All right. Well, welcome, everyone. My name is Sarah Jimenez-Valdez. I am a project manager with the International Association of Forensic Nurses. Today's webinar is titled Human Trafficking and the Forensic Nurse, which is made possible with grant funds awarded by the Office of Victims of Crime for the SANE Program TTA Project. I'm going to ask that you bear with me for a few minutes so I can cover a few items before we do get started. I'll start with a few brief disclaimers, and if we could forward the slide. There we go. Thank you. So this first disclaimer is from our OVC grant, and this presentation was produced by the International Association of Forensic Nurses under the grant number you see listed on the screen. This grant was awarded by the Office for Victims of Crime, Office of Justice Programs, and the U.S. Department of Justice. The opinions, findings, and conclusions or recommendations that will be expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. And our next slide here is regarding our CE that is being offered today. Since there are 1.5 continuing education units being offered for today's presentation, we would like to note that the authors, presenters, and planning committee for this webinar have no relevant financial relationship with ineligible companies to disclose. Upon verifying attendance today, attending the course in its entirety, and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. Lastly, the International Association of Forensic Nurses is an accredited provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. That's quite a mouthful. For those live attendees, which are here with us today, you will receive an evaluation within a week of this presentation. All that said, we encourage you to use the Q&A feature, and Dr. Irwine is going to be able to answer some questions towards the end of the presentation today. The chat is also available for use if you have any needs, technical needs, or questions throughout as well. I would like to welcome our presenter for today as we go ahead and get started. We are joined by Dr. Sherita Irwine, who is a family nurse practitioner. She is also an assistant professor at the University of Tampa and works for the Crisis Center of Tampa Bay as a forensic nurse. Dr. Irwine completed her Bachelor of Science in Nursing at Marquette University, her Master of Science at South University, her DNP at South University as well, and her PhD at the University of Central Florida. She holds a national certification with the American Association of Nurse Practitioners and a certification as a sexual assault nurse examiner. Dr. Irwine works closely with professional organizations and community resources regarding the topics of human trafficking and vulnerable populations. She is the president of the Tampa Bay Advanced Practice Nurse Council Group, the Region III Director for FNPN, the Director of the Free Network, a board member for Shared Hope International, and a member of the Black Nurses Association. With that, we welcome Dr. Sherita Irwine. Thank you, Sarah, and thank you, Megan, for bringing me here today to be able to present on this topic. As you guys just saw with my history and my bio, this is a topic that I'm very passionate about and actually very excited to be able to continue to present in the community and answer any questions about what we're doing and where we're going. So, by the time we're done, guys, the participants, you guys will be able to identify risk factors associated with human trafficking. We want to touch briefly on adverse childhood experiences because a lot of those kids that we are seeing are now the adults or, shall we say, kids that were experiencing this. We're seeing as adults. We want to explain some of the barriers faced by the survivors of human trafficking and then to be able to describe the professional role in the prevention and mitigation of human trafficking. So, that's a lot that we'll be able to do. You'll see different levels of information, some of it geared just to give us that background on human trafficking and then about what are we doing now and what should we be doing next. How does it tie into our role as that forensic nurse? So, just a little bit of background and then we'll go into more detail. Pretty much every year, millions of men, women, and children are being trafficked worldwide. That includes right here in the United States. I know that many of you guys are aware of it, but I want to reinforce it because even today, as I come into many professional communities, people don't realize that human trafficking is really happening here, originating here, not just people being brought here. It can happen in any community. Victims can be of any age, sex, race, gender, nationality. The traffickers use many methods to lure the victims into that situation. It can be through violence, manipulation, false promises of well-paying jobs, which really highlights one of the trainings I recently did in Jamaica, where many people are trafficked here in Jamaica with promises of a high-paying job, and then that romantic relationship as they really, really look at vulnerable populations. So, as we look at this, the traffickers are looking for people who are easy targets, and that's for many reasons, but a lot of it focuses on that vulnerability. So, as we jump into it, let's talk about human trafficking and what it is. We look at the Trafficking and Victims Protection Act, which is a United Nations definition, and it defines human trafficking as the recruitment, the transportation, the transfer, and harboring of persons. This is done through force, fraud, and coercion, and basically, it's a crime where that basically, it's a crime where that trafficker exploits and profits at the expense of adults and children, compelling them to perform labor or engage in commercial sex. When we look at that definition, we look at the AMP model. That's like an action, a means, and a purpose, and it's taken from that to focus on what human trafficking is. When we look at the action, guys, that action looks at the recruitment, the transfer, and the harboring of people. We look at the means, going back to that force, that fraud, and that coercion, and all of this is being done for the purpose of exploitation, trafficking. With adults, all of those need to be there, that action, that means, and that purpose for it to be identified as human trafficking, but with children, they don't need the means. Children can't consent, so it's just that action and that purpose associated with it. It's important to remember that not all commercial sex or labor exploitation is trafficking, and I'll talk on that a little bit later. I try to sum that definition up so that it's really easy to understand. I look at it as human trafficking being a well-hidden human rights violation that's based in exploitation. It's a business, a billion-dollar industry, where that person's freedom is being stolen for profit. Vulnerable populations are being targeted, but realize that it could happen to anyone, because what creates that vulnerability? We'll talk about that a little bit. 50 million people are being trafficked worldwide, with 500,000 people being trafficked right here in the United States. What's making this so profitable is that it's the product. That product, which is a person, can be reused over and over again, 1, 5, 20 times all in one day, so think about that as we talk about human trafficking. So, yes, there are some myths associated with human trafficking. Many of the myths say, this is always a violent crime. It doesn't have to involve violence. It may just involve that manipulation, where that person's stuck in that trafficking arena. All trafficking does not involve commercial sex. We'll briefly talk about labor trafficking, and even though we focus a lot on sex trafficking, please recognize that labor trafficking is huge. The victims are not just foreign-born or poor individuals. The victims are born right here in the United States. Some of the victims that I have encountered are from well-to-do families, so identifying that that potentially is what's going on. And then we look at human trafficking. It can pretty much happen anywhere. It's basically, you know, once again, foreign-born personal persons, people in the United States. It's not just the legal industries. When you talk to people, they're like, yeah, the women or the girls. No, it's boys. It's men. It's the LBGT community, so it's not only women and girls. And human trafficking, it doesn't have to involve the movement or traveling or transport of people. It could be happening right from someone's own home. Yes, there can be the crossing of the state borders or national borders, but it can be trafficking right from a victim's home. Human trafficking victims will attempt to seek help when in public. No, they've been trained. They've been trained not to speak up. They've been manipulated. They've been coerced. They may not seek out help. And the traffickers can pretty much target anyone. Many times, it is someone known to that victim. So let's take a moment and talk about that white van. We don't have to raise our hands, but I'm going to raise mine. How many of you guys have heard that? Yes, trafficking happens. You got to watch out for that white van. Did you see down the street that white van sitting out there? Human trafficking was happening out of that van. So yes, many of you guys have heard about the white van. Yes, the white van is a myth. Yes, we have to identify that. Yes, human trafficking can happen out of a white van. But think about it. How many people do you know with a white van? How many utility workers are driving white vans? How many white vans are just workers? So can a white van be used? Yes, but so can any other van or car or truck. You know what I mean? So really thinking about when you hear that, you can smile and think, yes, there may be a white van, but that story that you're hearing all over the internet about that white van is probably just a story. So I'll mention here, and then again, and you've heard me mention it already, because, you know, who's the victim? Vulnerable populations. Well, what do we mean vulnerable populations? Basically, that person who may have low self-esteem, the person who's walking with their head down, that person who's sitting alone or looking needy, but it doesn't have to just be vulnerable populations. Men and women, adults and children, migrants, undocumented, and United States citizens, LGBTQIA communities, anyone with an addiction, nurses, doctors, lawyers, judges, pretty much anyone can be a human trafficking victim. I utilize that as an example in terms victim. I utilize that as an example and take this moment to talk about a friend of mine named June, and that's not her name, but she's a survivor of human trafficking. June was trafficked from her father. Her father was her trafficker. June was initially a victim of childhood sexual abuse. When June was old enough, she said, I'm not doing this anymore. So her father pretty much said, well, I've been waiting for this to happen. Now I'm going to show you what, you know, what we can