Hello everyone and welcome to today's webinar. I'm Bumi Dovey and I'll be your moderator for today's webinar. Before we begin, I'd like to note that we'll take questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. We're fortunate today to have today's webinar, A Gynecologist's Role in Identifying and Responding to Human Trafficking, presented by Dr. Julia Guinness-Mintan. Dr. Guinness-Mintan is a female pelvic medicine and reconstructive fellow in the Department of Obstetrics and Gynecology at Northwestern University. During her residency at New York Presbyterian, Weill Cornell, she founded the Survivor Clinic of New York City, a dedicated clinic for women who had experienced sexual violence, including trafficking, female general mutilation, and torture and war. To establish this clinic, Dr. Guinness-Mintan secured grant funding from ACOG and established partnerships with dozens of social service organizations and governmental agencies in New York City. During this time, she served on the board of the Heal Trafficking Network, a national organization of health care providers working on anti-trafficking efforts. Now in Chicago, she started the Erase Clinic, which is a multidisciplinary medical home for survivors of trafficking. She is currently co-chair of the American Women's Medical Association's Physicians Against Trafficking of Humans Committee and serves on the Cook County Human Trafficking Task Force, as well as the Health Care Subcommittee. She's on the American Hospital Association Task Force Against Human Trafficking. Dr. Guinness-Mintan has trained hundreds of health care professionals in identifying and responding to trafficking in health care settings. We're very excited for her presentation today. Thank you so much, Dr. Dave. I really appreciate the introduction and welcome everybody. I wanted to just start off and say that some of the content in this talk can be very shocking and sometimes traumatic, and so just a warning to everybody that, you know, some of the stories I tell can be a little bit triggering, so just watch out for those. I'm gonna skip over this first slide because Dr. Dave did such a great job of introducing me, and I wanted to really start and tell you a couple of stories of patients that I saw both at my time in New York and now here in Chicago. All of these are real stories of patients who came into either emergency rooms, labor and delivery, or outpatient clinics that we were seeing them in, and all of them had experienced human trafficking. And so I want to first start and tell you Jade's story. Jade is a 21-year-old who had come to the emergency room in New York complaining of headaches over the last week, but also a history of seizures. And when talking with Jade, she really gave a very unclear story about why she chose to come to the ER specifically that day. Her headache wasn't any worse than any other days. She hadn't experienced a seizure any time recently, and as we discussed her full history, it turned out that Jade also was aggravated sex, and it had some really sad obstetric outcomes. In fact, at the age of 13, she had been raped and got pregnant by her mom's boyfriend, and then later on at the age of 17, had another pregnancy by her boyfriend at that time. One of her children actually was in a foster care situation, and she had to give up custody of the others to her mother. And so as we talked with Jade, I think what was actually really clear is that her headaches and her seizures were probably not really pathologic, but instead sort of psychosomatic manifestations of a lot of trauma and stress over the course of her life. And as we talked with Jade, it actually became clear that the way that she was surviving these days was through commercial sex work, and she had a pimp who was managing her, you know, commercial sex exploits. We ended up getting Jade into law enforcement and social services networks, and a couple years later now, actually, Jade is doing really well and kind of graduated from a long-term rehabilitation home. But I think that the point of that story is really that sometimes people present with stories that are not typical of what you hear of human trafficking. They may not come in with STDs or ectopic pregnancies or, you know, vaginal bleeding and lacerations. Sometimes it's much more subtle, and so you really have to look at all of their organ systems as signs of potential stress. The next story I wanted to show you was Marina. Marina, I saw in residency. She was a 33-year-old who came in with an ectopic pregnancy. Very, you know, clear diagnosis in the emergency room. We took her to the OR to manage the ectopic, and when we pulled up her gown to start prepping her abdomen, we saw that she had a tattoo from hip to hip that said, property of, and then a man's name. And I turned to my resident who had examined her in the ER and said, you know, what do you think about this tattoo? And he basically said, well, I don't know. I mean, women get all kinds of things tattooed on them. I, you know, I don't pay attention. I don't ask. And so, you know, we did the case and woke her up in the recovery room, and when I spoke with Marina later, it turned out that she had actually been trafficked by the man whose name was tattooed on her for about 10 years. She had been out of the life for about two years now, and actually looking at other parts of her body, she had several other tattoos that he had placed there that she since then had been able to scrounge up the money to cover up. This one was a really large tattoo, and she couldn't afford to get a cover-up of it yet, but that was her goal. And so, you know, Marina was not actively in the life anymore. She was resilient on her own and had found her own escape sort of in spite of us. And, you know, I think that what's really important sometimes is that we may be seeing these patients not at the time of initial identification or where you could play an important role necessarily in their exit from the life, but sometimes it's about trauma-informed aftercare, you know, and the conversations that we had with Marina then were more about, you know, what her hopes were for her own fertility and for her control of her sexual health, which I think were really important to her at the time. And the last story I want to tell you is about Alexis, who I saw here in Chicago just a couple of months ago. Alexis had actually presented to a couple of emergency rooms affiliated with our hospital at Northwestern, and she was seen for a fractured ankle. In the urgent care note, it said that she came in about two weeks after she had fractured her ankle, and the x-ray clearly showed the fracture. She was given a boot to walk with and had an appointment with orthopedics. Well, Alexis never came back to her appointment with orthopedics, and she kept coming back to different urgent cares with the same pain, the same sort of presentation, and