Hi, everyone. Good afternoon. My name is Dr. Janal Patel. I'm a PGY2 at Maimonides Medical Center. And with me are Dr. Erica Cohen-Mayer, also a PGY2 at Maimonides Medical Center, and Dr. Maria Bodic, who is an attending psychiatrist at Maimonides. Today's talk is going to be about human trafficking and the impact of that on our patients, our work, and what we can do to better understand it and advocate for those that we come across that might be impacted by human trafficking. So the objectives for today's talk will be to basically name the basic types of human trafficking and identify some red flags that can be used to identify the victims, learn common questions, and screening items that we can use to better understand and identify these victims, and also understand the role that we, as health care providers, play when assessing and treating victims of human trafficking. We're also going to talk a little bit about more of a public health point of view, talk about some social determinants of health, and wider implications of who is affected by human trafficking, and then go a little bit into trauma-informed care and list some resources that can help support those that are impacted by this. So to start off, I want to just briefly define human trafficking. At its core, it's the act of ultimately stealing freedom from an individual or a community by the use of force, fraud, or coercion. And the ultimate aim of this act is profit of some kind to exploit the individual or the community for some kind of profit. This way of conceptualizing human trafficking is something that I personally found helpful. So human trafficking involves three main aspects to it. The first aspect is some kind of action that is an entry point to force individuals into human trafficking. This can include recruiting them, harboring them, transporting them, providing them something, whether it's something financial or a shelter, housing, clothing, something material. It can also involve patronizing, soliciting, or advertising to basically recruit these individuals. The second component of this is you need some kind of means to perpetrate this action. So usually, these actions are enforced through some kind of force, whether it's physical or otherwise some kind of fraud or coercion, which usually involves threats or some kind of emotional abuse. And ultimately, the means and the action are done for a specific purpose. The two main categories of human trafficking that we're going to focus on today is commercial sexual exploitation or forced labor. So here we have just a visual representation of some statistics globally in human trafficking. One thing to note is that it is an industry that generates billions of dollars per year. The estimates and the statistics are kind of wide ranging, because it's not always something that's reported very specifically, but something that's reported in the media. 50% of slavery victims are in labor slavery. A lot of the time, you can have victims in forced marriages. 12.5% of slavery victims are in sex slavery. And 71% of slavery victims are women and girls. Lastly, 25% of slaves today are under the age of 18. So here is a map of the United States, looking at cases by state. And so as you would guess, the larger cities, larger states, have the higher amounts of cases. So New York, California, Texas, and Florida are the highest. So I'm going to go through some statistics. And I'm going to start with the most recent one, which is the number of cases per state. So I'm going to go through some statistics, basically demographic factors that were compiled through something called the Polaris Project. The project is basically a compilation of data that is gathered through the National Human Trafficking Hotline. Individuals that want to report incidents of human trafficking call this hotline, and then specific data is gathered when these reports are made. And the data that I'm gonna share with you is a compilation of all of that information. So when it comes to human trafficking, in terms of the gender, the vast majority of victims of labor trafficking are men, with 48% being male. And about what's relevant is about 30%, for about 30% of the victims, the gender is unknown, and 22% are female. When it comes to sex trafficking, on the other hand, 79% of those that are affected by trafficking are female, 7% are male, and the gender of 13% of the victims is unknown. The second key demographic variable is the immigration status of the likely victims. So when it comes to labor trafficking, about 73% of those affected are foreign nationals, only about 3% are either U.S. citizens or legal permanent residents, and the immigration status of 25% of the victims is unknown. In comparison, interestingly, for victims of sex trafficking, for 92% of these victims, their immigration status is not known when the report is made. And 4% are foreign nationals, and 5% are basically U.S. citizens or legal permanent residents. The second thing that I wanted to focus on is the race and the ethnicity of the likely victims. So for labor trafficking, 47% of those that are affected are Latinx individuals, and the race of 41% is not known when the reports are made. In comparison, for sex trafficking, less demographic information is known. As we saw on the previous slide, for 81% of the victims, their race is not known when the report is made. This slide goes into the age at which they basically entered into the human trafficking and into the exploitation. For the vast majority of the individuals, their age isn't known at the point of entry. 