do. All these people who you've been modeling in front of, because she was a model. She was from a prestigious community. She had been accepted into a local university. He told her that those people have all been waiting for this opportunity. So now I'm going to traffic you. So this person was trafficked from her home by her father out of a local high school and none of it was detected. He went to her doctor's appointments with her. He went to her appointments with her. He was right there and we all identified him as a perfect father. So recognizing that this person came from a well-to-do family and was trafficked from home and no one identified it. When I asked her, how did she get out of it? She pretty much said got married and then was able to identify that she had been a victim of trafficking, did not recognize it while she was in that situation. So that takes us to why do we train healthcare providers? We look at healthcare providers, guys, we are in that key position. We are the first line of defense. Many persons, many trafficking victims come to us. They come to us for the normal things, UTI, headache, maybe for some injuries, but many survivors had encounters with healthcare providers while being trafficked. Unfortunately, many of them identified that experience as negative. We were looked at or identified as not asking the right questions or basically not asking that perpetrator to leave the room or judging them. They felt judged when they encountered us. One of the research studies by Lederer and Wetzler, and you'll hear me mention it again, 22 to 88% approximately of survivors or victims of human trafficking were seen by healthcare providers. So we want to really reiterate that we are kind of that first line of defense. Basically, we need to be able to identify lack of knowledge regarding that recognition of signs and symptoms were identified as a potential problem. And then one that you guys and myself encounter often is that failure of that survivor to report or self-identify abuse when seeking care. So I like to integrate this one because when I did my DNP, my DNP was focused on education of the healthcare arena. And I've really spent the last few years, probably 10, going out and increasing awareness on what human trafficking is in general. But as I looked at it, I was like, okay, I'm talking about human trafficking and what it is, but my research was lacking the survivor's voice. So when I went back and completed my PhD, it was really focused on the reintegration of human trafficking survivors into the community, utilizing their voices. So with that interview or with that research, I did an interview of over 30 survivors of human trafficking. And yes, the majority of them, I'm going to say 28 out of 30, identified their experiences with healthcare providers as not so great. Some of the voices of the survivors were saying, so healthcare providers, I felt like they definitely failed me. If only they would have taken the time to ask me the right question or even ask me, hey, how are you feeling? Another person, another survivor, I was terrified of medical professionals. When I was in the emergency room, the first thing that doctors did was look in my arms for tracks. What they saw was a crack whore. So part of what we're doing now is we're trying to change that mentality of the healthcare providers when they're doing their assessment, increasing their comfort with the assessment. But many of you have probably encountered what I encounter, even when I come across and encounter a survivor, they don't identify. They maybe refuse the help that we're providing. But I want to reinforce here that many times it takes seven touch points, that initial touch point, seven more times before that survivor is ready to leave that trafficking arena for multiple reasons. And we can talk about that a little bit now and then later. But those reasons include, this is a person they may be in love with. This is the only family they know. I don't trust you. I don't know you. I've been tricked before. I'm not telling you anything. Or they've seen people be made an example of in front of them, do beatings, rapes, and death. So they have multiple reasons for not identifying or accepting the help at that first, second, third, or fourth touch point. So we have to stay strong and continue to provide our support. So we look at the scope and global impact of human trafficking. In the United States, there's both federal and state laws based on the United Nations definition of human trafficking, which is where we started. The federal legislation began in the year 2000. They developed the Trafficking and Victims Protection Act. It was the first comprehensive federal law designed to protect these victims of sex and labor trafficking. It was looking at the prosecution of the traffickers and the prevention of human trafficking in the United States and abroad. That 2000 document is updated every couple years to be able to identify and help facilitate how we manage trafficking survivors. That Trafficking and Victims Protection Act, once again, is protecting the victims. So we're concerned about protection. We're looking at prosecution of the traffickers themselves. And then the goal is further prevention of human trafficking. We also have to look at children under the age of 18. That's where many states have developed that safe harbor law. And that's to support and protect the children that are being trafficked. It also wanted to look at the inconsistencies in how these children are being treated. Because many times, a child, even adult of commercial sexual exploitation, they were picked up by law enforcement. But instead of being treated like that victim, they're being treated as criminals. So what we're doing there is we're focusing on treating that victim like a victim. So one of the survivors said, hey, I was picked up for prostitution and arrested, and treated like a criminal. So we want to be able to continue to educate and inform and how we can manage that. Because that decreases the trust of that survivor, that survivor in the legal system, as well as the health system. So it's making it harder for the identification. It's making it harder for us to treat them. So once again, many survivors of trafficking may not come forward due to a fear of being treated as a criminal. And this is based on their experience. So we want to encourage you, I encourage you to become familiar with your state law, so that you can at least be able to manage and educate that survivor as to what to expect. So we look at human trafficking as a global traffic or global threat to public health. And we look at it as because it's affecting people internationally, nationally, and locally. It's not just happening overseas, it's happening right here. We recognize that it impacts not just that individual, it's the family that's impacted, and the community. We look at the health outcomes. We look at the health outcomes. For many of you that may have encountered or come across or work with a survivor, you really, or you identify that they had those initial problems, the health outcomes in regards to physical and psychological. But we also have to recognize that they're long term. They're going to have these problems potentially throughout their life. So there's an increased cost to society based on the social services that are needed, as well as the judicial system, as we develop, implement laws, create task force, and be able to manage this problem. Over 50 million people we talked about were trafficked worldwide. This is highly profitable, as I said before, because the person can be used over and over again. 81% forced labor, 75% women and girls, 4.5 million exploited sexually with 25% children. We look at that, and when I think about the children, I think about the runaways. The runaways, we think, okay, they're out on the streets. Based on information that we have from the International Labor Organization, about one in seven of those children that are homeless or runaways are being targeted, maybe potentially brought into that human trafficking. And then we look at, again, that $150 billion in illegal profits, and that's really being based on this victim being used over and over again. So many of you guys have seen, okay, there is this number of California, Texas, and Florida being the top three in regards to human trafficking. This information comes from the trafficking hotline. I want to reinforce it's coming from a hotline. It's not the number that we're tallying of trafficking survivors. This is phone calls made into the trafficking hotline number, and this hotline receives about 150 to 200 calls a day. We look at these states that are listed, not the only states where trafficking is happening. It's just the top three states. These states are considered destination states, and that's because the weather, great weather, the tourism industry, transient population, and the high demand. So, trafficking would not exist if there was not a demand. So, as we look at ways to eradicate human trafficking, we have to look at ways for prosecution and pretty much decreasing that demand. Otherwise, it's going to always be here. So, we have to talk about technology because, yes, even during a pandemic, trafficking increased. The online recruitment increased significantly. We saw Facebook, 125% increase. Instagram, 95% increase. What I learned is that for many of these things, Instagram, Facebook, TikToks, there's different levels involved that I wasn't aware of where potentially people can buy and sell things. So, being familiar with technology and social media, recognizing that it is a breeding ground and that there's a lot of things going on in the dark areas of the technology and social media that you or I may not be aware of. I have to thank my children for that, for keeping me aware. So, as forensic nurses, we're seeing children and adults in our environment, definitely in my role at the crisis center, where these kids are being lured from someone, these adults are being lured from someone they met online. So these traffickers are luring young adults through tablets, through phones, through video game on consoles. So this is reinforcing that we educate in the community, the families, or any impact that we may have as we have different roles, we educate on, okay, if your children have these things, tablets, phones, video games, because we know that if they don't have them at home, they're going to go in the community and have access to them. But let's not have them in a room with a closed door. Let's not give this person an opportunity to come home and be unsupervised, or come into your home or the child's home and be unsupervised, recognizing that these traffickers typically invite this child or an adult from this group environment to a one-on-one environment using technology. Hey, let's meet up. Let's meet up in this specific room. Let's meet up in this private environment. And now they can entice them, they can entrap them, they can set up meeting places. So we have to look at how do we protect the children, the adults even, via technology and social media. I am still