1. Joy Turner Washburn, EdD, RN, WHNP-BC November 1, 2018
Human Trafficking: What You Need to Know as a Case Management Professional

2. Learning objectives
Summarize the types and venues for human trafficking in Michigan and the USA
Identify the common presenting characteristics of victims of human trafficking in healthcare settings
Describe the role of case management in the identification and support of victims of human trafficking
Identify credible resources related to human trafficking

3. Something to Think About . . .
“Of all the creatures on earth, man is the only one that is cruel. He is the only one that inflicts pain for the pleasure of doing it.”
~Mark Twain
Born and raised in a small village in Ghana, Natalia’s family was struggling to pay the school fees for their children’s education and welcomed the opportunity for Natalia to receive an education in the United States.
Shortly after she arrived in the U.S., the father she was living with began to physically and sexually abuse the young girl, creating a constant environment of fear for Natalia. For the next six years she was forced to clean the house, wash clothes, cook, and care for their three children, often working 18 hours a day while receiving no form of payment. She was never allowed to enroll in school as the family had promised, go outside, or even use the phone. One day, after she was severely beaten, Natalia saw an opportunity to run away from the home and a neighbor called the police. She was then taken to a local hospital for medical care. The nurse assisting Natalia was aware of the National Human Trafficking Resource Center and referred her to Polaris New Jersey.

4. Trafficking Victims Protection Act (TVPA)
First comprehensive federal law to address human trafficking (2000)
Prevention
Protection
Prosecution
Re-authorized in 2003, 2005, 2008, and 2013.
Bipartisan legislation in House and Senate for reauthorization
The Trafficking Victims Protection Act (TVPA) of 2000 is the first comprehensive federal law to address trafficking in persons. The law provides a three-pronged approach that includes prevention, protection, and prosecution. The TVPA was reauthorized through the Trafficking Victims Protection Reauthorization Act (TVPRA) of 2003, 2005, 2008, and 2013.
There are many anti-trafficking champions in Congress, and the work is well underway in both the House and Senate to get this reauthorization accomplished. President Trump has indicated that he is in support of reauthorizing the TVPA.

5. FEDERAL DEFINITION OF HUMAN TRAFFICKING
The recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act which is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age;
The recruitment, harboring, transportation, provision or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery

6. National Human trafficking resource Center
If you think you have come in contact with victim of human trafficking, call the National Human Trafficking Hotline at
Hotline personnel will help you:
Determine if you have encountered victims of human trafficking
Identify local community resources to help victims
Coordinate with local social service organizations to help protect and serve victims so they begin the process of restoring their lives and becoming survivors
Call local police (911) if victim at risk of imminent harm

7. Commercial Sexual Exploitation OF Children (CSEC)
Definition: the sexual abuse or exploitation of a child (less than 18 years old) for the financial benefit of any person or in exchange for anything of value, including monetary and non-monetary benefits, given or received by any person.
Examples of crimes and acts that constitute CSEC include:
child sex trafficking/the prostitution of children;
child sex tourism involving commercial sexual activity;
the commercial production of child pornography; and
the online transmission of live video of a child engaged in sexual activity in exchange for anything of value.
CSEC also includes situations where a child, whether or not at the direction of any other person, engages in sexual activity in exchange for anything of value, which includes non-monetary things such as food, shelter, drugs, or protection from any person.
Depending on the specific circumstances, CSEC may also occur in the context of internet-based marriage brokering, early marriage, and children performing in sexual venues.
Note: CSEC is not legally defined by federal statute or case law. However, several federal criminal provisions can be applied to conduct that falls within this definition of CSEC, including 18 U.S.C. §§ 1591, 2251, and 2423(c).