28% are minors and 9% are adults. There has been an increase in the amount of adults for whom the report was made between 2020 and 2021, with a 27% rise in the number of adults that were reported to be affected by human trafficking. For this slide, basically the main take-home message and the main thing that I want to share here is that there are three major types of recruitment tactics that affect the vast majority of the victims. The first one is familial. So what that means is that the individuals that recruit people into human trafficking know the victim a lot of the times and are related to them somewhere, through a family connection or through, either they are a first-degree relative or a distant relative, but in some way, the victim knows them. The second recruitment tactic is through someone approaching them as a potential partner or proposing marriage to a specific victim. So people can approach potential victims on dating sites or just in bars or in other settings and sort of become more intimate with them prior to recruiting them in human trafficking. And the final way in which, most common way in which individuals are recruited into human trafficking is through job offers and advertisements. So oftentimes, victims are promised some kind of job and a lot of the times, the details of those jobs are not made clear or the people that are advertising these jobs are very guarded about what this job actually involves. It's extremely misleading, especially for individuals that might be immigrants into the United States. So for 28% of the individuals, the recruitment tactic is familial, 24% are affected by intimate partner slash marriage proposition tactics and 31% are affected by job offer slash advertisement tactics. This kind of just summarizes what I had said and another thing I wanted to highlight is the top three recruitment locations. So where are these individuals usually located? So some of the most common means are online means. So either dating sites or social media like Facebook, about 23% are recruited through online means and 11% are approached just on the street. So like I said before, in bars, in other locations where people might interact socially. So it's very difficult to generalize what kind of areas might be at, where people might be at risk of being recruited into human trafficking just because of the broad nature of these locations. Where we come in as healthcare providers is something I'm gonna talk about through this slide. So the vast majority of victims of human trafficking encounter a healthcare professional at some point while they're victims of human trafficking. About 88% of those that are involved in human trafficking encounter a healthcare professional at some point and the vast majority of those encounters occur in the emergency room. So 68% of these individuals that do encounter a healthcare professional encounter them in an emergency room setting. And for us, this highlights the need to educate healthcare providers to better understand what these victims may look like, some of their red flags, so that we're able to screen them and support them when we do come in contact with them. So we'll be doing a small group activity. We'll split up into three groups. I think it comes to about four people per group. And each group will look at a different type of case example of human trafficking. What we want you to think about when you're going through this case, and we'll go through each case together afterward, are what other information would you wish to know? What red flags do you notice? What kind of trafficking do you suspect? And what would you do next? So I will come around and give out the cases. Maybe, I think, yeah, spatially we can make that work. And as we go into this activity, I don't know how you guys learn, but I learn best through doing. I just wanna get a sense of our audience. First of all, I wanna highlight the fact that we're all women in here, both the presenters and the audience. I know I'm assuming the gender, so if those of you who are in the audience who do not identify as a female, I apologize if I've offended you. But I can't help to have this feeling that we care, and that's why we're all in this room. And I just wanna see a show of hands. How many of you are psychiatrists? Almost everyone. Anybody a social worker or a psychologist? Anybody a trainee? A couple of trainees, great, okay. And as we start working on the cases, I also wanna tell just a very, very brief story of how this came to be. Our hospital is in Brooklyn, about two blocks away from Brooklyn Chinatown. So there are a lot of folks who are undocumented who were brought here at a very, very high cost. It's usually $30,000 to $40,000 that they've paid to their smugglers. And they are obligated to work in various settings, usually massage parlors, nail salons, back of restaurants in Chinatown to pay off that debt. But usually that debt never gets paid off. We're also a few blocks away from Sunset Park, which is a Hispanic neighborhood. A bunch of undocumented folks over there as well. And we've had a couple of human traffic, a couple, more than a couple, several, human trafficking victims in the emergency room that kind of sparked our curiosity of how big is this problem in our neighborhood and what can we do to address it. So as you take a look at the cases, think of through these questions and we'll maybe give five minutes and then we'll all discuss as a group. All right, we're hoping that you all had a very interesting conversation among yourselves. And we are looking forward to having you share with the group what you came up with. So I'll start by, I told you a little bit as you were going into the groups of kind of how this project came to be, but I'll just give another context to this story because these are real patients that we've seen in the emergency room. So one of the residents and myself were on call overnight, and we had seen this lady. I'm gonna read out the case out loud for those of you who did not have case number one. And then after multiple visits, we were like, something is not sitting right. Something's happening here. So I'm hoping that you had a similar feeling when going through this case, and I'm looking forward to hearing what are some of the things that you came up with, some of the information that you would wanna know. So she's a 34-year-old female. She speaks Mandarin primarily. She understands basic English, but not enough to engage in a psychiatric conversation. She has no previously documented medical history or psychiatric history. This was visit number one, by the way. She came multiple times to our emergency room, but when we first saw her, we didn't have any prior diagnosis. And this was what was documented in the chart. Was found by security on the streets nearby the hospital yelling and throwing things. Patient had a knife, gasoline, and lighters in her possession. This is kind of the ambulance report slash NYPD report that the patients come in. And then on the interview, through a translator, she said, I want to kill people who stole my money. I want to kill the director of the hospital. I was tricked into coming to the United States. I'm the only doctor of the Chinese president. She was drugged with morphine, reports Crystal Matthews. And at some point during her stay in the ER, she