was never wearing the actual boot. And it took a couple of really committed and, I think, insightful physicians to realize that there must be something else going on with her. And, you know, when I spoke with them and we sort of worked out her case in the end, it turns out that Alexis has been processed all over Chicago for the last two years, and she broke her ankle when she was pushed down the stairs by her pimp. She was, you know, at the beginning of her quote-unquote shift for that night and had to continue working the rest of the night. And so after she broke her ankle, she crawled or walked as best she could to the rest of her day. And in the morning, I think she decided that at that point it wasn't worth it to go to any sort of emergency room or get help, and so she let that go for a couple of weeks and continued to try to work. And when the pain really got bad and she finally presented to an urgent care, she was really afraid because her pimp's mother is actually a physician who works within our health care system. And she was afraid that she would have access to her charge and would find out that maybe she was, you know, somewhere where she wasn't supposed to be. And so really the point of this story is to say that anybody could be involved in trafficking, you know, that as much as sometimes we think because of what we see on the news or, you know, we see in movies that it's limited to certain demographics or socioeconomic groups, it really isn't. You know, she really delayed her presentation to care because she was afraid of someone within our own health care system. So what I want to really go over in this training session is to understand a little bit about both sex and labor trafficking. Most of the talk really is focused on sex trafficking because as gynecologists that is probably what we will see more of. But I do want everyone to realize that for every case of sex trafficking in the U.S., there's at least four cases of labor trafficking. And so we will cover a little bit about what labor trafficking looks like, and it's important to realize that somebody who is actually trafficked for their labor can also experience sexual violence. And somebody who is being sex trafficked can also be in forced labor of a different kind, and so they can oftentimes overlap. So let's just begin with a very important definition. So I think that many people confuse trafficking and smuggling, and there's this old, I think, sort of mentality that trafficking is this international problem that it has to do with moving people across borders. That is just smuggling. Trafficking is more complex than that. It can be the recruitment, transportation, transferring, or harboring of an individual by means of threat, coercion, or fraud for the purpose of either commercial sex, or forced labor, or domestic servitude, etc. So it's not just about moving somebody across state lines or across country lines. You know, the Uber driver, for example, who knowingly is working with a trafficking ring to bring women or men to their, you know, clients appointments, that person is a trafficker. The hotel owner who knows that trafficking is happening within his hotel and doesn't report it and works together with the traffickers is himself a trafficker. So it doesn't actually mean that you have to move anybody anywhere. The most important part about trafficking is the forced fraud or coercion part, and so we'll really go into more about how that occurs. Just a little bit in terms of the scope, and I want to make it very clear that the numbers here are probably both the tip of the iceberg and also very hazy in the way that they're sourced. So you'll see, if you look deeper into this world, lots of different numbers that over the years either become reinforced or completely overruled, and it's because this is an underground industry, and so our best numbers come from small studies. What we think we know is that about 40 or more million people are enslaved in some kind of either labor trafficking mostly or some form of commercial sex work globally. And if we were to give this talk a couple of years ago, in fact about five, six years ago, that number was actually 21 million. It's jumped to 40 million over the last couple of years as we look at a lot of the civil unrest and political violence that's happening around the world, and so right now with the number of refugees and migrants everywhere, the number of people who are being labor trafficked is huge. We think that somewhere between 14 and 17 thousand people are trafficked into the U.S. each year for the purpose of commercial sex. So those are the international, you know, commercial sex or sex trafficking numbers, but 77% of the cases that we see here in the U.S. are of domestic women. So this is not, you know, like Taken or any of those movies where it's about international predominant trafficking. We know that women and girls comprise the majority of forced labor victims, and that's really based on sort of Department of Labor statistics. When we look specifically at the National Human Trafficking Hotline, you'll see that the numbers really point more so in terms of men being the majority of labor victims and women being the majority of sex trafficking victims. It's a little bit hard to tell because a lot of the labor trafficking victims, it's based on their visa status, and oftentimes when women are in forced labor, it's domestic servitude, sort of, you know, nannies, home workers, and they are not here on a particular visa. So the numbers here are a little unclear. We do know that in 2017, the National Human Trafficking Hotline, which gets the majority of these calls and referrals, got at least 8,500 unique cases of human trafficking. Now, those are the ones that are reported to them, right? So that doesn't mean that that's how many exist. It's probably the tip of the iceberg, and we know that because 6,000 of those 8,500 were sex trafficking cases, and that's just because we've been talking about sex trafficking for so much longer in this country, and so people are much more attuned to how to identify it and how to call the National Human Trafficking Hotline. Even more so, we know that somewhere around 100 to 300,000 children are at risk of trafficking just in the U.S. every year. That comes from the Center for Missing and Exploited Children, and it really has to do with the number of kids who are either in foster care homes, they're runaways or throwaways, and they are really high risk of human trafficking. We know that about three and a half percent of adolescents have ever exchanged sex for drugs or for money, and actually many of those youths were boys or they're trans individuals. Any adolescent that exchanges sex for anything, whether it's, you know, for drugs, for money, for shelter, etc., that is human trafficking. There is no such thing as volitional prostitution under the age of 