8. Mandated Reporting
Effective May 29, 2017, the Justice for Victims of Trafficking Act of 2015 amended the federal definition of “child abuse” to include commercial sexual exploitation. Child sex trafficking is considered child abuse under federal law and must be reported to local law enforcement or child welfare agencies.
Michigan Child Protection Law requires mandated reporters to make an immediate verbal report to DHS upon suspecting child abuse and neglect, followed by a written report within 72 hours
The average life expectancy of someone who is commercially sexually exploited child is seven years from the time that the person is original
an exploited child is seven years : homicide and HIV/AIDS account for
a majority of the deaths.

9. COMPONENTS OF HUMAN TRAFFICKING

10. Three Categories OF Human Trafficking Victims
Persons under the age of 18 involved in commercial sex acts
Persons aged 18 or over involved in commercial sex acts through force, fraud or coercion
Persons forced to perform labor and/or services in conditions of involuntary servitude, peonage, debt bondage or slavery through force, fraud or coercion

11. Traffickers Prey on Vulnerable Persons
Previous history of physical, emotional, and/or sexual abuse
Isolation/loneliness
Lack of familial and/or social support
Homelessness
Runaways
Poverty
Substance abuse
Mental illness
Learning disabilities and/or developmental delays
There is no single profile for trafficking victims; trafficking occurs to adults and minors in rural, suburban, or urban communities across the country. Victims of human trafficking have diverse socio-economic backgrounds, varied levels of education, and may be documented or undocumented. Traffickers target victims using tailored methods of recruitment and control they find to be effective in compelling that individual into forced labor or commercial sex. 
While human trafficking spans all demographics, there are some circumstances or vulnerabilities that lead to a higher susceptibility to victimization and human trafficking ~ these vulnerabilities are:
Previous history of physical, emotional, and/or sexual abuse
Isolation/loneliness
Lack of familial and/or social support
Homelessness
Runaways: In the United States, runaway and homeless youth are at extremely high risk of sexual exploitation. These adolescents are lured into the commercial sex industry by promises of emotional,
economic, and domestic stability. Experts suggest that runaway adolescents are likely to be approached by a pimp or invited to participate in the commercial sex industry within 48 hours of being on the street.
Poverty
Substance abuse
Mental illness
Learning disabilities and/or developmental delays
Traffickers prey upon people who are experiencing needs ~ think about Maslow’s Hierarchy of Needs. Maslow called the bottom four levels of the pyramid ‘deficiency needs’ because a person becomes anxious if these needs are not met. Physiologic needs (food, water, sleep, shelter); Safety needs (employment, security, physiologic s
safety); Belonging needs (affiliation, acceptance, affection, friendship, love).

12. Venues for Human Trafficking
Prostitution and escort services
Pornography, stripping, or exotic dancing
Massage parlors
Agricultural or ranch work
Factory work or sweatshops
Businesses such as hotels, nail salons, home-cleaning services, construction, nursing homes
Domestic labor (cleaning, childcare, eldercare, gardening etc.)
Restaurants, bars, or cantinas
Begging, street peddling, or door-to-door sales.

13. statistics related to trafficked persons
2017 Global Estimates of Modern Slavery
Data collected in 48 countries
Estimate of 24.9 million persons trafficked worldwide
16 million in forced labor ~ private/public enterprises
5 million in sexual exploitation
3.9 million in state/government imposed labor
Some groups more vulnerable to trafficking
71% of persons trafficked are female
99% in sexual exploitation
58% in forced labor
40% in state imposed labor
The Global Estimate of Modern Slavery was developed by the International Labour Organisation and the Walk Free Foundation, in collaboration with the International Organization for Migration. The Global Estimate also benefited from consultations with UN partner agencies, in particular the Office for the High Commissioner for Human Rights (OHCHR) , and external experts.
The United States is a destination, origin and transit country for human trafficking ~ even if the numbers in the USA are only in the hundreds of thousands, that is still hundreds of thousands too many. As such, we have an obligation to confront and be accountable for the human trafficking occurring within our borders. The focus on sex trafficking of girls and women in Southeast Asia or Eastern Europe draws attention away from the fact that the tomatoes we eat may be the product of forced labor in Florida or that the person selling magazines at our door may be a homeless youth being trafficked state to state or that the women who work in nail salons in our community may actually be victims of labor trafficking.