became combative. She wanted to leave, but wasn't really able to express herself or say where she would go, what she would do. And when the mental health aides that we have in the ER and security tried to redirect her, she became combative and aggressive towards them. So she ended up having to receive intramuscular medications to manage her agitation. Actually, let me stop here for a second. When you see this first part of the case, is anything here that makes you think human trafficking? Or is this more or less of a usual substance use disorder, intoxication case that you see in the ER? And this question is for everyone, not just the group who had this case. And she actually said that to us. I think the trick for us becomes when someone comes in intoxicated and they're saying a lot of things, like I'm the daughter of the Chinese president, it's very hard to balance which part do you take seriously. I've been tricked into coming to the US or I'm the daughter of the Chinese president. So it was not even on our radar. We kind of documented exactly what she said without really thinking of any particular items that came up. So she received the medications, she slept for a number of hours, and then she was re-evaluated. And that time she really said that she does not want to talk to a doctor, she just wants to talk to the police. There were amphetamines in her urine, which she had told us when she initially came in, she said she had used crystal meth. We thought that some of the things that she was saying, like the fact that she was the daughter of the Chinese president, might have been psychosis, possibly in the context of substance use. She again talked about her meth use. She said she didn't have a place to stay. She answered yes when asked about history of sexual abuse, but didn't really give many details. And when prompted about her past psychiatric history, she denied any previous attempts, said she had never been physical with anyone, had not had any legal history. She said she had been admitted in the past, but couldn't give any details. However, after the sleep and the monitoring, metabolization, medications, she really looked much better. She was calm, she didn't seem paranoid, suspicious in any way. She said she was not interested in any help from us, substance use or mental health or otherwise, and just wanted to be discharged. Didn't really want any referrals or any other support from us. So this is where we are in the morning with this presentation. For those of you who discussed this case, and I'm gonna go back to the questions just so we have this in mind. What other information would you like to know? Are there any red flags in addition to being tricked to come into the United States, one that we highlighted? Do you suspect any particular type of trafficking? And what would you do next? Which group had this case? You guys, all right. Jump in. The one thing, going back to our topic today, which is human trafficking, the one thing that she said that was potentially a big red flag or a hint is she was tricked into coming to the United States. But again, saying that in the context of all the other things she said, did not ring a bell for any of us. And it wasn't actually until three visits later when we started putting 2N2 together. So I'll just share, because we need to get to the other case. I'll just share that when we see patients, usually in the emergency room, they have already been changed into gowns, meaning we psychiatry. So we did not see how she looked like when she came in. But at some point we saw her when she left. And her clothing was really kind of high quality, but also revealing. She had jewelry. She had a purse that looked very fancy. We did not figure out where she got the lighter or the gasoline, but she did have a pocket knife in her purse. And just there was a disconnect between I'm homeless, not employed, and kind of the clothing that she was wearing, the jewelry, the makeup, kind of all of these other things. And then only by the third visit we kind of put 2N2 together. I've been tricked into coming here. I have these fancy things. So we started asking her some questions which we're gonna bring back in a bit when we go to the screening tools and kind of more and more got revealed through that. But it was not on our radar at all the first, second time we saw her. And it took us quite a while to get to this suspicion. Unfortunately I don't have a happy ending to this even though we were able to confirm that she is under someone's influence. We don't know the details. She was not interested in pressing charges. And we provided her with resources, but that's kind of where it ended. At least as of now we'll see what happens next. So I'm gonna invite my colleagues for the second case. So I'm going to go through case vignette two. Who had this case? Which group had this case? Okay. So for those of you who didn't get this case I'm gonna run through the case and then we'll go through the same questions with this case as well. So I saw this case in the emergency room as a PGY-1. This case is about a 13-year-old Spanish-speaking female. She was brought to the ER by ACS after ACS was talking to her in her home. And while they were talking to her she ran towards the window and attempted to jump out. Per the ACS worker that was there and per the patient she was at home with, at that time, what she called family. And ACS has visited her because she had missed multiple days of school for the last three months. The patient kept telling ACS while they were there that she needs to go to work for her family and she can't go to school because of that. However, the ACS worker kind of kept reiterating to her that she's a minor and because she's a minor she can't work, she has to go to school and they are going to ensure that she is going to school from here onwards. When she heard this she became really distressed. She started crying. She had what they described as a panic attack. And then sort of suddenly she turned and she kind of leaped towards the window and they managed to drag her back and bring her to the emergency room. On my evaluation she had an individual at bedside, a female individual. At that time she said that this person was her elder sister. When I spoke to the individual they said that they were the patient's aunt. So there was a discrepancy there. On my evaluation the patient basically said that she had flashbacks and nightmares that were