surprised at the number of persons that come forward who said that they met this person online and then this happened to them. So in the United States, there's some significant types of human trafficking that we see, and we just focus on these. It doesn't mean that there's not other things going on, but we see a lot of the commercial sexual exploitation, the commercial sexual exploitation of children. In the labor trafficking arena, we see services, domestic, agricultural, and factory. When we're looking at that labor and the services and domestic, those are the ones that are hard for us to see, because those are the ones that are in someone's home, pretty much providing services that we're not able to see. Factory-wise, in the last year, I know many of you have seen online where they have children working in factories in situations that are not safe. So it is happening right here in our own states. With sex trafficking, some of the key points that we see being the illicit massage and beauty, the escort services and strip clubs, and the pornography. And you're thinking, okay, so we've decided, or we have many states that have messages. They have to post that trafficking is illegal in these environments, but we know that it's still happening. So being aware and being nonjudgmental as we're encountering survivors from these environments because they may identify it as the only way in which they can make the money that they need, or they don't have a way out. I have to touch on the commercial sex industry, partially because I have young adult children. And even though we all in this room know that this is illegal, we have to recognize that commercial sex is indeed happening. It's not the same as the commercial sexual exploitation or human trafficking, because this person identifies as a sex worker, but they, you know, in difference with this commercial sexual exploitation, this sex worker can work independently. They identify as free agents. They perceive themselves as having choices and the freedom to take precautions, like the ability to use protection when they're having sex. So recognizing that in order to be able to talk to people about human trafficking, you have to at least be able to go to their level and say, yes, I do identify that there are some people who choose to be in the commercial sexual industry. But I also go to the next step, as many survivors have asked me, it's like, how many little girls do you know who said, I want to be a prostitute when I grew up? So we have to look at what happened to them, potentially that child or that young adult or that adult that helped them to identify that they wanted to be in that commercial sexual industry, if this is indeed their choice. So looking at some of the economic and social factors associated with human trafficking, I wanted to definitely touch on the rural, the tribal, and the cultural considerations, and then just briefly spend a little time with the intimate partner violence. So when we look at the effectively addressing these trafficking in the rural communities, we have to look at, you know, pretty much look at, you know, let's say creative solutions as forensic nurses or as nurses, we have to cross, we have to collaborate. So cross sector collaboration is really what I'm thinking of as I talk about this. Domestic violence, sexual assault providers, we can play that critical role in these collaborations, starting with education. Sometimes this victim doesn't identify as being a victim. We can basically promise or build these collaborations to address trafficking in these rural areas because we're bringing the knowledge. So we have to look at factors that create that vulnerability in that rural area. Trafficking in rural areas, these trafficking survivors, they find themselves isolated. They find themselves with few opportunities for employment. They have a lack of services. We look at the barriers. Many of these survivors in these rural communities, they're in small communities. So they're thinking, everybody's going to know my business. Everybody knows what everybody's up to in this small town. So these trafficked persons are often stigmatized. But we have to realize that trafficking is happening in the rural areas. Back to the men, the women, the children, especially the runaway and homeless youth, because where are they going to go? And some of these people may hold temporary visas. When I look at the temporary visas, many people who came with temporary visas did not expect to get drawn into the situation where their visas or their documents have been taken away. And suddenly they're being held to or accountable for things that they can't control. Some other factors contributing to this, prior abuse or neglect, creating that vulnerability. Substance use disorders, creating that vulnerability. And that death or economic challenges. Small community, inability to get a job, and hard to get out of the situation. So there's some unique barriers when we look at the rural community and identifying it. When we look at the tribal community, we look at if someone's been trafficked and may be able to get out of this situation, where do they go back to? They may have a harder time returning to their cultural environment due to the stigma. There may be stigma associated with the family if they let this person come back. So that may impact, as we're looking at the cultural considerations, the whole family. So this person may not be able to return home. And then we look at intimate partner violence. We know that if the person has been exposed to intimate partner violence, even as a child, this is going to impact them as an adult. We look at their lack of trust, their ability or looking, unfortunately, ending up in situations that are traumatic, unfortunately, still based on that initial trauma that they experienced. Human trafficking victims are commonly trafficked by an abusive or exploitive intimate partner. So when we're looking at that IPV, we have to potentially look at is there risk for human trafficking? This, once again, can be held accountable, you know, due to whatever situations they've gotten into, criminal, holding them in that situation. So who's at risk again? Vulnerable populations, ones with substance use concerns, runaway, homeless youths, unstable housing, mental health concerns and recent migrations. Pretty much can happen to anyone. And the same with the victims. We've touched on that educational level does not matter, high-end or low-end. Socioeconomic status, same thing, high-end or low-end. And especially vulnerable persons with disabilities or mental disorders. So we've talked about victims. We've talked about vulnerabilities, but where are they? Pretty much anywhere, guys. I already talked about my friend who went to school every day, and I was a nurse in the school for over 15 years. So think about the potential that we may have had for being able to identify this person who literally came to school every day, trafficked out of school until a hotel was built across the street from that school. And that was locally. But our victims are showing up in the emergency rooms and urgent care centers, primary care offices, dental offices, GYN offices and strip clubs, massage parlors and nail spas. So pretty much any environment that we are encountering, that person can show up. Keeping our mind open into what we see, and once again, as we're going to reinforce, nonjudgmental in regards to how we view that person and the situation in which they are in. So with millions of people being trafficked that I talked about, why can't we find them? A lack of awareness. Because we're talking about the community, and a lot of people in the community, if you go and talk about human trafficking, they're going to be like, yes, these people are being trafficked overseas, brought into the United States. Well, we just talked about many people being trafficked right here in the United States, homegrown. There's undocumented migrants, runaways, homeless youth, at-risk youth, but the traffickers are preying on that marginalized groups. So yes, the survivors are difficult to identify because many of you, as I said, may have come in contact with a victim of human trafficking, they don't identify it. But we also have to realize they may not ever have identified as being a victim. Think about a child who was trafficked from infancy versus, or like one of the persons who I interviewed, her earliest memory was from the age of two, pornography. So trafficked from infancy, going to church is what she said. She thought that's what everybody did after church. So we have to realize that they may not identify as being a victim. There's a lack of resources. There's the cultural barriers and language barriers. One of the presentations I did, a person came up to me afterwards and said, thank you for this presentation, because my family was trafficked when they did travel from cross-country to the United States, it was labor trafficking. The dad, I asked him, how did they get out of it? He said that the family learned the language eventually, but they were trafficked for many years, the whole family. So able to relieve or get out of the situation through knowledge. And then the safety concerns. It may not speak up because of safety concerns. So once again, reinforcing, you know, we as the healthcare providers are key in this identification and the survey that was done in 2016 by Christian Stracker et al, it basically talked about 163 or 73 participants were seen by healthcare providers while being trafficked. 