14. Intersection between Human Trafficking and Domestic Violence
How to Distinguish INTERSECTION Cases
Must include some form of force/fraud/coercion
Must include a labor component (involuntary servitude, peonage, debt bondage, slavery)
Labor may take place in the home or at the trafficker’s/abuser’s place of business OR trafficker benefits from the proceeds (picking produce, prostitution, sale of child)
CANNOT walk away without fearing serious harm or retribution to self or others

15. Intersection with Sexual Assault
In human trafficking, the trafficker benefits from the sexual assault/abuse ~ generally this is a monetary benefit, but it may include in-kind benefits such as food, drugs, or means to pay off a debt

17. Potential Indicators of Human Trafficking
Frequent moves to different places
Lack of knowledge of how to get around in a community
Dependent upon others for transportation
Lack of financial records
Limited personal items or possessions
Not in possession of ID documents
Large number of occupants in a single dwelling
Brands/Tattoos/Scarring indicating ownership
Signs of malnourishment
Untreated chronic diseases
Delayed treatment of illnesses
Restricted/Controlled communication
Third party insistent on interpreting
Limited command of English language

18. Common Physical Illnesses
Sexually Transmitted Diseases
chlamydia, gonorrhea, trichomonas, HIV
Pelvic Inflammatory Disease
Urinary Tract Infection
Chronic Headaches
Back Pain
Gastrointestinal Disorders
Frequent Respiratory Infections
Substance Abuse/Withdrawal
Untreated Chronic Diseases (with or without complications)
Asthma, Diabetes, HTN
Deformities and/or chronic pain from improperly healed fractures and strains
Tuberculosis
Malnutrition
Dental Problems

19. Physical Assessment Findings: Injuries
Genital and/or Anal Trauma
Rape, Foreign Objects, Fisting
Head Trauma
Bruises
Wounds
Abrasions, Ligature marks, Needle marks
Lacerations
Knife or Razor
Burns
Cigarette, Iron, Acid
Fractures
Gunshot Wounds
Vehicular Trauma (run over or dragged by a vehicle)
Unwilling Pregnancy
Unsafe Abortion

20. Common Mental Health Illnesses and Psychiatric Symptoms
Trauma Bonding (Stockholm Syndrome)
Depression and/or Anxiety
Suicidal Ideation
Panic Attacks
Poor Self-Esteem/Feelings of Worthlessness
Dissociative Reactions
Shame and Guilt
Fear and or/Paranoia
Eating Disorders
Post Traumatic Stress Disorder

21. Interactions with Victims/Survivors
Tips to Keep in Mind
Behavioral Cues
Don’t take strong reactions personally
Be aware of own triggers
Manage emotional responses
Provide breaks (especially during activities that induce strong emotions)
Consider use of adjunctive supports such as scented oil diffusions, stress balls, soft lighting, soothing background music etcetera
“Frozen” or “Spacey”
Rapid mood changes
Angry or Hostile
Weepy
Over-reacting to words/behaviors of other people
Difficulty sitting still/”antsy”
Disinterested or Uncooperative

22. Trauma Informed Care Approach
Physical Safety
Emotional Safety

23. Actively seeks to Resist re-traumatization
Trauma Informed Care: Substance Abuse & Mental Health Services Administration (agency within the U.S. Department of Health and Human Services) A Program or Organization which is Trauma Informed:
Realizes the widespread impact of trauma and understands potential paths for recovery;
Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
Actively seeks to Resist re-traumatization
Source =

24. Trauma Informed Interventions
Incorporates the following principles:
The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery
The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety
The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors

25. Responding to Human Trafficking Victims/Survivors
Respect differences & avoid assumptions
Create a safe space for communication
Establish rapport & trust
Maintain confidentiality
Assist the person to identify, express, & cope with feelings
Facilitate exploration of options & potential repercussions of options
Provide affirmation & moral support
Support the victim’s/survivor’s decisions