distressing to her. She, when I realized there was discrepancy I asked the individual to kind of completely step out of the emergency room and stay in a separate waiting area. The patient then described being smuggled across the US-Mexico border by gang members and had said that when she was first smuggled there was a large sum of money that basically her family needed to pay off. She was smuggled in order to engage in prostitution so she can work to pay off her family's debt. After my evaluation I went to the waiting area to find this family member but they had left and was not contactable. They had left a phone number which I called and left voicemails on but there was nothing. We didn't hear back from this individual. So the patient had pretty severe symptoms of PTSD and eventually was admitted to a child inpatient unit. ACS was updated as well. Other details about this case that were on the slides is that the patient also reported having a boyfriend who was an adult and one of the reasons why ACS was called by the school as well is because of this history of having a partner who was an adult. So I'm gonna go back to these questions that we were talking about. What other information would you want to know about this case? What red flags in particular do you notice? What kind of, I mean it's kind of obvious from what I said about this case of what kind of trafficking do you think this is and what would you do next for this case? I found it, it's great that you mentioned that you shouldn't assume where this patient is from just because she was smuggled across the UX Mexico border. So the patient is actually from Guatemala and she is not, she was not from Mexico. We had to, she was held in the emergency room at the time for multiple days because at that time there were no beds available in the child inpatient units. She was essentially boarding. So at that time we did a lot of digging basically to try and identify who her parents are and where they are. And through liaising with ACS and like social work we were able to find like a distant relative that lived in the United States and then we were then able to get the contact details of her parents from there. Absolutely, one of the biggest red flags was the discrepancy between what the patient said her relationship was with the individual at bedside and then what the individual said their relationship was. For any psychiatric cases usually the family member or the relative shouldn't be at bedside. But I think for me this case really drove it home that it was really important to separate whoever the adult was in the room from the patient so that I can get an account of both sides before they have a chance to kind of talk amongst themselves about it. Initially as with the case that Dr. Boddick described this patient was very, very guarded and before all this information came out initially it looked like she had attempted to harm herself because of school refusal that she didn't want to go to school and she kept talking about her not enjoying school and not wanting to be at school. But when we started talking about her sleep she started talking about nightmares and as she started describing her nightmares I asked her very specifically to describe the content of those nightmares and that's where we kind of went into this further detail about what she had experienced prior to that she had just talked about not wanting to go to school. She felt that by sharing the information with the team that she would be putting her parents at risk in Guatemala and so that was the main reason for why she actually didn't want to share any information because she didn't know whether this would mean that there would be significant consequences for her family back home. So those were all great points. The red flags for this patient, absolutely like you said was her immediate kind of reaction to jump out of a window and endorse SI as soon as she was told that she can't work and the fact that the presenting complaint was that this child wanted to work and ACS was preventing the child from working. And the type of trafficking in this case was sex trafficking and in terms of what we would do next like you said we admitted her to an inpatient unit and ACS was involved and she needed extensive social support and also she needed a lot of reassurance and liaison with her family. A big stressor for this patient was the fact that she felt responsible for her family's safety and well-being and we needed to be really, really proactive to ensure that she was in constant communication with her family so that she feels reassured that she's not inadvertently harming her family by seeking help or by disclosing what she's experienced. Any questions about this case before we move on to the next case? So who had case three? Okay, so I'll go through the case. This is actually a case more so in the medical ER and it can have us thinking about what kind of things do we talk about with our colleagues who are not in psychiatry and how might it play out if the patient isn't seen by psychiatry at all. So this is a 45-year-old Spanish-speaking man who comes to the ER with low back pain. He's accompanied by his employer who acts as a translator. The employer states that the patient works for him as a farmhand and spends a great deal of time bent over performing repetitive tasks. On your initial eval, the patient looks thin, fatigued. He's avoiding eye contact and sitting quietly as his employer answers all of your questions on his behalf. With some finagling while the patient is going to x-ray, you ask the employer to wait in the waiting room and continue the interview with a certified medical interpreter. Before we go on, what kind of red flags are you noticing here? Yeah, yeah, yeah, so I agree. I think that is the number one red flag here is that the employer is doing all the talking on behalf of the patient. I think that any provider in an emergency room would find that peculiar, if not, you know, concerning. And like you said, it can be really difficult to separate these types of people, and so you have to kind of think on your feet. And it was sort of like an excuse was made, hey, patient's going to x-ray, we need you to wait in the waiting room, and that's when the opportunity arose to talk to the patient alone. So I'll keep going. The patient, now that you're able to talk to him alone, says that he works long hours, he has substandard living conditions, he doesn't have