1. Josephine Ensign, FNP, DrPH bjensign@uw.edu

2. Terms: Homeless/street-involved youth CSEC: Commercially sexually exploited children (youth) Trafficking victims Youth ‘Sex Workers’ Teen Prostitutes

3. Human Trafficking: As defined under U.S. federal law, victims of human trafficking include children involved in the sex trade, adults age 18 or over who are coerced or deceived into commercial sex acts, and anyone forced into different forms of "labor or services," such as domestic workers held in a home, or farm-workers forced to labor against their will.~ Polaris Project

4. Human rights issues UN Convention on the Rights of the Child that covers non-discrimination, right to a nationality, juvenile justice, access to healthcare and education, freedom from drug/sex/slave labor, and freedom of religion and of expression. All nations of the world except Somalia and the US have ratified the Convention.

5. Homelessness and Human Rights in US Between 1999-2010 were 1,184 documented unprovoked physical assaults on homeless people in US resulting in 312 deaths/ Hate Crimes Highly correlated with municipal laws/climates criminalizing homelessness (e.g.: no panhandling) 5,000 teenagers/year are buried in unmarked graves Source: National Coalition for the Homeless

6. Mortality rates/reasons Mortality rate for homeless/street-involved youth 11 times that of general population of young people (Montreal/2004) Main causes of death were suicide and drug overdose

7. Estimates of numbers of homeless youth: Worldwide 80 million (UNICEF) US/Europe 10 million US 500,000-2 million Seattle 500-2,000 _____________________ 1.6 million homeless youth each year in US Young people ages 12-17 years more at risk for homelessness than are adults

8. Reasons for homelessness Abuse and neglect Family discord/blended family stressors Poverty War/military repression Discrimination Lure of the streets Parental substance abuse/mental illness/HIV/jail Sexual minority youth Lack of national identity/birth registry

9. Homelessness and Poverty in the US Homelessness for young people is more of an “equal opportunity” situation Is not the consistent link with pre-existing poverty as there is with homeless adults However, poverty is linked with chronic homelessness for young people

10. Commercial sex act: Prostitution Exotic dancing/stripping Pornography Sex tourism Survival sex Escort services

11. Who is at risk? Any young person—but those most vulnerable include: Homeless/runaways h/o abuse, neglect (90% h/o sexual abuse) LGBT youth Parent incarceration/substance abuse

12. Environmental Risk Factors: Adult sex industry Transient male population Proximity to borders/ports Poverty Violence Gangs/street-involved economy

13. Risk factors/societal: Sexism and misogyny Racism Homophobia/Transphobia Sexualization of girls and young women Commoditization/consumerism Poverty/lack of decent jobs

14. Prevalence: 1 in 3 teens on the streets will be lured into prostitution within 48hrs ~150,000/yr nationally 300-500/yr in Seattle (Boyer, 2010)

15. GEMS: Girls Education and Mentoring Program, NYC You-tube 5 minute spoken word video “The Making of a Girl”“The Making of a Girl”

16. HOMELESS YOUTH CLINIC Evening drop-In Clinic Wed. and Thurs. Serve Homeless youth ages 12-23. Homeless: Sleeping in a car or on the street Camping/Squatting or doubled-up Transitional Housing or Emergency Shelter At-Risk=Homeless in the Past 12 Months

17. YouthCare’s Bridge Program: The Shelter: 12-bed, co-ed under 18 Long term residential recovery program: 6 beds Was a demonstration intensive rehabilitation program (2010-12) Now is 2 beds/Pathways under 18 transitional living program (#40 CSEC youth to date) Focus now is on community coordinated response network

18. Main Health Problems Malnutrition/eating disorders Dental problems/injuries/fear of dentist Rashes/abrasions, lice and scabies Injuries (exposure, fights, traffic, cutting) UTIs, vaginal yeast infections STIs, pregnancy, menstrual problems HIV/Hepatitis B and C Substance use/blood clots, abscesses Depression and PTSD

19. Health Effects of Sex Work/Prostitution Very little specific to CSEC Youth For adult women/men/trans people focus has been on HIV/STIs Viewed as vectors of disease to general population Studies indicate that type/location of sex work affects health risks Hierarchy of status and control from ‘call girls’>brothels/sex clubs>street work/no drugs>street work+drug use

20. Barriers to health care Confusion over ability to consent for care Concern over confidentiality of care Clinic hours that conflict with school/work/shelter Discomfort with traditional adult-oriented health care settings Competing priorities

21. Additional barriers to health care: Lack of trustworthy adult to help navigate system Lack of insurance/payment source Disrupted and incomplete educational backgrounds Stigma of being labeled “street, prostitute/sex- worker, drop-out, juvi kid” (worse stigma if also have mental illness label)

22. Additional barriers to care/CSEC Youth: Coercion/control by pimps Dissociative disorders blocking their awareness of physical signs/symptoms Somatization—malingering

23. Attributes of effective health care services: Services are sensitive to patients’ fears of adults, authority figures and systems related to histories of abuse and trauma. Services address developmental and educational issues. Services are respectful of patients’ unique sub- culture (street families, alternative economies, protection of identity, etc) Services are respectful of patient’s knowledge/survival skills

24. WA State Medical Treatment of minors w/out parental consent: (at any age) Family Planning services Pregnancy care including prenatal care Emergency services—if impractical to obtain consent Treatment requested for suspected STI BUT—hospital and clinic administrators/risk officers can (and do) set their own rules on this….