53% or over 50% were seen in the ER. I worked in an urgent care and I did not identify any, but now I'm thinking back as to what potential cases may have been there. Why don't they leave? Isolated, right? They have been isolated from what they're comfortable with, but we have to identify that sometimes they do leave. They leave, they run, but they may get caught. So we basically, when they're getting caught, they're being identified and then made an example of, as I mentioned before. They sometimes return to trafficking willingly because it is hard to live outside of the arena. So many of the trafficker or trafficked persons that I interviewed, they returned multiple times. They said, I can't live out there. I can't eat. I can't drink. I don't have a place to live. There is no support. I don't have the medical care. And he was giving this to me, or she was, because the trafficker does not have to be a he. So I just say he, know that the trafficker can be anyone. We have that traumatic bond and that Stockholm syndrome. So you guys are familiar with that, where there's just that bond, a phenomenon that begins when they started getting that attention. They bonded with that trafficker. They sympathize and identify with their captor. They are making money for the family. This is their family. There's threats of exposure in some situations or threats to have the children taken away, being reported to law enforcement, to social services, and then the threats of bondage or violence. I'm sorry. The debt bondage, once again, we have that person who's working consistently, and even if they go to the doctor, now the amount that they owe continue to rise. So there's many things that are keeping that person in that situation, but we're really going to reinforce that, you know, they may have tried to leave and they ultimately have returned. Most of the survivors I interviewed had left and returned multiple times. So why don't they self-report? We've talked about this a little bit. They're held in captivity and isolation, locked in rooms and homes. But many times, guys, they're locked in mentally. It's not just behind a locked door. The majority of them were locked in mentally. There's the fear, the shame, the hopelessness, and the self-blame. They're blaming themselves. They can't see a way out. They ran away from home. They've been trained to lie. They basically don't trust the system in which they're in, and then they have that dependency because of that bond that we talked about. So what is needed? We have to look at that multidisciplinary team approach, that multidisciplinary team model, and I know that there's some facilities that are working on it. A lot of it goes back to funding, but we, the forensic nurse, we're in a key position as sexual assault nurse examiners. We have some of that baseline information, but we have to realize that this is a little bit different because this person of sexual assault may have been assaulted by one person. This person in the human trafficking arena has potentially been assaulted by many people over a period of time. But that multidisciplinary team involves forensic nurses, police department, sheriff's offices, attorneys, because we have to look at how do we get their records expunged? How do we support that survivor as they continue to move on? Social services, victim advocacy, and their mental health as we talk about the long-term mental health consequences that they have. Some of the barriers to care for us as that forensic nurse is that victim's failure to accept assistance, and that's where we get frustrated because we're like, we're here. We're here to support you. We're giving you these resources. They lack trust. They've been groomed to lack trust. They've been abandoned and abused multiple times. They're dependent on that trafficker and that fear. So we as that forensic nurse have to be patient. Once again, I've heard of a person who's in the middle of an exam, and this person literally, that survivor, that trafficked victim had to leave in the middle of a forensic exam to be able to go beyond the street and then return based on she couldn't afford to be missed. So there's a lack of trust. We look at the staffing. What is really needed? I think as literature is starting to show, if we have that environment where we can work collaboratively, that forensic nurse collaborating with that mental health support right on that spot, right in that moment, we could be effective. So in some environments like emergency rooms, integrating that health care provider, having that support, we might be able to make an impact. But those are some of the barriers. And it goes back to funding, financial support in the community. So let's talk just a little bit about children and human trafficking. So 26% of the world's trafficking victims or children are 25 to 26%. We talked briefly about one in seven US runaways were likely to be victims of sex trafficking, and that came from the National Center on Missing and Exploited Children. Of those, 88% of those were in social services or foster care when they ran. So we look at homelessness, runaways, foster cares, kids in the mall, guys, they're looking, they're being targeted in the malls, go in the malls next time you're there and see how many kids are roaming around. There's one victim that I worked with, basically, the survivor or the trafficker was manipulating her through, I'll take you to the mall, let's let you pick up this nice purse. This is your payment, you know, being with somebody. So this person we're looking at, what are they bringing home? Let's be cognizant. So it's pretty much happening at bus stops anywhere. Targeted by family, friends, intimate partners, and strangers, and once again, through the use of violence, threats, and death bondage. So 978 allegations of human trafficking were made in the Florida's welfare system. So we're looking at these children, once again, being identified from runaways. I think there's also more support that's needed in foster care because when we're grouping these kids together in this environment and with the trauma, we have to look at that separating ground for someone else to nab and pull this kid into trafficking. So some of the people who are trafficking are literally some of the kids in that environment. They're bringing others into it. They've been tasked with that job. Risk environments, the home environment, we look at adverse childhood experiences and prior abuse. And yes, some of it is from escaped civil conflict. We look at the physical, psychological, as well as the self-identity. That's the trauma of the trafficking. Out of the 30 victims that I had worked with, or survivors at that stage with my PhD, over 20, over 25 of them, so I'm going to say 75% continue to have identity issues, low self-esteem. One of the biggest questions that I consistently found is, I don't know who I am. I don't know how I fit in this new arena. Those are the people that we are encountering. So we have to take patience as we try to help them in regards to staying out. How can we help? Awareness, which is what we're talking about today. Competency and identifying and referring, which is what we're talking about today. Remembering to take care of ourselves because we are identifying and seeing persons who are staying in the situation. That is traumatic for us as a healthcare provider, the secondary trauma. So let's take a moment to talk just a little bit about adverse childhood experiences because once again, if you're seeing that adult, most of them have had that adverse childhood experience. What it is, is that potential traumatic event. So adverse childhood experiences are potentially traumatic events that occur in children under the age of 17. So that's that physical, that sexual, that emotional trauma, that abuse, physical neglect, family dysfunction, such as that intimate partner violence, that substance use disorder. ACEs have severe implications because they impact that physical and mental health of that youth, but it also goes into adulthood, having some short-term or long-term consequences into adulthood. ACEs are common. ACEs are costly. So we have to also remember that ACEs are preventable. So I do want to share this short video with you and then I'll continue on. So my first trafficker was my mother who started selling me to the landlord and the landlord was part of a pedophile ring. This all became very normal for me. When I reported it to my mom and she did nothing about it, I realized that nobody was going to ever do anything about this. So by the time I was nine years old, my behavior became so difficult and just outrageous for my mother to deal with and for schools and just in general. The emotional trauma of what I've been going through manifested in really extreme behavior problems. So I ended up in foster homes, eventually into group homes because even foster homes weren't well equipped to deal with a child like me. In group home, I was abused there by some of the older boys and one of them in particular started pimping me in the streets. So I've been pimp trafficked, familial trafficked, and then by the time I was 18 and I was on the streets on my own and had no pimp, I was survival sex and having to do whatever I could to survive in that space. So young men and boys and grown men who have experienced this, we shut down, we do not talk about this and we will overcompensate and become overly male, overly aggressive, overly violent and really disconnect from our emotions. Later on, you know, when I was being trafficked on the streets, there were times when I would come to the emergency room. I had broken ribs and I'd been raped by my trafficker because I didn't comply. I'm living on the streets. I'm dressed kind of dirty clothes. I obviously hadn't washed and nobody asked, how did this happen to you? They just, you know, saw me as one of those street kids, you know, who is part of the problem of society. The difficulty for healthcare workers is really challenging and you can't even really rely on just one red flag. Plenty of perfectly normal healthy kids may exhibit one red flag. It's multiple red flags that then begin to start to trigger, like we need to look deeper into this. I think ultimately what I'd like to leave people with is that if you don't know to look for something, you're never going to see it. So if you're not looking for boys as potential victims of trafficking, you're never going to find a boy. He could be sitting right in front of you. You're never going to even think about him being a possible victim of trafficking. I like using that video because it reminds us, just in case I ever forget, which I usually don't, that human trafficking is not just women, but it also reminds us of, think about that child. What did that person look like when they came into the emergency room? And I know I've said many times in my different jobs, but I was that emergency room nurse. I worked in an emergency room in a prominent neighborhood, and this was many years ago. And yes, the medical records or electronic records said, asking people, do you feel safe at home? I didn't feel comfortable asking that question many years ago, because these people are all in a great neighborhood. Why would I ask that question? We should feel comfortable asking that question of anyone. So really reinforcing how important it is to ask uncomfortable or difficult questions, no matter what that person looks like, and to try to establish that rapport. So yes, we know that there's a connection between child maltreatment and serious health outcomes. When we look at that exposure to one ACE versus that exposure to multiple ACEs, that's going to negatively impact that person, as we said in the initial slide, them into adulthood. The increase in ACEs, the more significant the impact that it's going to have on them. So that psychological as well as that physical impact is negative, and it becomes even worse with that piling up of ACEs. Some common ACEs that we see, foster care, welfare system, poverty or near poverty. So these are situations when they're likely to have three or more ACEs, reinforcing that that's stacking up against that person. Race and ethnicity, the Hispanic communities and non-Hispanic Black youth and children, we recognize that they have a higher incidence of ACEs. So these are the adults that we may be seeing. We have to ask about what happened in childhood, maybe not in that moment, but at some point as we continue to establish rapport, we have to look at what may have happened to get this person into this environment or situation in which they're in. So we also see increased ACEs with the prior sexual abuse, school level, grades, as well as the family support. So the increased