access to nutrition or transportation, is all provided by the employer. He gets to make one phone call to Mexico per evening to his family, and so you start talking about just vaguely or generally, are you open to hearing about how we might work on changing this situation, talking about different housing options, and you know, things like that. And the patient expresses concern about his immigration status and potential deportation. And so this is the kind of place where we hit maybe a bit of an impasse, like you all had been talking about. And when patients are not really open to talking about things, it feels like our hands are tied. So I am curious, what would you do next? What else would you want to know? And how would you deal with this case in the emergency room? I like that idea, but you know how emergency rooms work and you know how no one wants to admit patients to their services. I think that's a great idea because it would also be providing the patient with a safe space and maybe opening the door to more conversations. But, you know, say medical workup returns negative, there's not a whole lot I can do to admit this patient. I talk to him about back care and then, you know, what else would you do or what else can you think of? They also posed the idea of wondering if you could also sexually contact the patient. Yeah. You know, go back home, you know, turn it over. Right. And just make eye contact. What kind of questions would you ask to get at that? Mm-hmm. Yeah, and the thing is again with these patients is a lot of the time it's just no I'm fine, no I'm fine, no I'm fine, but it really is up to us to ask those questions. Exactly, so it's about creating that safe space and even a therapeutic alliance, even if you're coming from the side of medicine or emergency medicine, and reminding patients that they can come back. It becomes a sticky situation when the patient depends on their employer for transport and for nutrition and for medications. I think one thing that we do in the ER is actually talking to the patients about writing down the hotline phone number as a generic follow-up phone number. You would obviously have to work this out with the patient because it depends who will be making those follow-up phone calls, but creating at least a bit of a plan for having a resource that the patient can use once they leave the hospital is kind of the idea. So yeah, putting down that phone number on the discharge paperwork and that's really all. Right, and you can ask all these questions and you can kind of try to glean as much information as you can, but there's only so much you can do, right? Any last thoughts or questions on this case? Okay, so following on from these cases, I'm just going to go through some of the important red flags for both adults and for children that are evidence-based and have been compiled through data gathered from initiatives such as the Polaris Project. So one of the most significant red flags is when a, for an adult, is when a third party, so someone like an employer, is in control of their schedules, their social interactions, who they can see, who they cannot see, and as you saw with Dr. Cohen-Meyer's case, having an employer that speaks for you as well kind of comes into that drive of controlling the victim of human trafficking. Another red flag is significant isolation from their community, family, or friends. A lot of the times victims are trafficked across states, across countries, as was the case for the child vignette that I shared. They live miles or sort of just continents away from their family members sometimes. Another pretty kind of, it seems obvious, but another one for adults is evidence of violence, so bruising, swelling, scarring, injuries that they either don't want to seek help for or that they minimize or they go to great lengths to conceal. Another one, and this is also significant for patients that we see in our hospitals, specific tattoos or branding. If there are large human trafficking operations in a specific area, there might be repetition of specific tattoos that you see between victims, or they might be in a specific place. They might have specific logos or letters or wordings that if you ask the patient about their meaning or what the tattoo kind of means to them, they're not really able to coherently explain what the significance is of this tattoo for them. Another one, and this links back to the case that Dr. Borik went through, specific clothing that sometimes isn't in keeping with the social situation they describe or with the weather or with the situation that they're in is also a red flag. In the case that we discussed, having pretty expensive clothing, purses, when the patient says that they're homeless is a red flag. Another one is having frequent changes in housing. If a patient repeatedly comes back to the emergency room, for the first time they gave one address, another time they give a different address, another time they give a different address, and they're not really able to again describe what kind of housing this is, or they might not be able to explain what caused the shift between one house to another house. Again, this drives home the point of taking a really detailed social history from these patients, trying to understand the logic and rationale between changes of employment and changes of housing. Another huge red flag is identification documents in the hands of a third party, so asking questions like, do you have access to your passport? Do you have access to your birth certificate or your identification documents? In the initial case, when the patient had said that they were tricked into coming to the United States, this question might be pertinent, whether they have access to the documents that they used to come into the United States, or if they don't, do they know where they are? And who has access to them? The next one is malnutrition, dehydration, or just looking frail, and this again applies to the case that Erica shared, Dr. Cohen-Mess shared, signs of malnutrition, signs that they might not be getting adequate access to food, to a shower, to basic things that most individuals that might be living in a house by themselves, for example, if they claim to do that, would have access to. Other couple of risk factors are kind of medical complaints, so dizziness, headache, memory loss. Again, memory loss and headaches can be from traumatic brain injuries, which may be a result of