18. We know that children are approached and solicited to engage in commercial sex within about 48 hours of running away from home. Traffickers are really good at finding vulnerable individuals, and they'll circle bus stops, shelters, after-school programs, and look for kids like this. It really happens within every race, within every ethnicity, oftentimes below the age of 15, just as young women are sort of entering adolescence and looking for that kind of love and connection and validation. And unfortunately, after they're recruited, we tend not to find them or recover them really for about two years. So shifting gears a little bit just to labor trafficking, I want to point this out in light of sort of recent discussions, obviously nationally, about immigration. When we look at labor trafficking, most of the time it occurs because of legitimate visas that we give out, but those visas are given through organizations, through companies that are not appropriately using their workforce. This is forced labor, it's fraudulent labor, it's coercive labor. So this is just over the course of two years, 2015 to 2017, the National Human Trafficking Hotline kept record of about 800 human trafficking victims who were confirmed as actual trafficking victims and who were here in this country on visas. So, you know, again, they're not being smuggled over the border, you know, in the middle of the night without any identification. They are here because we have let them in legitimately on visa status. 70% of the victims in the status set are men, mostly from Mexico, Guatemala, and the Philippines. And most of them are here on what are called H-2A or H-2B visas, and these are predominantly agricultural workers or temp workers, sometimes farming, animal husbandry, that sort of thing. You know, the U.S. gives out about a hundred to a hundred and fifty thousand of these visas every year, and sometimes they're given to companies that really do not have any kind of oversight or safe labor practices. The problem with these visas and what makes them so prone to trafficking is that the visas tie the workers to a single employer, and so the trafficker then in that organization can really coerce that employee and say that, you know, if they don't do the job they're supposed to do or if they, you know, try and get help from anybody, if they complain in any way, they'll lose their immigration status because they'll get fired from that job and their status here is tied to that job. This is just a map looking at the scope of just these H-2A agricultural visas here in the U.S. So you can see on the heat map that it happens everywhere. Obviously in places, you know, major cities on the East Coast and in the Midwest, we see a lot of it certainly close to, you know, LA and the southern portion of California as well, and anywhere where there's agriculture here in the U.S., we're getting calls about labor trafficking. So why is this so lucrative, right? Why does trafficking still exist in today's modern age? So it exists because really when you compare it to other illegal activity, things like selling drugs or selling arms, trafficking of humans is a lot more profitable and involves a lot less risk. So when you find a kilo of cocaine or you find a semi-automatic weapon, you can't blame that inanimate object. But when you find a human being, it's very easy to convict that person with prostitution, which is still a crime in our country today, right? Or to say that they entered the country illegally and therefore, or they've overstayed their visa, right? And therefore, there could be a criminal case. And so for traffickers, they offload a lot of their risk by engaging in human trafficking as opposed to the trafficking of arms or drugs. So we talked a little bit about at least this first part about immigration status and how that becomes a point of coercion or fraud for a number of undocumented workers. But recruitment debt and isolation is really big in this as well. So many migrant workers don't realize that in the United States, you're not actually allowed to ask for a fee for recruitment. And some companies will tell their workers that they have to pay an exorbitant recruitment fee in order to get the job. And so they'll borrow money at really high interest rates in their home country to pay that fee. And then they also pay for their visa. And finally, they get here and find that they owe their trafficker some insane amount of money and couldn't possibly ever pay that off. On top of that, they're also isolated. Oftentimes, agriculture work happens in really rural or sparsely populated areas, where the employees are far from anybody who speaks their language or identifies with them or any sort of community members. And there can very well be physical threats. The traffickers can use locks, armed guards, dogs to keep people in one space and to keep them quiet. In sex trafficking, the forced fraud and coercion looks a little bit different. Oftentimes, it's reinforced by a social stigma. And this is a quote from one trafficking survivor who basically said, you know, I feel like you walk home from work, and people are just starting their day around you. And they look at you, and they know what you do, right? And that being commercial sex work or prostitution. And the way they look at you, you feel as though you don't belong in this world. And so there's a social stigma around this work that really isolates people and makes it difficult to trust anybody and to ask for help. On top of that, there's a lot of physical and psychological abuse. And, you know, sex trafficking is propagated by repeated rapes, by verbal threats, physical abuse, a lot of lies about how that person might be surveilled. And then it's followed by love and kindness, right? So it's very similar to the cycles probably everyone has seen of domestic violence. People say that the most addictive high is the inconsistent high. And so, you know, when a trafficker, you know, has two or three good weeks with you, and you go on a real date, and you get, you know, some nice gift, and you feel like you're being loved, you keep looking for that possible high, you know, and if only you do a couple more dates tonight, if only you bring back a little bit more money for daddy, maybe he won't beat you tonight. And that kind of constant psychological abuse keeps them in the life. And the last point of force and fraud really is Stockholm Syndrome, right, or the love or need for the trafficker. Oftentimes, these relationships begin as romantic relationships. And you can imagine, I mean, these are oftentimes young women who are in their adolescent years, who, as we'll see, one of the risk factors is a history of domestic abuse. And they feel that they need somebody who loves them and will care for them. And so sometimes they rely on their trafficker, either as means of food or shelter or love. And that love sort of carries them through a lot of the really horrific acts that that person makes them do. So we know that one of the major risk factors is childhood sexual abuse. 