vulnerabilities, increased number of ACEs, increasing our risk of human trafficking, tying that all together. So feeling comfortable, asking that uncomfortable question, even if it's adult, you know, have you had any of this happen in the past, any child maltreatment, anyone who's making you do something that you did not want to do, and then providing support based on the responses that you get, but feeling comfortable asking questions instead of thinking, oh, they're just being so rude. I'm not going to ask, I'm done talking to them, I'm exhausted. That's a defense mechanism that they may be using. So when we're looking at screening for human trafficking in children, this goes back to the little girl I was talking about in the mall. Do they have large amounts of cash, prepaid cards, or great purses, cell phone purses, or, you know, $100, $200 purses that they would not be able to afford? We look at, you know, why would this child have hotel keys and mobile phones like this? Go back to some of the basic human trafficking questions. Do they have ID if they're of age? They don't have ID. Who's holding onto that ID and why? Signs that they've been coached. They're giving you the generic answers. They're not speaking for themselves. They're letting someone else speak for them or looking across at that person in the room before they speak to you. And then we look at tattoos and branding, which is really hard because when I say children, we're really not talking just children. We're talking adolescents, but everybody has a tattoo. It could be a home tattoo or, you know, so everyone has tattoos almost. So that by itself isn't enough. We're looking at the branding though. Do they have this person's name all over them? Does it say daddy in a barcode? Yes, there's still barcodes and some of these barcodes are usable. I'm wondering if, you know, maybe QR codes are the next thing. Is that usable? So basically looking at things and, you know, reinforcing, you know, reinforcing your comfort in asking these questions. Do we push now? Do we ask important questions? Yes. Looking at the history. Is this child running away from home all the time? Are they basically in unstable housing? One of the survivors, her unstable house was a gang, a gang home with her brother. Family disconnects from family and friends. So that means potentially that trafficker is isolating them. Close connection with overly controlling adults. One of the children I've come in contact with, she's like, oh, all my friends are older. And I'm thinking, okay, well, she was homeless or not homeless. She was a runaway, a chronic runaway, but all my friends are older. I'm like, oh, older, like 18. She's like, oh, no, older, like 40. So having that conversation, asking these questions, regular unexplained school absences, this goes back to that collaboration that we have in the community. Because this one that I had talked to, this child that I talked to was a runaway who wasn't attending school, but she would have frequently attend school. She would go sometimes. School never let dad know that they had seen her in the last year. So there is a lack of connection, a lack of communication. We need to work as a team to be able to make a difference in some of those arenas. So yes, there are some screening tools out there to help identify trafficked persons. The screening tools are effective in helping to identify those at risk for trafficking. But we look at what happens next. That's what many of us encounter, that question, okay, I've screened them, they identified as trafficked, now what happens? So we recognize that positive screening identifies that person that is an elevated risk, but it doesn't necessarily confirm someone has been trafficked. So screening is good. Screening can identify risk. Screening can reinforce that those persons have been trafficked. And these are some of the tools that we use, the quick youth indicators, the short screen. But when we look at the tools, the inconsistent tools being used inconsistently within the facility, having inconsistent findings. So that reinforces that, yes, we need to look at how do we consistently find a tool that's used in most places, and what do we do once we've identified this person as being trafficked? That's one of the biggest things we have to do next. And then gaming and exploitation. So yes, online exploitation, we're looking at which apps and which games can be dangerous. How will I know when someone is a predator? So this person is attempting to develop trust with someone. So when we're talking to kids or persons that potentially have been trafficked, we're like, okay, if someone's calling you from a game or contacting you from a game or an app, you want to identify as, you know, are they trying to get you in a different room? So educating that family that yes, predators are coming through the games. And then reinforcing that social media is a commonplace for sex trafficking and exploitation, as this person takes the time, months, to develop a relationship with that victim, develop that trust. It's worth their time. So they're going to invest in that situation. So when we talk about some of the survivors that I interviewed, once again, one survivor discussed her history of childhood sex abuse by her parents. She described her earliest memory of abuse as starting at age five. She said, this is where they got the bright idea to have multiple guys come over and they taught me how to be ready. Another survivor with a history of childhood sexual abuse correlated her adverse childhood experiences to her low self-esteem, her increased vulnerabilities. Now she could see, I see this now. The reason why it was so easy to be recruited was because I was vulnerable, I was insecure. And even recently we saw in the news, guys, where a mother was utilizing her 15-year-old with the stepdad, having relationships with her to teach her to be ready for sexual encounters. That's still abuse. So obviously they're being prosecuted. That was recently in the news, but recognizing that those things are happening. And then we, once again, have to touch on labor trafficking, and it is just as important as the sex trafficking. We still have that same definition, illegal smuggling of people for the purposes of forced labor, bonded labor, involuntary child labor, and using the same forms of manipulation, lies, threats, violence, and coercions, and different industries. It can be within the United States. It can be outside of the United States. And one more short video just to really reinforce that. My name is Angela. I was born and raised in the Philippines, and I met my trafficker from a friend of a friend that there is a Filipino that lives in California, and they were looking for a caregiver. And then if I get here to the United States, she was going to help me to get my green card. And she's a woman, and that's why I guess I trusted her more. She's my own people, and she speaks the same language of me, as me. I thought she was a friend, because when I first got here, she even hugged me, and she told me that we're going to be a family. We're taking care of six elderly. We get up every day, start 4.30 in the morning, and go to bed like 10 or 11, and then every two hours, we have to get up and check our patient, because we have elderly patient that has dementia. I don't have a room in the facility, so I sleep on the floor in the hallways. There was a time that for six, eight months, we didn't get a day off. So we straight work for 16 or 18 hours a day. My trafficker told me that I have to work for her for 10 years. She told me that I owed her $12,000. And my trafficker told me that if I talk, they were going to call the police, and then they were going to call the immigration, and I don't have document to prove that I'm legal here. There was a time that I even feel like I'm going to kill myself. So I was rescued by a neighbor. My neighbor always talked to us, and he always asked me that if I had a day off. And I always said, yes, I did yesterday, and he always told me that, I saw you there yesterday. So one day, he handshaked my hand with a piece of paper, and he told me that this is my number, and if you need help, call me. Because I don't even know that there was a human trafficking. I thought, in my mind, human trafficking is only sex trafficking. I didn't know that human trafficking is also in labor. So before I start working in the facility, my trafficker and I went to the clinic to get a TB test and physical exam. Before we left the facility, my trafficker told me that, let me do the talking. You cannot see in my face that I was in trouble. In our culture, in the Philippines, we always smile, even though, you know, how bad the situation is, we always make the most out of it. But maybe that time, if there is a poster, they will tell you that if your working condition is this, then you need, you know, you could be, get help with that number. Maybe I could save that number, and I could reach out for help. Another video that I feel like is very impactful because she didn't realize labor trafficking existed. And when we look at labor trafficking, guys, it's happening where people are going into the homes, cleaning. We see it in the agricultural arena. But how many of you guys have seen people, kids, adults on the street selling things? That's a form of labor trafficking. Who are their traffickers? We have to identify that, yes, sometimes there's self-trafficking going on, but many times this person can't get picked up. They can't leave that corner or that area until they've sold a certain amount of things. And in the home environment, we don't know that trafficking is going on until that person is either seen by somebody or comes to our facility, and we're able to get that information. So really reinforcing the importance of us being cognizant and asking important, sometimes difficult questions. So that goes back to who engages in human trafficking. Yes, there's organizations, organized crimes, mom and pop, even the guerrillas. But let's go back to organized crime. Yes, we're seeing gangs significantly being part of the organization because we talked about it being a billion-dollar industry. But we have to look at the mom and pop situations. We've seen the news. We've seen the recent stings in regards to people we would least expect to be a part of that trafficking, from teachers to, once again, healthcare professionals and persons in the legal arena. Family members, I'm pretty sure I saved a slide on there. When I look at family members, that was an incidental finding for me when I did my research. And it was recently done. It's just been done in the last few years. Over 50% of the survivors I interviewed were trafficked by family members. I did not expect that one. So it's a learning environment for us as we continue to go along. And yes, the guerrilla, the force, the kidnapping, the drugs, the alcohol. When we look at that and we think about the drugs and alcohol associated with it, sometimes these survivors are victims of trafficking. They're forced to take the drugs and alcohol to be able to be a part of this, but sometimes they take