physical trauma or sexual trauma that the victims might experience, and chronic undertreated diseases that might not necessarily correlate with a specific disease, so for example, shortness of breath, chest pain, chest discomfort, which again might be a result of substance use if these patients are being drugged or pollution, or it also might be somaticization if they're going through significant abuse. And the final red flag that I'll go into is current substance use or alcohol use disorder. A lot of the times these individuals are pretty stigmatized, and they are very guarded, as we shared. They don't really want to talk about the experiences that they're having, and if they come in intoxicated or they come in with paraphernalia that indicate that they use substances, there is almost a second layer of stigma that is added to these patients where their accounts, their concerns might be minimized because they look like they're intoxicated. But substance use and alcohol use disorder is a one of the biggest red flags for these individuals, and it's something to keep in mind when assessing them. For children, some of the red flags are similar and some of them are a little bit different. So the first risk factor is changes, abrupt changes sometimes or chronic changes in school attendance habits, appearance, friend groups, interests, attitude, just the way they interact with other people, and liaising with school workers or ACS is really important to get this background for child patients. Access to luxury items like manicures, designer clothes, purses that the parents haven't provided this individual, and it seems not in keeping with their socioeconomic status and they're not able to explain how they got access to these items. Another red flag is truancy, so multiple runaway attempts and frequent violation of rules. The sexually provocative clothing is again similar to the red flags that I shared with adults. Another one is what they have in their belongings, so things like hotel key cards. Children really shouldn't have access to these on their own, but if you find things like a hotel key card or refillable gift cards, again things that the parents don't have but they have access to, that is a huge red flag. For children that are smuggled, that don't live with their parents or they don't have their parents around them, lack of any identifying documents, lack of a birth certificate, a passport, any kind of ID. The next red flag is having claims of an older partner, either an older boyfriend or an older girlfriend, as was the case with the child patient that I talked about. A lot of the times the individuals that solicit them into human trafficking approach them as a potential partner, and that is an entry point for coercion into human trafficking. So individuals that claim that they have an older boyfriend or an older girlfriend might not be a red flag just for sexual abuse, but also for human trafficking of child patients. Another one is having covert social media accounts, like we talked about before. Social media and online accounts are one of the biggest locations as an entry point into human trafficking, so having social media accounts that the parents are not aware of, that they go to great lengths to hide, is another red flag. As with adults, unexplained injuries, bruising, swelling, and then finally in children that are part of the juvenile justice system or the foster care system are some of the greatest at-risk individuals for human trafficking, so that's another thing to keep in mind when assessing them. This slide just summarizes overall the five most common risk factors per the Polaris project. So the biggest risk factor is recent migration slash relocation. Individuals that are recently immigrated and relocated by force especially have an enormous amount of vulnerability, and they are pretty open to exploitation for that reason. The next risk factor is having persistent physical or mental health concerns. The next one is having some form of substance use. Unstable housing is another one, and the last most common risk factor is runaway or homeless youth. Dr. Conway is now going to talk a little bit more about specific types of human trafficking. So I'll start with a bit about sex trafficking, just the way we define it as recruitment, harboring, transportation, provision, or obtaining of a person for the purposes of a commercial sex act, and this is induced by force, fraud, or coercion, and those words will continue to come up again and again because that's really the meat of human trafficking. So some specific indicators and red flags to think about with sex trafficking would be controlling or dominating relationships, and we can see this play out in our emergency rooms. Sometimes we'll have partners come to the ER with patients who are so controlling that they won't leave the patient's side, and so this is when we have to involve security to get our patients alone. You want to be aware of children under the age of 18 who are providing any sort of sex acts, people who are engaged with a manager. Sometimes that's the wording or language that will come up in patient interactions, like Dr. Patel was saying, document confiscation, so when patients don't have access to their documents or a lack of control over their personal finances. Again, these things can be hard to kind of flesh out with our patients, especially if they are acutely mentally ill, but they're just things to keep in mind. If a patient's being monitored, their movements or their communications, if they don't have access to transportation, and of course physical or sexual abuse in the history. This is just a bit of a visual representation of where sex trafficking can happen. It really can happen anywhere. It can happen or be kind of precipitated online on the internet, but it can happen across backgrounds, communities, socioeconomic strata. Some places to keep in mind are illicit businesses, like illicit massage businesses, bars and strip clubs. It can even be like through outdoor solicitation, escort services in residential spaces. And labor trafficking is defined as, again, recruiting, harboring, transporting people for labor services. Again, through force, fraud, or coercion, and this is for the purpose of involuntary servitude, debt bondage, or slavery. So some common environments to consider for labor trafficking are agricultural labor, like in case vignette number three, sweatshop factories, janitorial