70 to 90 percent of trafficking survivors have experienced that in their childhood. And we know that just having had child sexual abuse puts you at 28 times the risk to be arrested for quote unquote prostitution. Now, most prostitution is actually trafficking in some form or another, but nonetheless, certainly at higher risk. The foster care system is also a major risk factor. 85 percent of trafficked youth have been through the welfare system. And oftentimes, one of the biggest risk factors actually for recidivism back into the life after some sort of exit is going back into the foster care system. We know that LGBT youth are seven times more likely to engage in survival sex. And survival sex oftentimes can then turn into a trafficking situation. And that about half of transgender youth report some involvement in commercial sex work. And then lastly, psychiatric vulnerabilities. There was actually a really big case here in Chicago last year of a group of adolescent boys who all had some sort of cognitive delays or learning disabilities who were all being trafficked by the same man. He would bring them into a community health clinic about once a month to get STD testing. They all got bused in together. And it took a couple of months for the community health workers to realize that, you know, something was wrong, that these, you know, boys could not, they didn't have the verbal skills to really express what was happening to them, but they clearly had experienced some kind of trauma. And it turned out that they were all part of one trafficking ring. I think this quote is sort of self-explanatory, but basically, you know, this pimp who's now actually working with the National Human Trafficking Hotline would often say, you know, with the young girls, you promise them heaven and they'll follow you to hell. So who are these traffickers, right? I think that we often assume that a trafficker, a pimp, right, is, you know, some guy in like a fedora and a suit who, you know, looks like a cartoon figure of a pimp, right? They're usually not. They can be anyone, male or female. They can be that person's friend or relative or intimate partner. Oftentimes, especially if they're coming into a health care setting, they're not going to bring somebody who obviously looks suspicious. So I've had some of my colleagues who are in this work, you know, tell me stories like, you know, a woman comes in with somebody who says, oh, you know, I'm her minister and we're going to pray together because she's, you know, feeling so sick and I want to pray for her good health. Well, the minister, you know, is holding the Bible upside down and backwards, right? And it's really just people will come in claiming whatever roles in order to avoid suspicion. So where are people being recruited to particularly to engage in sex trafficking? Most often, it's by people they know. Friends, boyfriends, their family members, oftentimes at school or places like malls, parties, you know, anywhere where it's easy to pick out the vulnerable person. You know, I've heard some traffickers say, you know, it was very easy for me to figure out who to pick out of the crowd. It was the girl who had her eyes down, you know, who didn't want to look anybody in the face. The girl who had just gotten into a fight with her friend and she was about to leave the party and you could see that she was on the verge of tears and, you know, somebody who clearly looks like they're vulnerable and that a moment of love and attention can make or break that experience for them. We know that most recruitment actually today happens online through, you know, cyber kind of bullying or cyber like chat rooms in which, you know, people will target posts like this, like I hate my mom or I, you know, I hate school, I'm gonna drop out of school, you know, I hate my life. You know, again, this is a very clear sign for traffickers that this is somebody who, you know, wants love and attention and where they can jump in and provide that until they're ready to groom the person and turn them out. One last thing I would just want to point out before we move into some of the health outcomes is I think there's a common belief out there that if somebody consents to the first time that they exchange sex for money then it's not human trafficking or that if they're getting paid then it's not human trafficking. But the reality actually is that the initial consent obviously does not mean that all future sex acts are consensual and it actually has nothing to do with how this is viewed in law enforcement. And who gets to keep the money is not relevant to the crime. You know, money is only one way that somebody can be coerced into a particular act, but if there are other forms of physical fraud or abuse or coercion then the money is really irrelevant. I just wanted to point out, you know, probably everybody has heard a little bit about the SESTA acts and about how websites like Backpage, you know, have now been taken down and how great that is. And it is great because certainly Backpage was a really big player in how people were accessing commercial sex, but it doesn't mean that just because Backpage is taken down that there's no longer human trafficking in this country, right? It's just spread out to a number of other websites that are in fact harder to track. Law enforcement was actually getting very close to decoding a lot of the symbols and being able to track the phone numbers used on Backpage and creating these elaborate sort of national networks of trafficking. And actually now that Backpage has been taken down, it's getting a little bit harder to recover people. Okay, so why do we care about this, right? Why are any of you on this webinar? How is this a health issue? So it's a health issue in a number of ways. I just want to first go over how people who have been trafficked present in health care, and particularly some of the psychological effects and then we'll get into some of the physical effects and how you can identify this. So psychologically, anyone who's been trafficked will come in with a mixture of multiple severe traumas. You know, as we talked about, they oftentimes have early onset trauma such as childhood abuse and then chronic trauma as a result of their sexual exploitation and violence. And then on top of that, oftentimes they're traffickers also engaged in some kind of intimate partner violence with them and so there's this complete overlay of different levels. And so when that person is interacting with you, traumatic stress really evokes one of two emotions in people. They either feel sort of overwhelmed by it or completely numb to it and it just depends on that particular person's coping mechanism. But oftentimes if they feel that