Human Trafficking: Working with Medical Professionals September 2013 Voiceover: Beat Intro 00:00 This is the Beat—a podcast series that keeps you in the know about the latest community policing topics facing our nation. Kimberly Brummett 00:08 Hello and welcome. My name is Kimberly Brummett and on behalf of the COPS Office I’d like to introduce you to Dr. Allison Jackson. Dr. Jackson is chief of the Child and Adolescent Protection Center at the Children’s National Medical Center here in Washington, D.C. Today, Dr. Jackson is here with us to discuss the center’s work with at-risk youth and how medical professionals and law enforcement can work together to identify and assist trafficking victims. Dr. Jackson, please tell us about the work you and your colleagues do at the Child and Adolescent Center at Children’s National Medical Center here in Washington, D.C., and your experiences with juvenile trafficking victims. Dr. Allison Jackson 00:43 Thank you for having me. The Child and Adolescent Protection Center is one of the divisions within Children’s National Medical Center. Children’s National is the largest provider of pediatric primary care for the children of the District of Columbia so our responsibility is quite vast. We serve as a medical safety net for nearly 80,000 visits of children to the hospital. We serve the local community of the District of Columbia but we also serve a national and international population of children as well, who come and seek specialty care for children. Our division serves anywhere from 1,300 to 1,500 children each year, of which it seems that about one to four each year are identified as victims of trafficking. I would suspect that that’s probably an underestimate. We know that we’re not always picking up that that’s what the situation really is. Our team is a multi-disciplinary team in that we have medical and mental health providers who are dedicated to evaluating children when abuse or neglect is suspected. Trafficking really is a form of child abuse so we include that in the number. Our direct clinical services include providing medical evaluations, doing forensic medical collection of evidence by physicians and sexual assault nurse examiners, and then providing crisis intervention and ongoing mental health services which, hopefully, can mitigate children from entering into the world of trafficking. We know that many of these children have histories of maltreatment that lends itself to the circumstances that they unfortunately often find themselves in. Doing outreach is obviously a very important part of what we do. Prevention efforts around different forms of child maltreatment is something that our team is also committed to and educating the community—both professionals and laypersons—in how to prevent child abuse and neglect in children. Because we are academically linked to George Washington University, we obviously also provide education and training to medical trainees on topics related to child maltreatment in hopes that we can reach providers and increase their awareness of issues like trafficking and other forms of victimization of children so that things can be identified early. The other critical component of what we do is partnering with other agencies that are involved in the management and care of children who are trafficked or otherwise abused and maltreated, which includes law enforcement and child welfare and their respective legal partners. Kimberly 03:49 Great. As a medical professional, how do you identify at-risk juveniles? Allison 03:54 Well, I think with anything in medicine, it all starts with what we call “getting a good history,” which what some people outside of the medical field would call an interview, but it’s really the history- taking. Establishing a rapport with the patient so that they feel comfortable enough to talk with you and then delving into, not only the complaints that bring them to your care at that time, but also assessing the circumstances in which they find themselves that may impact their health and wellness. Kimberly 04:23 What are unique healthcare needs of juvenile trafficking victims? Allison 04:27 The first thing is that they often don’t find themselves or view themselves as victims, which can make it difficult to engage them in a way that can be a partnership in their care. I think coupled with that is that they tend to be adolescents. What we know about adolescent development and how the brain is developing and the skills they are acquiring can sometimes make it more difficult for people in positions of authority and adults to engage with them and for them to feel comfortable enough with an adult to provide information that would be helpful to them. The poly-victimization that juveniles who are involved in trafficking have experienced is very common. Many of them are runaways; that’s often how they enter into that lifestyle, often running away from something bad—not because they’re bad but because they’re running from something bad. They may present as bad and that is protective. You don’t want to look vulnerable in an environment where vulnerability can be taken advantage of. They may have these very hardened exteriors. Getting to the root and being able to understand their story provides a challenge for healthcare providers, but really helps to identify the needs, both the medical needs and the mental health needs, of them. Certainly physical trauma is a unique finding that they may have experience in. It may be something acute, an acute injury or a recent injury. It may be something older that may have been untreated or treated but the circumstances that caused the injury may not really have been uncovered. Identifying physical injuries and treating them appropriately certainly would be one of those needs. Obviously when we’re talking about trafficking, we’re usually talking about—at least in the domestic population, more commonly talking about—sex trafficking. The risks that accompany that include not only physical injuries to the genitalia, the anus, the mouth, but also infections. The sexually transmitted infections—of which there’s a fair number—some of which we can treat and cure, some of which we can manage but not cure, some of these which may be life threatening. Many of these children may have had an infection for an extended period of time. Certain infections like gonorrhea and chlamydia can ascend into the more internal parts of the female genital tract and can damage them such that it can impact their fertility. At a time when they would be ready and wanting to have children, they may struggle with infertility because of scarring of their Fallopian tubes, part of their genital tract that inhibits conception. Then obviously things like HIV, hepatitis, and syphilis. There are some other outcomes from sexually transmitted infections that may not directly affect the individual. For example, trichomonas is another sexually transmitted infection which, untreated, can cause pre-term labor. If a female were to become pregnant and have trichomonas, now we’re not only dealing with the