25. Things to keep in mind: Survival skills of the youth can speed up some developmental processes and delay others They are dealing with normal developmental issues of adolescence along with the realities of the life of CSE and/or homelessness Adolescence is usually the healthiest time of life Positive body-work health care options—what body can do instead of body as object

26. Features of adolescence more pronounced in homeless (and what to do about it) Intense peer orientation (Include friends in encounter/be alert for exploitative ‘friends.’ Use peer-outreach workers when possible) Interest in trying new things/risk-taking (Harm reduction model works best.)

27. Brain development in adolescence Rate and scope is second only to that of infancy Brain areas responsible for planning, judgment, problem-solving and emotional control are reinforced by positive interactions with adults and communities

28. Health education for street- involved youth Builds on positive aspects of survival skills Culturally appropriate Realize primacy of basic needs Deals with reality of violence in their lives Harm reduction approach

29. Protective Factors/processes for youth applied to homeless youth Presence of at least one caring adult (favorite aunt, grandparent or service provider) Sense of purpose in life (finding meaning in experience of homelessness) Sense of belonging to a caring community (street family and/or service providers)

30. Clues to “the life” Excess amounts of cash/consumer items Hotel room keys Signs of branding (tattoos) Lack of knowledge of where they are Eye contact—are groomed to look down Suspicious injury/trauma Use of prostitution specific lingo

31. Street Slang/Lingo Track—where they work Bottom Girl/Bottom Bitch—the head girl Daddy—pimp Dates—Johns—customers Renegade—work by yourself Out-of-pocket—work for another pimp

32. What you can do/CSEC youth: Recognize them as survivors Remember it takes time to build rapport Understand PTSD and trauma bonding Use a harm reduction approach Help them create safety plan Maintain appropriate boundaries

33. Quotes from young people: Perspectives on health care/health promotion from homeless young people Asked them what helped/didn’t help them be/stay healthy Asked how to ask about survival sex/CSE Feedback for health care providers working with them

34. 17 y.o. female: “it helps when they (providers) talk to me instead of like telling me what to do.” “don’t shy away or shun us because we’re scrubby or dirty. We’re human beings too, and we need help.”

35. 18 y.o. male… “I’d say that not being able to rest-- just being homeless--, is the biggest thing getting in the way of getting better. I kind of caught myself laughing- --even though my parents and I didn’t get along, I found myself reminiscing to when I had the flu and was home and they took care of me and even my mean ole’ step-dad brought me fluids.”

36. “It helps when doctors and nurses understand the homeless situation and how we’re living” (19 y.o. male)

37. “Teach us more how to take care of ourselves. We didn’t get that growing up.” (22 y.o. male)

38. 16y.o. female: “I’ve looked down at some of my friends for having slept with guys for money or to stay at their place. And basically, if your best friends have that much stigma about it, trusting a health care provider is going to be that much harder.”

39. Focus group on how to ask: “Forms are too impersonal. It’s easier to lie on a form than it is to a direct question.” “Leaving it up to the patient to pick it up, it’s not going to happen. You have to ask directly in a tactful and non-shaming way.”

40. Focus group on how to ask: “It would be best to ask it with the chart or the computer closed and maybe a promise not to write it down. Like--It’s going to be in my mind and your mind and nowhere else.”

41. How to ask/screen for: “Do you ever have sex when you really don’t want to for whatever reason?” (youth focus group consensus) “Have you ever traded sex for money or other things you need to survive?” (standard screening question)

42. Burnout prevention: Work within a healthy/supportive team Work within a system that values people/good leadership Find a healthy/ongoing personal outlet for grief/anger Try to tie direct service with larger advocacy/activism

43. Anita Roddick (1942-2007, founder of Body Shop) "If you think you are too small to have an impact, try going to bed with a mosquito in your tent."

44. Secondary Trauma: A good resource is Trauma Stewardship: An Everyday Guide to Care for Self While Caring for Others by Laura vanDernoot Lipsky and Connie Burk

45. Resources: Homeless Young Adults Ages 18-24: Examining Service Delivery Adaptations. National Health Care for the Homeless Council. (Can be found online at www.nhchc.org. www.nhchc.org First Build Trust. Helping Homeless Youth. Maggie Jones. Northwest Public Health. Spring/Summer, 8-9/ (2007.)http://www.nwpublichealth.org/docs/nph/s2007/jones_s2007.pdf Quality of Health Care: The Views of Homeless Youth. Josephine Ensign. Health Services Research Vol. 39, No. 4, 695-707 (2004). A Health Needs Assessment of Street-based Prostitutes: A Cross-Sectional Survey. Jeal and Salisbury. J of Public Health. 26(2):147-151 (2004). Sex Worker Health: San Francisco Style. Cohen et al. Sex Trans Inf. 82:418-422 (2006)

46. Resources: Psychological and health impact of working with victims of sex trafficking. Kliner and Stroud. J of Occ Health; 2012; 54:9-15. Human trafficking: the role of the health care provider. Dovydaitis. J Midwifery Women’s Health; 2010; 55(5):462-67. Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people. Coren et al. Cochrane Database, Feb 28, 2013.

47. Resources: The Washington Anti-Trafficking Response Network 206-245-0782 National Center for Missing and Exploited Children 1- 800-THE-LOST National Human Trafficking Resource Center Hotline 1-888-373-7888

48. WEBSITES: National Health Care for the Homeless Council (and Clinician’s Network) www.nchc.org National Coalition for the Homeless www.nationalhomeless.org www.nationalhomeless.org Health Care for the Homeless Network: Seattle http://www.metrokc.gov/health/hchn/ http://www.metrokc.gov/health/hchn/