need to control others or to maintain control of their situation, they can appear to be really angry, abusive, demanding or if they're numb and kind of dissociated, then they're withdrawn, don't react to any sort of stimuli, to any kind of pain. And both of these types of patients are, as all of you know, really difficult to interact with sometimes. You know, the first is the difficult patient that just makes you not want to continue caring for them. And the other is the patient that's actually really easy to miss the trauma on because they seem so resilient and so, you know, in control. It's really important to understand, I think, that the kind of trauma that happens to people who are trafficked is different from other levels of trauma. So what this continuum shows is if you take something like a single impersonal event, and the example I always use is something like 9-11, right? If you were in New York on 9-11, you experienced a single very traumatic event, but you realized that it wasn't personally directed at you. And so the amount of psychological work that it takes to overcome that is really different from something that's a single interpersonal event. So, you know, you were raped, let's say, you know, while you're running through the park. So it's a single event, clearly very traumatic. But it is, you know, interpersonal, it was clearly directed at you. But you know, it's not going to repeat itself. Next up in line is this multiple interpersonal events with a single perpetrator. So this is, you know, women who experienced domestic violence repeatedly from their intimate partner. There are multiple events, they're clearly targeted just at you at the individual level by a single individual. And then you get these multiple interpersonal events with multiple perpetrators. And this is what most human trafficking victims experience. So clearly a number of acts of violence, but they really feel that they can't trust anyone because anybody could be the next perpetrator. It could be the guy down the street, the, you know, cop that tries to help them, the, you know, person in the emergency room, really anybody. And so the amount of psychological work that it takes to exit the life and to find, you know, some sort of trust and comfort with other people is very different for somebody who's lived that life. So when we look at what those psychological health outcomes look like, this is just one study. It's, you know, a number of years old at this point, but looking at about 200 female survivors of sex trafficking who were interviewed within two weeks of entering post-trafficking services. And you know, just as we sort of learned before, about 60% of them said that they had experienced pre-trafficking abuse. 95% of them experienced physical and sexual violence while trafficked. And they had multiple post-trafficking, both physical and psychological complaints. So 63% of them had 10 or more concurrent physical health problems. Many of them had PTSD, 40% had had suicidal ideation within the last seven days, 62% of them had some memory difficulties. And then when you look even broader at not just psychologic health, but injuries, cardiovascular, respiratory, gastrointestinal health, really the full review of systems, you can see that none of these are under 50%. So we know that trauma affects every organ system. And you know, of course, the psychiatric and sort of neurologic components are going to be really high here. A lot of these patients actually have traumatic brain injuries as well. But they also, you know, will complain with palpitations and shortness of breath and irritable bowel. They have, you know, mess mouth from the substance abuse that has been forced on them, etc, etc. So the health effects sort of span every system. This is another study, this is from Lederer and Wetzel, and they really looked at, again, the psychologic manifestations of this stress. So when looking at 106 women during their trafficking experience, you know, 54% of them had PTSD after 61%. When we look at attempted suicide, 40% while trafficked, 20% after. So really, really, really high rates. So the point of this slide really is to make sure that we're all aware that even though we're talking about oftentimes sex trafficking survivors, and we think of things like STDs and ectopic pregnancies, you know, trauma, a lot of times what they present with actually are untreated or poorly controlled medical conditions. You know, so this is just a series of 24 patients I took care of in New York. You can see, you know, 15 of them had major depressive disorder. Certainly some of them had, you know, terminations of undesired pregnancies, had substance abuse issues, you know, but seven of these 24 had things like diabetes and sickle cell disease and hypertension and were not getting the appropriate care for those conditions. And it's really important, I think, that when somebody doesn't present to care for a condition they know they have, right, or somebody is not taking their medications or appears noncompliant, to understand why it is that they're noncompliant, very often, it may not be human trafficking, it could be any other, you know, trauma or socioeconomic issue, but it's important to ask why that is. So we know that human trafficking victims definitely interact with the healthcare system. This is just one study from a couple of years ago looking at both labor and sex trafficking survivors. There was 173 survivors that responded to this survey, and this was primarily in New York City. 79% of them had been labor trafficked and 55% had been sex trafficked, and so it's actually really interesting to see that there is a lot of overlap sometimes, and so they don't fit into neat categories. 68% of them said that they had seen a survivor, or sorry, had seen a healthcare provider while trafficked, and actually there are other studies, and I'll show you this next one, where it can be anywhere from 68% to 88%, close to 90%, who interact with the healthcare system. The ones who did not see a physician often said that it was either due to inability to pay or they were afraid of the trauma that that person would inflict on them, or they were prevented by their trafficker or somebody else from seeing a healthcare provider. You can see that in this bar graph, you know, when you look at how many of them had seen an OBGYN, 25%, and emergency or urgent care provider, 55%. So certainly they're coming to our ERs, they're coming to our labor and delivery units. This is the other study I was referencing, and this is, you know, again, 88% had some contact with the healthcare provider while being trafficked, most of them in a hospital or ER setting. Okay, so I want to focus on this slide for a couple of minutes. This is just in terms of recognizing the signs, and a lot of this we've sort of talked about, and some of it may be really basic, but just to highlight a couple. When