26. Sample Questions to Ask
Has anyone ever controlled, supervised or monitored your work or actions against your will?
Has anyone ever forced you to do something physically or sexually that you didn’t feel comfortable doing? If yes:
Was the person who forced you given money or other benefits for the acts you were forced to do?
Was there ever a time when you wanted to leave but felt that you couldn’t?
Did you feel it was your only option to stay in the situation
What do you think would have happened if you left without telling anyone?
Has anyone threatened you or a family member with harm?
Did any one ever introduce you to drugs or medications?

27. Screening Tools for Human Trafficking (Adults)
Office on Trafficking in Persons, “Adult Human Trafficking Screening Tool & Guide” January creening_tool_and_guide.pdf
National Institute of Justice, “A Screening Tool for Identifying Trafficking Victims” September 2016, trafficking/Pages/screening-tool-for-identifying-human-trafficking- vicitms.aspx

28. Screening Tool for Child Sex Trafficking & Commercial Sexual Exploitation (Children’s Health Care of Atlanta)
“Clinical Practice Guideline for Assessment and Treatment of Potential Victims of Child Sex Trafficking and Commercial Sexual Exploitation (CSEC)≥ 11yrs old”, May guideline-may pdf
Prior to beginning the survey, build rapport with the patient. Indicate that you routinely ask these questions of adolescents so that you can find out whether or not they may need help, and if so, how you might be able to help them. Emphasize that the child does not have to answer the questions if he/she doesn't want to. Also remind them of limits of confidentiality (cannot guarantee that caregivers or others won't eventually get access to the chart and see information;
you are obliged to tell authorities if child reveals possible abuse or thoughts/actions related to hurting themselves, or others).
6 baseline questions with 2 follow up questions if 2 or more yes answers to the baseline questions ~ Sometimes kids are in a position where they really need money, or they need drugs, or they need food or a place to stay. They feel they have no option except to exchange sex or some sort of sex activity for the money or the other thing they need. Have you ever had to exchange sex for money, food, shelter or something else you needed or wanted?

29. Commercial Sexual Exploitation-Identification Tool (CSE-IT)
Originally developed in 2014 by the West Coast Children’s Clinic
Piloted over 15 months
56 agencies in 22 California counties and San Antonio, Texas
Revised in 2017 to CSE-IT 2.0
Evidence-based screening tool designed for use in multiple child-serving systems, including schools, health care, social service agencies, law enforcement
Download a copy of the CSE-IT or learn more about other versions of the tool at

30. Point of First Contact with Potential Survivors
Current Client who recently divulges the information
Advocate-in-Person responding to a crime scene
Referral from another organization

31. Case Management Approach
Case Management Approach includes:
Assessment of needs regarding services and supports
Identify/Coordinate/Manage services, treatments, and supports,
Coordinate and Manage Communication across multiple systems
Act as a liaison for the victim/survivor
Collaborative process intended to promote quality of care and cost- effective outcomes to enhance the physical, psychological, and vocational health of the Victim/Survivor

33. Core Competencies
Just as with intimate partner violence and sexual assault survivors, case managers who work with victims/survivors of human trafficking must be educated in:
Victim/Survivor Issues
Crisis Response
Violence Prevention
Multi-disciplinary Cooperation

34. Conceptual Framework for Trauma Informed Practice in Case Management
Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences
View Trauma in the Context of Individuals’ Environments
Minimize the Risk of Re-traumatization
Create a Safe Environment
Identify Recovery From Trauma as a Primary Goal
Support Control, Choice, and Autonomy
Incorporate Universal Routine Screenings for Trauma
Use a Strengths-Focused Perspective: Promote Resilience