food service, and other service industries. But again, it can really happen in any sort of setting. Something really interesting to think about is how we are all involved in labor trafficking in some way. It can be through our clothing purchases, through the foods we consume, home furnishings like carpets, jewelry purchases, and even our hobbies. So some sort of facts about that is that minority workers in China are forced into seasonal cotton picking, and this accounts for 85% of Chinese production and 20% of world supply of cotton. Through our food consumption, bonded labor is used in a lot of the Southeast Asia's shrimping industry, and that supplies the highest amount of shrimp to the United States. Hundreds of thousands of children are forced to work in India's carpet belt. So it's really jarring to think about just the statistics here. Actually, slaveryfootprint.org is something that you all can look into afterward, and it actually is an interactive platform where you can enter some of the things you consume, some of the things in your home, and it generates this graphic of how many slaves you have working for you. I will say this is actually a very modest amount of slaves. I've done this myself several times, and it usually comes up with a lot more than 35. And I'll pass it over to Dr. Bodic. I'm assuming none of you in this room really thought that you have slaves working for you, right? It's just I strongly encourage you to play with this website. It's asking you questions like, have you gotten a manicure? Have you ever gotten a massage? Have you ever bought this? And you can answer yes or no, and then at the end it does an estimate. And it's really eye-opening. Obviously, there's not a direct slavery relationship, and I'm not saying we should not get manicures anymore, but it is something that we should keep in touch. And I wanted to talk a little bit about some of the solutions or some of the potential interventions that we could do. And there are many screening tools available out there for labor trafficking specifically, for sex trafficking specifically, for adults, for children, etc. But there's actually no validated screening tool. Despite this being a billion-dollar industry and a million lives problem, there's no validated screening tool. So we actually decided to develop our own based on a literature review. And no, we have not been able to validate it because we have nothing to validate it against. And because these three vignettes that we showed, for example, are almost confirmed victims of human trafficking. They're not actually confirmed. So it's very hard to do like a case control type of validation. But I wanted to talk a little bit about the process because this is something that can easily be done in each institution. And it can be and actually has to be customized to the community where your institution is because the specific red flags or the specific questions that you ask are gonna have to really fit into the demographic. And I told you a little bit earlier about where our hospital is geographically. So if we don't take into consideration the fact that we're two blocks away from Chinatown or five blocks away from the Hispanic neighborhood, then we're gonna miss the whole point. Not that just these two particular nationalities are at risk, but these are the folks that we see most often in the emergency room. So there are if when you read the literature when you try to kind of put this together, there are five main categories of limitations or of things to be aware of. So freedom of choice, which you heard earlier. So can you leave and whenever you want or come back whenever you want from your house? Can you choose to work or go to school? Or can you choose what kind of job to do? Who do you want to date or communicate with? Do you have access to your identification documents? We already mentioned that. Do you feel safe where you're at? What are your living conditions? And are you being forced to engage in any kind of work or sexual activities that you're not consenting to? So reading articles about this and summarizing, we did like a very classical literature review, right? You do a PubMed search by human trafficking, sex trafficking, labor trafficking. I won't bore you with the methods. We were overwhelmed by the amount of articles, like thousands and thousands of articles. So we really had to kind of limit it to specifically the ones that referred to screening tools. And this is basically what we came up with. And we did a short version and a long version because while we are psychiatrists and we work in all of the settings in psychiatry, most of the interaction that these folks have are with emergency medicine. They come to the ER for medical problems. So we wanted something that could be used by our emergency medicine colleagues very easily. So we came up with these five questions that we put on a card and on placards and distributed all over the emergency room, educated attendings, residents, nurses, techs, security, everybody who might come in contact with these folks, even the janitorial staff. Have you ever been restricted with regards to who you speak to or where you go to, including family and friends? Do you have to ask for permission to eat, sleep, or go to the bathroom? Do you have access to your IDs? Have you been forced to engage in unwanted sexual activity or labor? And have you been physically harmed or threatened? And we actually had a more layperson's version of this. These are the official questions that we published in our manuscript, but we had an adapted layperson's version of these questions. So this is the short version. We felt that this is short enough that any emergency medicine physician or nurse could ask, and it's not making their life much more difficult or it's not making the process much more cumbersome. And for any screening tool, for those of you that have maybe interacted with scales or used, you know, like PHQ-9 already has nine questions. If you wanted a little bit more detail, nobody would fill it out, right? Like when you go past the number of questions, it becomes very difficult. But we did realize that for us in psychiatry, if we end up being consulted on these cases, which we have been for VNN number one and VNN number two, we have a little bit more time and we have a different understanding, hopefully, that our emergency medicine colleagues of what are some of the other things that maybe we