you look at a patient's history, so we talked about the untreated chronic conditions that somebody's not following up for and, you know, making sure to ask about that. Certainly things like multiple pregnancies with poor pregnancy outcomes, poor obstetric history or not getting prenatal care, frequent STIs, sometimes it's just a lack of knowledge about where they are or how they got there or who brought them there, or just inconsistencies in their story. I've, you know, had patients be identified because they tell me one story about how it is that they came to the ER, and then, you know, I go out to the waiting room and I talk to the person who brought them in and they tell me a very different story, you know, and then 10 minutes later they tell the medical student a different story. So those inconsistencies are really important to know and to ask about. Certainly anybody with a history of child abuse or domestic violence, I would routinely screen for human trafficking, and we'll talk about how to do that sort of screening or what to ask for. And then some of it just has to do with the, you know, street smarts of knowing about references, right, about the life, the game, the track, daddy, you know, et cetera. And when patients use that terminology to, you know, very calmly without any judgment to ask about that and to, you know, really get a better story. In terms of the physical signs, so we talked a little bit about late and acute presentation to care. Certainly in terms of gynecologic presentations, so, you know, vaginal lacerations, vaginal wall thinning, you know, rectal injuries, STDs, you know, I've had patients who've told me that, you know, because they can't take a week off during their menses to, you know, not be making money for their trafficker, they will put whatever they need to put into their vagina in order to, you know, continue to work. So that can be a dish sponge, it can be, you know, wadded up paper towels that then cause, you know, infections weeks later. I know one of our colleagues had come and given a talk to us last year in which she said that she saw somebody who had this circumferential laceration in the vagina all the way around the cervix from a cap from a shaving bottle that she had placed, you know, into the vagina to really kind of act as a cervical cap while she was menstruating. And then, you know, had intercourse with that in place and got this laceration. Other physical signs, so any kind of tattoo that is sexually explicit or has a name or a gang symbol or barcodes or dollar signs, you know, I routinely and I probably sound like a broken record to a lot of the people I work with, but I routinely ask everybody about their tattoos. And I think we're so used to seeing tattoos on everyone that we don't even think about them. But tattoos are very personal, private choices. And I think, you know, we ask all kinds of private questions of our patients. And there's certainly no reason why we shouldn't ask why they got a certain tattoo. Oftentimes traffickers will tattoo their names or their gang name or, you know, things that are financial like barcodes and dollar signs. I have been hearing a lot more recently that traffickers realize that we're doing a lot of training around this and that people are getting smarter about asking about tattoos. And so they've started actually implanting dog trackers instead of, you know, tattooing people. And so if you do have somebody who tells you that something's implanted in them, I wouldn't take that lightly. I actually would get an x-ray and make sure because we're coming up with more and more cases nationally of people having dog trackers. Other things, of course, like broken bones, concussions, traumatic brain injuries, or any injury to a protected area. So it's actually really hard to be injured on, you know, your inner thighs or on the neck or the inner part of the mouth. And so if people are presenting with those injuries and they give you some bogus story that doesn't quite make sense, I would really ask much more about that. And then the last thing has to do with behaviors. I think that of everything on this list, the most important is actually the last one. And that has to do with countertransference. So I don't think that you can really teach what a trauma survivor looks like or feels like, but I think you know it within yourself. So when you are talking to a particular patient and you feel, you know, you feel comfortable, you're confident, you're having a great conversation, you're counseling them, everything's going great. You feel like you're getting good feedback from them. And then you walk into the next room. And as you're talking with that patient, you feel suddenly anxious or really sad or you notice that your body language changes and you want to get out of that room. You're not sure who that other person is and why that person is making you feel so uncomfortable. And why is it that suddenly your counseling sounds really off, you know, and you don't feel sure of yourself. Oftentimes that's because your patient is feeling all those things. They're feeling fearful or anxious or depressed or really uncomfortable. And when you recognize that feeling in yourself, you should ask what it is about that interaction that actually makes the patient feel that way. Because oftentimes you'll uncover that there's something else that they want to be talking about. You know, of course, I think there's a lot of barriers to us getting involved in human trafficking identification. And some of them are external things, right, like lack of training, which hopefully now none of you have, you know, language barriers, handoffs, time, all of that, right. But what I really hope that we can overcome are internal barriers. And that number one is the healthcare provider's beliefs about choice. I think for too long, we have believed really that commercial sex work is a choice. And for a very small minority of people, it is, but I think that the default should be first to assume it's not and to rule out trafficking before assuming that it is. The other is that we often feel that social work is not our job, right, that we have social workers for that reason. And while it might be that, you know, you have a 24-hour social worker, and they're always available and eager to help, many hospitals don't. And sometimes outpatient offices don't. And you really need to feel that you can at least start that work until they can get into the right hands. And then the last is that difficult patient scenario. So I think that many of us, you know, have a really hard time with the trauma response, right, and that patient who's belligerent, who wants to control the situation, who is cursing at staff, who's noncompliant. No one wants to take care of that person, right? And so we all pull away, when in reality, I think we need to believe that people don't want to be that