35. A Closer Look at Case Management
BENEFITS
CHALLENGES
Consistency of a “point person”
Critical aspect to move from victim to survivor to thriver to victor
Client care tailored to meet specific needs
System navigator for the victim/survivor
Stabilization of situation so that victim can work with law enforcement/legal services
Serve as a constant source of support during the investigation & prosecution of the traffickers
Limited financial resources, especially for domestic victims/survivors
Lack of accessible/available services
emergency/permanent housing
dental services
mental health services
Length of service eligibility
Access to needed information
Burnout /turnover of case management staff

36. Best Practices in Case Management
Identify Primary Case Manager for each victim/survivor
Identify appropriate services
Understand the limitations of each service provider’s response capacity and the funding restrictions under which they operate
Remember that needs assessment is not a static step, but rather an ongoing process of engagement
management-service-planning/
Identify appropriate services. Few victim service providers offer a comprehensive array of services to all types of trafficking victims in-house. To address the victim’s needs, a diversity of service providers are needed as Task Force partners. Use your Victim Services Committee to map out potential needs and identify appropriate resources.
Understand the limitations of each service provider’s response capacity and the funding restrictions under which they operate. For example, service providers that typically work with homeless youth may not be equipped to assist adult victims, and immigrant-serving groups may not be allowed to provide services to U.S. citizens.
Remember that needs assessment is not a static step, but rather an ongoing process of engagement. As one set of needs are met, another may be identified, particularly as the victim’s case moves through the criminal justice process.

37. Case Management Phases
Crisis Support
Transitional Support
Sustainability Support

38. Similarities between Domestic Violence, Sexual Assault, and Trafficking Survivors
Survivors face similar barriers to leaving abusive situations and reintegrating in their community
Survivors may have similar needs for basic services and safety planning
Survivors may experience significant economic and financial abuse and need to create economic independence

39. Stages of Recovery http://humantraffickingelearning
Victim
Survivor
Thriver
Victor

40. Needs of Victims/Survivors
Crisis Intervention
Safety Planning
Basic Needs
Transportation
Advocacy
Links to other providers
Resources/Referrals
Goal Setting
Counseling
CBO/FBO May Provide:
Gift cards or Pantries for food/gas/clothes
Funds for housing
Healthcare services
Financial literacy assistance
Education/Job skills training
Mentorship/Spiritual support
Non-paid accompaniment

41. Using Collaboration to Assist Survivors
Case Manager
Law Enforcement
Government Agencies
Faith Based Organizations (FBO)
Community Based Organizations (CBO)
Healthcare Providers
Schools & Colleges
Businesses
Legal Services

42. Government Services
Victims/Survivors of Human Trafficking who meet eligibility criteria may be able to access these resources
Temporary Assistance for Needy Families (TANF)
Children’s Health Insurance Plan (CHIP)
Substance Abuse & Mental Health Services Administration (SAMHSA) Programs
Supplemental Nutrition Assistance Program (SNAP)
Special Supplemental Nutrition Program for Women, Infants, & Children (WIC)

43. Housing
Emergency shelter funds are available from federal victim assistance programs through Immigration and Customs Enforcement's (ICE) Homeland Security Investigations (HSI) and the Federal Bureau of Investigation's (FBI) victim specialists for up to 30 days if there are no other resources available.
Take into consideration short-term housing options for victims with a criminal history that may prohibit them from placement in other housing.
Victims that are also fighting addiction and substance abuse are often prohibited from placement in most shelters, including trafficking shelters

44. Coalition to Abolish Slavery and Trafficking (CAST) offers free support to social service providers assisting trafficking survivors with legal needs in the following areas:
Criminal Victim Witness Advocacy
Criminal Re-Entry
Immigration
Reporting to Law Enforcement
Civil
Referrals
Program Support
Ethics & More
To receive individualized assistance, please Please allow 72 hours for a response.