it to cope with the situation in which they're in. Then the Romeo, declarations of love, gifts, and false promises. That Romeo is the one who takes the time to get that person's trust. They build it. They give them gifts. They tell them they're going to help them get this job. They're going to sing. They're going to be this actress that they want to be. And soon this dream that they have becomes a nightmare. And that goes back to now, why did they stay? And we look at feeling guilt, feeling stigmatized, feeling judged. So we look at some of the methods of control and force. We look at this person. They potentially may have been put in a compromising situation. So being in that trafficking arena, they've been told under drugs, under alcohol, or been involved in stealing, soliciting other people. So that information is used against them, used to keep them in that situation, used as threats, and that's how they get them in that situation and keep them there. We can have the kidnapping, the threats of harm, the kidnapping and potential pulling out their children or other family members, the rapes, the torture, and the hitting. So any of these can be used as methods of control and force them to stay in this situation, which ties into that next slide of threats of harm to them, their family, their friends. Controller finances, because if you leave the situation, what are you going to do? Punishment of people in front of the survivor to use them as an example, and then reinforcing what I said about getting them involved in these criminal activities, shoplifting, selling drugs. Now, they can basically turn you in if you try to leave. So you have that being held against you. So literature supported some of my findings with over 50% of child trafficking experiences being facilitated by family members or caregivers. This is unique. It's difficult to identify because this person does not recognize that they're being trafficked. They've normalized it. The traumatic impact is severe. These are the people that they trust and not realizing how they can get out of it. Few resources have been developed because first, we're not identifying that it's happening. We look at, okay, where do we bring education? If we bring education into the school system, maybe that'll help that person be able to identify that this is not the norm because we go back to, yes, this has been normalized. So healthcare providers' engagement with children who have been exploited by their family members, we have to look at how do we feel comfortable separating that child, asking questions regarding what's going on, and then feeling comfortable with the responses that we receive. And we all know no matter what environment we're in, we're mandatory reporters. It's important as we're talking to that child that we let them know that some information that they're sharing with us can't be held as confidential based on being mandatory reporters. So that way, when you have to share this information, you're not breaking that trust that they have and that bond that you may have connected or created as you've met with them multiple times or over and over again. So realizing that this is indeed a thing, and it's really impacting how we are able to care for and identify the survivors, and remember those children are the adults that we're encountering. So key indicators of human trafficking. This is that person similar to the child trafficking, but that person doesn't have identification or travel documents, feeling comfortable asking them, where are they? And we're going to look at this, guys, in a conversational manner. So we're all able to have a conversation. You don't have an ID, I'm sorry, where is it? Who has it? And why aren't you carrying it? They may present with some unusual patterns of bruising, burns, tattoos, or scars, asking about them. Instead of thinking, oh, I'm too embarrassed to ask or it's not any of my business or whatever, one of the survivors I interviewed, and this is a little graphic, so I'm going to apologize, and if you need any support afterwards, I usually start every presentation saying, make sure you have support systems, but the role we play in helps us to have those support systems. But this survivor didn't have nipples. She said every time she came to the healthcare arena, she had EKG, she had EEG, she had multiple times where she was assessed, we failed to ask her why she didn't have nipples. Her trafficker had removed them. So feeling comfortable in these difficult situations, things that we don't think about, doing our physical assessment, asking the questions. Person missing or broken teeth, injuries to heads, black eyes, looking for that traumatic brain injury, looking at fractures, potential dislocations, listening to the story that we're being told or the history, and then being able to further ask questions based on what we need to know, not necessarily what we want to know. There's many times, there's so many more questions I want to ask, but what do I need to know in this situation? Looking at that person who presents with frequent pregnancies or miscarriage, miscarriages caused by that potential abuse, identifying, once again, I worked in the emergency room, and I looked at that person with the frequent STIs as, oh, my God, here she comes again with those PIDs, and I never said it, but that's that implicit bias. Those are some of the things we're thinking. Recognize your implicit bias, move beyond it, and ask the appropriate questions and get a good history. Remember with that patient under the age of 18, they can't commit. They cannot become involved in commercial sex industry. They're not old enough to. So anytime, that's called trafficking, and that person with the tattoos, a high number of sexual partners, or they're just not wearing the right clothing. Depending on the state, it's hard. I live in Florida. No one wears the right clothing, apparently, with the young children, but is the clothing appropriate for the weather or the venue? And then they use common language that we would see in that commercial sexual industry, the prostitution industry, that vulgar, what someone would say, or harsh, or atypical language. Some of the key indicators for labor trafficking, some of what we just talked about, so I'll zip through these a little bit faster, but have they been abused or threatened in that work environment? Are they allowed to take breaks, food, water while at work? Can they take or use appropriate personal protection equipment based on where they're working? Are they doing work that's different than what they were recruited for? That's a big one. Are they doing the job that they were supposed to be doing? Do they have to live in the housing provided by that employer, or do they have a debt that no matter what happens, it's still going to take them 10, 15 years to pay off 10, $15,000? So is that debt appropriate? And then we look at the school related, are the kids attending school? Are there unexplained absences? Is there a change in what they're wearing? Are they dating older people? Do they have untreated injuries? Is there a sign of abuse? Remember how we briefly talked about that drug or alcohol abuse? Think about why it's happening. Is it a coping mechanism or is it forced on them? And now they need to do this to be able to maintain that addiction. Do they appear fearful, anxious, withdrawn, or do they have that tattoo that they've been branded with, with a trafficker's name? So one survivor I did encounter did have that trafficker's name as she identified him as the boyfriend, but she said it was her boyfriend. So that moment, that's what I had to accept it as. Do they hold knowledge beyond their years and are they chronic in regards to runaway or homeless? So as we tie this all back together, guys, I know some of this has been information you've heard before, but I'm reinforcing it because it doesn't go away. Your role as a healthcare provider has to be recognizing that signs of trafficking. What does that person look like? Oh, this is hard because they look like us. They can look like any everyday person. We have to look at that victim-centered, trauma-informed approach, looking at what happened to them, asking questions about what do they need in that moment. What they need in that moment may not be what I need to do for them in that moment. And then identify that, yes, there's going to be challenges in that identification and assistance because they don't trust, they've been burned, they are in a system that may not have worked out well for them, and we are there to help. They may not be ready for our help. So let's wait for that sixth and seventh or even more touch points as hopefully we come in contact with them again in the future. So our role, we have to be able to recognize that victim. We want to isolate them from that trafficker. So we want to make sure we're safe though. safety becomes important at all times because if you're in a situation, that victim's probably going to support that trafficker. So make sure you stay safe as that provider and then keeping that victim safe by isolating them from that trafficker and then asking questions. Utilize an algorithm or screening tool if you have one in your facility. If you don't have a screening tool in your facility, now's the time to look at, can we get a little group or a task force to be able to develop one and put it in our facility so that we can consistently screen the same way. Developing a thorough physical exam and detailed documentation of our exams findings. We're great at this. Maybe a little bit more difficult because now we're talking about potentially multiple perpetrators, but this is one thing that we're great at, detailed documentations of our findings. I use this in all of my trainings guys because I want you to know that every training I do, I tell everybody to integrate their scenes, making sure that if they have a SART team, integrating their SART team and looking at the state approved sexual assault evidence collection kit instead of just whatever they had on hand, making sure that we can do the most for that person in that moment. This is just the basic beginning of an adult algorithm. That person presents to our facility, starting with, are they above the age of 18? Check. If we check it as they're not, then we're gonna move on to whatever policy we have in place for pediatrics. If they say yes, now we're gonna go to that policy for adults, thinking about what services that we are gonna be able to provide them, recognizing that they may not utilize it, making sure it's okay with them that we are hopefully being able to utilize some of the services that we have in place. And then following our protocol appropriately. So this is just the beginning of showing you how easy is it to develop a protocol in the facility in which you work. And this is us asking our question. This is not a checklist of, we just have to ask each question. This is a conversation. Do you have identification? Yes or no? Who has it? Where do you eat or sleep? Hey, can you come and go as you please when you're at your work? And has anybody hurt or threatened you if