way. They're here in the healthcare system because they want help. They just don't necessarily know how to ask for help in a way that makes them feel comfortable. And so you have to assume that you actually do have power in that situation, right? You are in control of this healthcare setting. And to not feel threatened by that person, but to sort of lean in and make sure that you continue to help them. So what are some of the questions you can ask if you get a sense that maybe somebody's being trafficked, whether it's for labor or for sex? So one thing that I often like to ask is, you know, do you have a safe place to stay? Or do you know where you're going to be sleeping every night? I think the question about do you know where you're going to sleep every night is actually a really good screening tool, because you can ask that of anyone and not, you know, make people feel like you're judging them in some way. You can just say, you know, I asked this of everyone, just like I asked about, you know, do you have sex with men, women or both? You know, do you have a safe place to stay every night? Or do you know where that will be? I asked people, where do you work? And where do you live? Where do you sleep? You know, is this all one place? Tell me about your tattoo. How did you choose to get it? When did you get it? Did anyone help you to get it? Obviously, things like has anyone hit you or hurt you today or this week or this month? Has anyone forced you to do anything that you don't want to do? If they're foreign, right, what made you leave your home country? And oftentimes, actually, where I start from is I'll say, were you ever a victim of violence in your home country? Because many times immigrants are afraid to say that they've experienced any violence here. They're worried that saying anything bad about their employer or anything bad about the United States is going to somehow, you know, set them on a track to being deported. And so, but they're much more likely to talk about violence in their home country. And so I start and say, you know, were you ever a victim of violence there? And they'll say, Oh, yes, you know, the gangs in my town, etc, and I have to leave. And then I'll say, Okay, well, so how did you come to the US? And where are you staying now? Do you have a safe place to stay? What do you do for work? And then slowly sort of work around to the well, you know, are you being paid? How many hours are you working? Has anybody been holding your passport or, you know, telling you that you owe them a debt in order to go back to your home country, things like that. If you're asking specifically about sex trafficking, then don't be afraid of the real question because nobody is going to come to you and say, Hey, I'm a victim of sex trafficking, right? You have to specifically ask, you know, have you ever traded sex for money for drugs for food to avoid getting hurt? Right? Has anyone forced you to have sex so that they could make money? They're very sort of simple yes or no questions and don't rely on the person knowing anything about you know, what sex trafficking is. And then lastly, what do you do? Right? So number one is obviously to get that person alone and comfortable in talking with you. They're oftentimes not in the healthcare setting by themselves. They can't be trusted to do that. So they're there with, you know, either another male or female person who is watching them and watching their answers, or they have their phone with them and they are constantly texting, you know, while you're examining them, while you're talking to them, they're constantly on the phone with somebody telling them what it is that's happening and what they're telling you. So you need to get them alone from that source of influence. And then ask for need to know information only. This is not the time to find out, you know, exactly when they were abused as a child and what their mother or father did and how they ran away from home and how many people a night are they servicing, you know, it doesn't matter. You really just need to get enough information to help get them to the next sort of immediate safety and potentially to making a police report or, or getting into social services. You do need to tell them about your reporting obligations. And those may vary a little bit state to state. But what I can say nationally is, number one, anybody who is under the age of 18 that discloses that they are in any kind of commercial sex work is 100% is human trafficking and you are mandated to report that nationally. The way you report that would be through your local law enforcement. The best place to start is actually to call the National Human Trafficking Hotline and find out from them who the most appropriate local law enforcement is in your area. Because it's not always just, you know, calling 911 and talking to the beat cop who may or may not be human trafficking trained. For adults, your reporting obligations vary a little bit. But across all states, what's common is if you feel that that person is in your office or emergency room or labor delivery unit, whatever, if they are there as the result of a crime, then you can call law enforcement and report that crime. Now that crime can be, you know, human trafficking, that crime can be, you know, they were they were shot or they were abused or they were, you know, I don't know, forced to use substances against their will, whatever. But I would do that with your adult patient's consent, because they really know what is safest and best for them. And if you call law enforcement and you don't have a safety plan in place, it may actually make their situation much worse. So the other thing I would do is inquire about their immediate needs and safety. And here I just say consider a social admission. I think that we admit people for far less important things, for all kinds of bizarre diagnoses and pain control issues. And we don't think enough about psychological pain and how that can be an important admission diagnosis. So if you don't have a 24 hour social worker, or you're not really sure what's going on, but you sense that somebody is in immediate danger, don't, you know, feel like you need to come up with some immediate plan and discharge them. It is okay to, you know, consider a social admission for a couple of days while you work on, you know, how to get them someplace safe. I would discuss the benefits of disclosure, particularly with foreign trafficking survivors. So across the country, they are eligible for T&U visas, which will grant them permanent citizenship status in the US. And then in several states, Illinois being one of them, they're also eligible for restitution of funds. And this is actually for both sex and labor trafficking. So if they cooperate with law enforcement, then they will get back the money that they made for their trafficker. So I do think it's important that people