infection of that individual but the potential for having a premature infant and all the complications that can accompany that. STIs are not minimal. They’re not insignificant. They’re not something that you just go get a shot for. There’s much more to it than that. Other medical needs that they may experience include malnutrition. They may not be eating balanced diets. They may be eating chips and sugary snacks and not healthy meals. That can also affect things like their cholesterol level, their weight, and their blood sugar. Many of the diseases that we associate with adults—heart disease, diabetes—we are seeing in the adolescent population. I think this population of youth are at even higher risk of those things. That’s not to exclude the fact that some of these children and young people have underlying medical conditions that predate them entering into this lifestyle of trafficking. Asthma, for example—they may have it and it may be untreated or inadequately treated. The long-term consequences of poorly- treated asthma and the damage it can do to their lungs certainly places them at risk for long-term complications that could have been avoided. I think the elephant in the room, so to speak—the thing that often medical providers may not necessarily be as attentive to in patients that have so many other medical physical needs—is mental health. These are, again, as I mentioned, children who have experienced more than many adults in their lifetime, who have been exposed to any number of forms of violence—sexual exploitation, physical assault, and sexual assault—some of which may have predated the trafficking. The impact that has on their mental health is huge and something not to be minimized. We like to think that kids are resilient, and certainly some kids have more resiliency than others, but we also know that trauma affects the brain. It affects brain development. It affects things like memory and attention. The kid who might be labeled as ADHD may actually not have ADHD; they may actually have post-traumatic stress disorder. Do we treat those things the same way? Really teasing out their experiences to help frame and contextualize their mental health is important for providers to be able do. Along those lines, some of these kids may have cognitive limitations. They may have learning problems. They may be that much more easily coerced for that reason. They may not continue school; they may drop out. That may be a way that we pick it up as a matter of fact, that they’re not going to school. The healthcare needs are vast for this population of children. It’s not a one-time visit evaluation that these kids require to get at the heart of all of the issues for them. Kimberly 12:07 What roles do medical providers play in identifying and treating human trafficking victims? Allison 12:13 The first role is knowing that trafficking happens, just having that awareness, learning about it. Even for medical providers who may hear that their patient is “prostituting” or a prostitute, recognizing that they are victims and they are not criminals. Knowing how to engage them with that context and to elicit information from that that will reveal that, in fact, that’s what is happening. Again, it’s difficult because they may have hardened exteriors that make it harder to establish rapport and they, again, don’t always see themselves as victims. There’s an art, but there’s also a knowledge base that you have to have to be able to do that. Screening patients for victimization as a routine—not just if you have a suspicion but as a routine. Assessing patients for family violence, dating violence, sexual victimization, and physical abuse. Those are things that not only might help us identify a trafficking victim, but might also help us identify someone who’s at risk for becoming a victim of trafficking. Then, of course, the responsibility of reporting to authorities, whether it’s Child Protective Service agency representatives or police. Then knowing when to refer. Every medical provider is not going to be able to do all of it for one patient in particular, but to be familiar with the resources that are available—that can best serve children who have these experiences. Kimberly 14:13 How can medical professionals and law enforcement work together to identify and assist trafficking victims? Allison 14:20 I’d have to first say communication across disciplines. I don’t know what the experience of law enforcement is with medical providers in a professional capacity as a routine. I know my own personal experience as a child abuse pediatrician that works on a multi-disciplinary team, and I understand the value of collaboration and conversation with law enforcement. Truthfully, some physicians are a little anxious about talking with police—unfamiliar, maybe feel intimidated—so may not come across necessarily as being helpful. It really is a partnership. The physician may have information that may help the detective or officer with their case. Conversely, the detective or officer may have information that can help inform the provider on how best to evaluate and care for their patient. The other piece is that law enforcement knows more about trafficking culture than medical providers. They really need to help educate us about what’s the language we use, what is it called. I can’t go ask my patient, “Are you being trafficked?” I can’t use that language. They know the verbiage, the street language, because they see it and they engage with them on a different level. Educating health care providers about that certainly would be important. Medical providers have to document well in the medical record. They have to document what their patients disclose. They have to document the physical findings. They have to have some curiosity about physical findings that might seem insignificant. Tattoos, for example. It’s a fad. We see lots of tattoos. Some of them may be someone’s deceased parent but some of them may be a pimp. If we don’t know that, if we don’t know to inquire, just have a little curiosity—“Who’s that?”—that information may be helpful to those who are investigating. Just the cross-pollination and conversation, sharing information, is the most important thing. Kimberly 16:53 Well, thank you, Dr. Jackson, for providing us with your expertise and time today. Allison 16:56 Thank you for having me. Voiceover: Beat Exit 16:59 The Beat was brought to you by the United States Department of Justice COPS Office. The COPS Office helps to keep our nation’s communities safe by giving grants to law enforcement agencies, developing community policing publications, developing partnerships, and solving problems. Voiceover: Disclaimer 17:15 The opinions contained herein are those of the authors and do not necessarily represent the official position or polices of the U.S. Department of Justice. References to specific agencies, companies, products, or services should not be considered an endorsement by the authors or the U.S. Department of Justice. Rather, the references are illustrations to supplement discussion of the issues.