you tried to leave? We can start this history basically with pretty much anybody and be able to go through, like I said, with our checklist of where do we go next? Has your family been threatened? Can you leave your job if you want to? Do you live with your employer? Do you owe them any money? These are not words that you have to use. Make it into the language that you're comfortable with so that you can do a thorough screening. The role of the forensic nurse is collaboration. This is what I'm hoping we walk away with today. We're going to be able to hopefully get the team to invite the nurses, us, the forensic nurse, because we're seeing some literature showing that we are being called to the table, finally. I can tell you that I go to many trainings, presentations, hardly ever do they say, yeah, we had this forensic nurse or even this nurse when we did this team or when we brought these people in. And someone was like raising my hand, like where's the nurse? Where's the healthcare professional? The forensic nurses are being called in. We're being called in, yay, to help evaluate some of the victims of human trafficking, to be able to identify their health needs. And in that moment, they may not have any according to them. And we are going to be okay with that knowing that we made that first touch point and created an environment where they felt like they could come forward if they need to. Or we may collect that forensic evidence. We need to do it. Once again, for that victim-centered approach, which may be different from that sexual assault approach, recognizing that this victim has gone through multiple traumas over a long period of time with multiple people. And if we're able to do this and involve that mental health provider while we're doing it, that's going to be crucial. Now, some of the barriers to that, guys, is funding, right? Awareness and funding. We talked about you, myself, that forensic nurse separating that victim, establishing that trust. And I use that word trust loosely because they're not gonna trust us, not initially. It may take years. But establishing that environment that they identify as potentially safer. Offer immediate support based on their needs and what they want. Share human trafficking resources based on their need and their safety. We're not gonna pull out a big pamphlet and say, here's some information on human trafficking because we now put them at risk. We maybe look at, you know, do we have a pen with a number on it? Do we have a tongue blade with a number on it? Do we have a little comb with a number on it? Something that they can potentially have. And when we have a tool, an in-depth screening tool if human trafficking is suspected, as well as our medical forensic exam. So we wanna be team partners. We wanna be invited to the table to be able to work collaboratively with law enforcement or whoever's engaging in identifying these survivors. We wanna evaluate the victims and identify their needs and collect our forensic evidence. Legal considerations, if that person's under the age of 18. And then if they're above the age of 18, law enforcement and their role. We wanna help law enforcement guys. We wanna be able to educate a possible law enforcement. Are you thinking they know it all? No, I had a law enforcement contact me once and say, I have this child who's age blah, blah, blah under the age of 18 who says they are self-trafficking but they're just a prostitute. That was this year. That was law enforcement. Education is ongoing. We have to make sure that this victim or survivor know that the exams or anyone on the team, that the exams may be delayed because we have to meet the immediate needs of that victim, their mental health needs, their physical needs. So there may not be an immediate exam as we look at collecting our forensic evidence. So looking at our SART, our sexual assault response team, increase awareness and education because we may have a team but they may not know what human trafficking looks like. Integration of that SART team into the human trafficking task forces that are in the community. Working closely with the law enforcement human trafficking units. That's the table I wanna be at. I wanna be called. I recently was able to be able to be a part of a task force unit from a local area. And it was incredible. Protocol development to guide that medical response. And then expand that role of the SART team. And reinforcing the importance that we do that trauma-informed care. We wanna make sure that physical and emotional safety of that individual is most important. Safety, giving them a choice. Collaboration within the community, giving them a choice. Making sure that things that we're utilizing are trustworthy empowering them to make a decision. Many of them have never had the opportunity to make a decision of their own. So barriers to care, back to tying it all together guys. The lack of knowledge of the client or the provider. Dismissal on behalf of the law enforcement in regards to the reinforcing the need of education which I talked about in collaboration. And failures of the organization to include the healthcare providers. We're seeing it. There's literature saying that we're being called forward but not completely because we look at it. Lack of resources. How does that team, that law enforcement team or that FBI team have that person that forensic nurse available? So there's a lack of resources. So maybe we need to be creative and brainstorm on how we can have that. But that is a definitely a barrier to care for our human trafficking survivors. So in the community, human trafficking, what's next? That response of a forensic nurse when human trafficking is suspected. That trauma informed basis for human trafficking survivor. Asking for that victim's consent to contact law enforcement. We're asking based on obviously this person being older or because we know what we need to do for minors. But many times, even myself was in a situation where I saw a person obviously being trafficked and I didn't know what to do. I'm like, what do I do? Because I want this person to be treated as a victim and not as a criminal. So getting their permission to contact local resources. One of the things I learned afterwards from a law enforcement officer is checking to see if they have a human trafficking unit when we call law enforcement. That's gonna get them the care they need. Providing information on community resources. But the community resources guys have to be up to date which is ongoing and it's a process because due to lack of funding, some of those resources are going out of business. Some of those homes that took in survivors of trafficking may not be there anymore. So we definitely wanna give them something that's reliable and viable. Otherwise we're gonna lose them. And assess safety. Safety comes first, safety comes in the middle, safety comes last. Building a safety plan. Part of what I talked about initially, we need a protocol. We need community awareness on resources, ensure that they're up to date. We need to collaborate with law enforcement. Development of implementation of a human trafficking documentation tool. Do you guys have one? I don't have one. And then engagement at the local and state task force level. I don't think they realize what they have available by having us, the forensic nurses ready to be able to be involved in this. So surviving after trafficking, guys, this was hard. Every survivor I encountered identified trafficking after, you know, staying in this community, living in the community, surviving after leaving trafficking as difficult and near impossible. And I interviewed them close to the pandemic. So many of them were really struggling. We're looking at housing. So if we look at a person who's been trafficked from infancy, guys, they don't know how to write a check. They don't know how to pay a bill. They don't know how to buy food. How do we have housing that's long-term and that eventually will get them to a point where they're sustainable? And then the life skills. They may have records from prostitution or stealing that need expunging. They need to learn how to manage finances and the physical and psychological support. Think about that body that is responding, that stress response, and what is it doing now? Many of them were suffering from health conditions. Mental health is ongoing. Most of them were not utilizing mental health support because they wanted to, because number one, it's not affordable, potentially. Number two, it's difficult to find. And several of them have had bad experiences. So we wanna make sure that we can reconnect with mental health because it is so needed and identification of resources. But the majority of them were struggling. Several were still thriving, but the majority were struggling. So we wanna change the narrative. We wanna look at how do we change the term from survival sex or the survivor sex and not use prostitution? You know, it's like, that's not a prostitute. That person is surviving. And many of the survivors I interviewed said, I'm thinking about going back because I can't afford to live right now. So that recidivism is tied to the survival sex and we have to take prostitution out of it. Some of that is cultural. As I work in some of the communities, especially one of the targets I'm working on is the African American community and through the churches. That person's not a prostitute. That person's not a hoe. That person is a victim. So some of our ongoing challenges involves community education. And that's not just, you know, oh, while we're at work. This is beyond work because we're not gonna make a change just as a forensic nurse in our workplace. We're gonna make changes as a forensic nurse in the community also. So we look at prevention and education. How do we get into some of the schools? We don't have to talk about sex and trafficking. We can talk about internet safety. We can talk about relationships that are good relationships versus bad relationships. We look at public awareness campaigns, being able to hit some of the high spots and empower these vulnerable communities through education. We have to look at legislative changes. Nothing can be done without funding. Funding comes through education of legislators and funding comes through development or legislative changes come through development of laws and resources. And then education of healthcare providers. I would love to say that we are knowledgeable about it. Yes, we are in the room because we do this a lot, but a lot of healthcare providers still give me that blank look when I go out and educate within the communities and I'm doing it a lot in the hospitals. So recognizing that it's an ongoing need as well as in our universities. So let's start educating our nurses, healthcare providers at that level of education. And then combating at the community level. I think we talked about all of it. The community partnership. Who can we partner with? Integration of our team. Human trafficking task force and law enforcement. Knowledge of our community resources are necessary. There are so many survivors who told me that we