understand that it's not just a, you know, moral or ethical reason to report that they actually can, in tangible ways, change the course of their life. The other thing I would do is just verbally provide the human trafficking hotline number. And that's, you know, for somebody who is not feeling that they're in a position to report right now, they can always call that number. You can also always call that number. So if the person, you know, leaves your office or your OR or your whatever, and you feel like there's still something there that makes you suspicious, you can always call that hotline and provide an anonymous tip. And then the last thing that I would just want to say is in terms of documentation. So you know, we're getting better and better at having local and national EMRs. And it's important that we document our suspicions about this, because we see that there are real health outcomes that come from trafficking. And so trafficking in and of itself needs to be a diagnosis and something that we can track as a patient moves from one healthcare system to another. So I would document in your notes and perhaps in a problem list or medical history or wherever it will be best seen, you know, what your suspicions are, what your conversation with that patient is. And you guys should all know that as of October 1st, there will be new ICD-10 codes for both labor and sexual exploitation. And so you should use these. And that will help us both for, you know, tracking the scope of the problem nationally so we can get better numbers than the ones that I showed you at the beginning of this talk. It'll also put a lot more resources financially, I hope, and research-wise into understanding what we can do in healthcare. And last but not least, I really want to say it's all well and good to have gone through this talk and to say, you know, this is how we identify it, and this is what we do, and here's all the numbers, and oh my gosh, there's all these great success stories. But, you know, the truth is that I've probably seen, and in talking with a number of my colleagues across the country who do this work, we've all seen probably 5% of the patients who we interact with that are being trafficked that we can, quote-unquote, rescue or recover in that first interaction. You know, most of the time when people exit a trafficking situation, it is of their own resilience. It's not because of us. And so we can either help them, or we can get in the way and re-traumatize them, or we can ignore them, right? But we are not always going to rescue them. And so I think it's important that we realize that we do the best that we can, but you're not going to win each one of these battles, and all you can do is just keep an open door and make it clear that that patient is always welcome back in your office or ER or wherever. So hopefully all of you have learned a little bit here. I'm happy, of course, to take any questions on this, and I just really want to encourage you all to be prepared to go out and teach others in your hospitals and your communities about how to recognize this, how to be there to comfort people, to assist people. You know, trafficking really is not just a law enforcement issue or a criminal justice issue. It is a public health issue, and we have to be on the forefront of helping to fight this battle. So thank you very much. I'm happy to take questions. Thank you very much, Dr. Guinness-Montan, for a very informative and eye-opening presentation. We have a few minutes for questions, which you can submit in the question box on the left-hand side of the window. I'll start with a couple of questions just from hearing your talk. You know, people are obviously reluctant to ask questions, especially when they feel nervous about what to say if someone were to actually divulge that they are a victim in this situation. Can you tell us a little bit about some of the most helpful things that you've said in the past when someone has divulged that they are a victim of sex trafficking, or what, you know, you alluded to some of the next helpful steps, but just a couple words of what can you say that would be helpful to that patient in that situation? Absolutely. So I think the first thing is to not look surprised or shocked. You know, somebody will immediately shut down if you look like you are, you know, helpless and really surprised. So the first thing I usually say is, thank you so much for telling me that. That must have been incredibly hard for you to say. And I'm so sorry that you're going through this, and I'm going to stay here and help you figure out what we're going to do next. And it's completely in your control what we do next. So I'll tell you what some of my obligations are. Sometimes I may need to involve law enforcement, but I'll tell you if I do. But regardless, we will, you know, work through this. And I have a number of resources here and a number of staff that I can call and, you know, help to, you know, do whatever is important for you to get out of this. Yeah. Thank you very much for saying that. I think that really illustrates how much, how important it is to put the control back in the patient's hand and not take away more control in a vulnerable situation. So it's really nice to hear you say those words and helpful, I think, to our audience. You mentioned trying to get the patient alone, especially when these pimps or people who are trafficking your patients are involved. I imagine that it's probably challenging to have the person who's supervising them leave the room. Have you found any strategies to be effective in trying to get your patient alone? So this is where I think a little bit of creative fibbing is allowed in medicine. I think that you can find all kinds of ways to make sure that that patient is there by herself. So I've, you know, told people, well, this unit is on lockdown and everybody has to go out into the waiting room, you know, or I have to actually watch her urinate in order to know that she can go home safely from surgery. And so I'm going to take her into this private bathroom, you know, and you can't be in there or I have to do an x-ray. And so we're going to go into a room with radiation in it. I can't have you in that room, you know, just whatever, you know, creative ways you can find to get them alone. Good. Good. I think that that was an incredible presentation, one that's benefited our audience greatly. Thank you very, very much, Dr. Guinness-Mintan, and I hope everyone learned a lot from today's webinar. Just a reminder, our next webinar will be on PEXI, which will be presented by Dr. Barry Ridgeway on September 12th. And thanks again to Dr. Guinness-Mintan for a really informative talk. Thank you very much, Dr. Dave.

Dr. Julia Guinness-Mintan

gynecologist

human trafficking

identifying

responding

prevalence

types

risk factors

psychological health effects

physical health effects