45. Documentation
Realize that records may be subpoenaed for legal proceedings
Case Notes
Factual & Objective
Identify by client code rather than by name
Case Note Examples
I drove Miguel to medical appointment. He is distraught to learn he has syphilis from being forced to engage in sex acts with males
I drove client #MG for a medical appointment. Arrangements made for follow-up care

46. ICD-10 Human Trafficking Codes
Went “LIVE” on October 1, 2018
Allows for differentiation of human trafficking from other forms of abuse
Supports appropriate treatment of victims
Retrieved from: 09/icd-10-code-human-trafficking.pdf
Existing ICD-10-CM abuse codes fell short of differentiating victims of human trafficking from other victims of abuse. Without proper codes, there was no way for clinicians to classify adequately a diagnosis and to plan for the resources necessary to provide appropriate treatment. This also prevented critical tracking of the incidence and/or reoccurrence of labor or sexual exploitation of individuals.
As urged by the AHA’s Hospitals Against Violence initiative, the first ICD-10-CM codes for classifying human trafficking abuse were released in June AHA’s Central Office on ICD-10, in partnership with Catholic Health Initiatives and Massachusetts General Hospital’s Human Trafficking Initiative and Freedom Clinic, proposed the change.

47. Case Study

48. “You may choose to look the other way, but you can never say again that you did not know.” ~ William Wilberforce

49. QUESTIONS???

50. Credible Sources for Information on Human Trafficking
National Human Trafficking Resource Center
Polaris Project
HEAL Trafficking
International Justice Mission
Human Trafficking eLearning
U.S. Department of Health & Human Services
U.S. Department of Homeland Security

51. Resources & References
Utilizing Trauma Informed Approaches for Human Trafficking related work
Federal Services available to victims of trafficking available-to-victims-of-trafficking
Office for Victims of Crime vital-role-of-case-management-service-planning/
Human Trafficking: A Trauma Informed Health Care Response (webinar) events/human-trafficking-trauma-informed-health-care-response
SOAR Online Training (U.S. Department of Health & Human Services)
Children's Healthcare of Atlanta. (May 2015). Clinical Practice Guideline for Assessment and Treatment of Potential Victims of Child Sex Trafficking and Commercial Sexual Exploitation (CSEC) ≥ 11yrs old pdf

52. Resources & References
Clawson, H., & Dutch, N. (June 2008). Case Management and the Victim of Human Trafficking: A Critical Service for Client Success. U.S. Department of Health and Human Services.
Futures without Violence. (May 2017). Anti-Human Trafficking Resources.
Heffernan, K., & Blythe, B. (2014). Evidence-Based Practice: Developing a Trauma-Informed Lens to Case Management for Victims of Human Trafficking. Global Social Welfare, 1(4), doi: /s
Macias-Konstantopoulos, W., & Owens. J. (January 2018). Adult Human Trafficking Screening Tool and Guide. U.S. Department of Health and Human Services (HHS), Administration for Children and Families, Office on Trafficking in Persons (OTIP), contract number HHSP I/HHSP
Office of Justice Programs. (n.d). The Vital Role of Case Management & Service Planning (in the Human Trafficking Task Force e-Guide).

53. Resources & References
Egyud, A., Stephens, K, Swanson-Bierman, B., DiCuccio, M., & Whiteman, K. (2017). Implementation of human trafficking education and treatment algorithm in the emergency department. Journal of Emergency Nursing, 43(6),
Greenbaum, V. J. (2017). Child sex trafficking in the United States: Challenges for the healthcare provider. PLoS Med 14(11): e
Lederer, L., & Wetzel, C. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law, 23(1),
Recknor, F., Gemeinhardt, G., & Selwyn, B. (2017). Health-care provider challenges to the identification of human trafficking in health-care settings: A qualitative study. Journal of Human Trafficking, 4(3),
Washburn, J. (2018). Update: What nurses need to know about human trafficking. Journal of Christian Nursing, 35(1), doi: /CNJ
Wyatt, T., & Sinutko, J. (2018). Hidden in plain sight: A guide to human trafficking for home healthcare clinicians. Home Healthcare Now, 35(5), doi: /NHH