gave them information on resources that were not valid. So what do we do next? If we are in immediate danger, the survivor's in immediate danger, I'm telling you to call 911. Whether or not there's a trafficking unit, we potentially have to look at that. That's the last thing we wanna do is put someone at further risk, but we have to look at what's important at that moment. But if possible, let's see if there's a human trafficking unit or division. You have to follow the policy that's in place for where you work though. But remember, everything you see is not just gonna be in the work environment. If there's a suspicion of trafficking, we're gonna call a hotline, which is pretty easy. You can call it or text, be free. There's a Department of Homeland Security as well as if you're in Florida, the Florida Abuse Hotline, but whatever is the numbers in which you live, look at your community resources or who you would call based on your local area. Adults, state-specific and facility-specific guidelines, because I really wanna make sure you do what you do or what you're supposed to do according to where you work. But we know we're mandatory reporters. State-specific policy, and make sure that that client, adult or child, is aware of what you're doing, because that first touchpoint may not be your final touchpoint. So what do you do? Guys, let's build your own human trafficking task force if you can. We know that if you work in an emergency room, we know that we need time. We need time to be able to do our assessment. So maybe if they help you to be able to or allow you to be able to have a task force, then that may allow us the time to see the patient and ask questions, because everything we talked about today requires time. So look at getting initial improvement, trying to get a leader, recruiting some members for that task force and identify community partners. Those members goes back to that slide when we talked about law enforcement, the potential non-governmental organizations. Have a survivor on board, and that's one thing I miss saying throughout this whole thing. We have to have a survivor on board to be able to make sure we stay on task, but what does the survivor really need? So having that survivor's perspective as we're looking at creating task forces, getting our community resources and working collaboratively. So just tying it all together with a brief case study, this person was trafficked as a young child. She was trafficked by her mother and later by her boyfriend. We, healthcare providers, helped her to leave trafficking with her young son. Now, this problem with the situation is she's struggling. She struggled with suicidal tendencies. She struggled with mental health issues. She's struggling to find her purpose in life, and that was 10 years post leaving the situation. She felt that we, the healthcare providers, had abandoned her. What we looked at as we needed to get her not just out of the trafficking situation, but out of the state to be able to make sure that she was safe. So by taking her away from everything because the trafficking situation was her family, she point blank said, I grew up in a situation where everybody was pretty much ignored and I had this relationship with my mom. Obviously, as she got older, she realized that she needed to get out, but she felt abandoned in our attempts to help her. So we look at, and I don't have a concrete answer because that was years ago, but what do we do to help in that system? And I think on the other hand, once we get that person there, making sure they have strong resources. Is there a way for us to touch back with them and see that they're okay? So maintaining that relationship and making sure that we're helping them so maintaining that relationship and that collaboration once we have helped that person get out of that situation. So guys, that was a lot of information and I wanna thank you for this opportunity to be able to speak with you today. This key part at the bottom with resources is identifying resources near you so that they can best help you because most places have resources available. We just don't know what's going on with the resources in regards to funding. Under shared hope, I put a couple of links. I'm not sure if we're able to share those, but these guys are. It's basically just the warning signs of trafficking as well as familial trafficking. So sharing that information and it's all information that's free. And then I'm able to answer any questions that you guys may have. Sarah, do you want me to look at the Q&A or? I can answer those, or I'm sorry, I can read those off real quick. So it says, does anyone know of any, I'm sorry, does anyone know of any prevention intervention programs for buyers of children slash adolescents who are sex trafficked? Also, what evidence-based prevention programs exist to teach children about risk for trafficking? I just downloaded the target prevention programs from Shared Hope International. And I'm not sure if you guys have heard of it, but it's a program that's being launched by Shared Hope International. I have not looked at it yet. Thank you. Yes, so there are, depending on where you are, there are definitely prevention programs. And what they're really trying to do is go in the schools and be able to start educating there. So that's gonna be across the board, some of the ones that we have. I definitely don't have a problem sharing some of the ones that I know have been vetted. And then even the screening tools, the tools they identify as having been vetted, the ones that I listed. But once again, the situations vary so much. And then back to our now what question. So I don't want you to be disappointed. You're like, okay, I did this, I got this, now what? It's going to be us working in the community, seeing what resources we have personally in the community so that we can move forward. So yes, we can share that information and I can give it directly to these guys so that you have some links to specific tools. Hopefully that answered that. Awesome. The next question is how do you get buy-in from the rest of your ED co-workers to ask these hard questions where they just want to treat them and straight up? I think we have to reach high. And this is the one, and this is a great question guys, because that's my next level. When I have some free time, I tell Megan all the time, I'm like, okay, this is what I want to do next. I want to go to the head of the facilities because we have to get buy-in. We can't see our patients in 15 minutes or having our staff be comfortable. So maybe we can have these mandatory trainings, but we have to get buy-in from the top in order for us to get any buy-in from our co-workers to ask these questions. A lot of people don't feel comfortable. And I was one of those people, that's why I say it when I train, I didn't feel comfortable asking that simple question. Do you feel safe at home? Of course you do, you're with your mom. She has lots of money. That's not good enough. So if we share some of our stories, but it's really going to come in from the top in order for change to happen and them giving the support. And then letting people know that we walk away, you and I walk away feeling frustrated all the time because we want to help somebody who's not ready for our help. And that's part of it, unfortunately. Okay, we have one more question. I have questions about how much we should be documenting in the EMR and how do we offer support to hospital staff when the patient declines services? I have had staff and providers wanting to hold them against their will and or calling law enforcement. In our hospital, the forensic nurse is a first line call when trafficking is suspected. So I really need to improve our documentation. Does anyone have a template they use? A lot of the, and this is a great room to ask that question because there may be someone else in this room who has it. One of the things literature wise, what I'm seeing is the electronic medical record, there's a separate template that's not part of that record. And I think that's going to be our safest method for being able to do it. If your facility is supportive of, now you can freely document what you saw instead of putting it right in that record. And no, you're right. I'm glad that your facility, yay, is the first person to call that's called or the forensic nurse is the first person that's called because that's what we need to see. I'm glad that they're doing that and that you are working to let the people know they can't hold anybody against their will. Number one, they're going to put them at risk because they're going to leave and the trafficker is going to make an example of them and they're going to have to prove that they didn't say anything. And if law enforcement is called, if it's not the right group, if it's not the right unit, this person may be treated as that criminal. So we have to be very sensitive with that. So I'm sorry that you're encountering it, but those are the great things that you are in a platform to make some change. So hopefully you have the support from higher up to be able to start looking at how do we manage this and change this response because that person does have a choice unless there's something going on that we have to report. All right. And we had one person ask if you would be willing to share your contact information. Absolutely. I go out and do this in the community for pretty much any environment. I mentioned that I did it in Jamaica. My goal is to kind of go across internationally too and did a group of Jamaican family members. It was a healthcare facility because it's happening worldwide, but I love talking on this topic, as you know. And we still have a huge gap because I know we all feel frustrated. And once again, I'm going to raise my hand, myself included, when I've worked with somebody and I don't have the tools beyond, okay, now what? It's like one of them, I handed a folder at the end. I'm like, I'm so sorry. I have nothing else to offer you right now. That is just, we have a lot of work to do. Well, I think with that, we are over time. So I want to be mindful of that, but we do want to give you a great thanks, Dr. Sherita Irwin, for joining us for this presentation. I agree with Eileen that this information has been incredibly valuable to all of us that have heard what you had to say. I do want to have, or do a special thank you to our IFN staff, Megan Crow, Amy Valentine, and Haley Kosen, who make these presentations possible. We ask that you please complete the evaluation for those CEs. I'm going to drop my contact information in the chat. If you have any questions that arise from now or until I reach out, feel free to contact me. And on behalf of the International Association of Forensic Nurses, we thank you all for joining us today and look forward to seeing you on a future webinar.

Human Trafficking

Forensic Nurse

Vulnerable Populations

Healthcare Providers

Multidisciplinary Team Approach

Adverse Childhood Experiences (ACEs)

Physical and Mental Health Effects

Survivor Stories

Trauma

Safe Environment

Awareness

Competency

Victim-Centered Care