commercial sex industry Runaway/ homeless youth Abusive relationships

Survivors’ trauma and situation impacts medical assessment Fears consequences of identifying as victim: retaliation by trafficker - especially common are threats made against family members or loved ones deportation (foreign national) social services interventions (especially for youth who previously experienced abuse or harassment in foster care placements) In crisis mode Trouble recounting history/details May not self-identify as victim Loyalty to trafficker(s) Cultural/language barriers Mistrust of health professionals Limited understanding of rights

Best practices when interviewing a trafficked person Use the same words the patient is using and don’t correct them, especially as it refers to their relationships and situation. Be open to unfamiliar narratives and stories. Use your authority to create a safe space for talking: Always speak with your patient privately. Always use professional interpreter services when a language barrier exists. DO NOT rely on a friend or associate of the patient if interpretation services are required. Use a trauma-informed, non-judgmental approach when interviewing patients.

Recommended line of inquiry Excerpted from Caring for Trafficked Persons Handbook, IOM, July 2009 and Domestic Violence Assessment Guide, Family Violence Prevention Fund, Traffickers often prevent trafficked persons from receiving regular medical care. However, trafficked persons commonly find themselves in the Emergency Room when injury or illness escalates to the point of becoming life-threatening. Ask simple, direct questions such as: Are you in a personal or work relationship with a person who physically harms or threatens you? You seem to be in a hurry to leave. We are here to help you and it is important that you remain for treatment. What is making you feel anxious to leave right now? Have you been hurt while working on the job either by someone you work for or with?

If you think your patient is a victim of human trafficking Communicate messages of hope: You have rights. You are not alone and not to blame. You are entitled to services and help. Assess safety: Are you afraid to go home? Do you have a safe place to stay? What would happen if you didn’t return to your work site/residence this evening? Make referrals: Connect your patient with the hospital social worker, or Connect your patient directly with an appropriate service provider

If an identified patient is not ready to accept your help… Validate/normalize their feelings: Reassure them that they have the choice not to accept your help at that time. Provide information: Many trafficked persons will seek assistance for their situation when they feel safe and able to do so. Tell your patient where they can go for help in the future (i.e. return to the clinic). Make sure to communicate options verbally since traffickers are likely to destroy written instructions if they are found.

If you think your patient is a victim continued… Do not try to rescue the patient. Do not ask about the patient’s immigration status. Do not contact authorities without patient’s permission (unless mandated to do so). Do not make promises you can’t keep. Provide the patient with contact information for a social service agency or call 311.

Safe Horizon services for trafficked persons Social Services –Access basic needs and benefits, health care, housing, education –Safety Planning –Interpretation Legal Services –Rights-based education –Immigration assistance (where non U.S. Citizen) –Criminal Justice Advocacy and Support

Services for trafficked youth available through Safe Horizon’s Streetwork Project Street outreach Drop-in centers Emergency shelter Drug counseling & referrals On-site medical help On-site psychiatric help Computer access Meals & food pantry Showers & laundry Wellness counseling & services Syringe exchange Overdose prevention training Low-threshold buprenorphine assessment & treatment Hygiene supplies Safer sex supplies HIV testing and counseling Groups

Referrals Safe Horizon Adults:Youth: Anti-Trafficking ProgramStreetwork Project Comprehensive Provider Directory human_trafficking_services_resource_directory.pdf

References Human Trafficking Services Resource Directory. ng_services_resource_directory.pdf Caring for Trafficked Persons Handbook, IOM, July Toolkit to Combat Trafficking in Persons, Global Programme against Trafficking in Human Beings United Nations Office on Drugs and Crime, First Aid Kit for Use by Law Enforcement First Responders in Addressing Human Trafficking, UN GIFT Global Initiative to Fight Human Trafficking. Domestic Violence Assessment Guide, Family Violence Prevention Fund, 2008.