should keep in mind and we should ask about. So we would want to go into a bit of details about what are your living conditions, what are your working conditions. So you'll see there's some interplay here, like identification and safety are in the previous one as well. We also learned from reading the literature that it is OK to ask directly, are you being trafficked? And we didn't really think about that before, even though there's such a good parallel between asking people about suicidal ideations, right? Like we kind of finagle around or don't always feel comfortable asking these questions directly. Or we might think that we're putting thoughts in people's minds if we ask them about suicidality. But actually, the literature recommends that you should ask people directly if they're being trafficked. It should not be your first question, obviously, because that kind of kills the report. But you should be asking that question directly. And then any other questions specifically about what the person maybe has to trade in order to get their needs met, like do you have to trade shelter, do you have to trade for sex, do you have to trade sex for food shelter to get your needs met? I don't have it on this slide, but specifically for our hospital, as I was mentioning earlier, given the demographics, we ask people if they work or have ever worked in a massage parlor, in a nail salon, in the back of a restaurant, dish washing, or in kind of agriculture. Landscaping is more common because there's not that much farmland in Brooklyn. But that's usually what we hear, like they work in landscaping in Brooklyn. So these are some of the things to keep in mind. This is the screening tool that we've developed. And we came up with a flowchart. I'm realizing the font might be a bit small. And I presented this before, and I got kind of an overall outrage from the audience because this flowchart basically says that psychiatry should be called for everyone that emergency medicine suspects to be a potential victim of human trafficking. And human trafficking itself does not mean a mental illness, does not mean a need for an emergency psychiatry consult and such. But looking at the resources and availability of emergency medicine and at the fact that we, particularly in our emergency medicine department, don't have social worker on the clock, we really felt that because we have psychiatry around the clock and we're fortunate to be decently staffed, not perfect, but decently staffed, we could really try to contribute to identifying these victims if they're OK with talking to us. Obviously, this is not the same idea as a consult for someone who is considered a danger to themselves or others, meaning psychiatry will do their best to talk to them and come up with a disposition even if the patient refuses. This conversation is with the patient's consent. But basically, this flowchart says that if there's any kind of suspicion, let me see. Can you see my cursor? No, no cursor. OK, I'm sorry. So starting on the orange thing on the left side, if there's any kind of red flag identification by any provider, meaning emergency medicine attending, resident, nurse, mental health, tech, security, they bring the patient to a private space and they ask them if they're interested in having a conversation about what they might be struggling with. If they are not interested, this is the square all the way to the right, the rectangle all the way to the right. We have a little pamphlet that we put together that we give to the patients with the information for the hotline, how they can report, some shelter things. We have a slide at the end with the resources that we're going to share. And then we also have a small business card-like thing where we've converted the normal number for the hotline that has 888. We change those to 000. And we tell that to the person verbally. But if, let's say, that card that we give them gets taken by their employer, their trafficker, whoever that might be, and they try to call, they won't be able to. So this little trick between the 888 and the 000 has actually helped us not expose that person or not put them in danger. Should the trafficker find that business card and make a call, they might then retaliate against the person who gave you this. Have you called? What's going on? But if they try to call a number that starts with 000, they won't be able to. So we've developed this little card that can be easily slipped into the discharge papers or in someone's pocket, as well as an actual pamphlet, brochure, if people feel comfortable taking that one. The orange thing in the middle says, if you're interested, if the person is interested, call psychiatry. We're available day and night. During the day, we also have social work available. At night, we don't. And then there's a list here with a lot of acronyms of potential resources that we can give to patients, depending on what it is that they're interested in or not. We always encourage them to press charges and report the situation. The overwhelming majority of people don't feel comfortable to do so. And actually, we've noticed that insisting basically breaks the report, makes them more guarded, makes them less likely to engage with us. So we don't really push on that. But if they are interested, then we always help them call NYPD and press charges. And you'll hear on one of the next slides, for children, we are mandated reporters. So we actually do call the Special Victims Unit. We have the local number for the Brooklyn agency that handles this, so we report it to them. And let me see. I'm going to go briefly over this, because we don't have much time left. And I want to save some time for questions. You heard a lot about risk factors. I would say social determinants of mental health are some of the really big ones. I'm hoping everybody in this room is familiar with the ACEs, score, economic pressures, racial inequalities, homelessness, migration, marginalization, mental illness, cognitive issues, developmental. We kind of heard about all of these things. But there are many different levels of impact of poverty and of social determinants in general that put people at risk for trafficking. And this is a brief. Oh, actually, this is yours, right? No, it's still mine. OK, I'll talk about this. So this is a brief visual of ACEs, which we've actually used not so much to teach ourselves, because hopefully we know this, but to teach our patients and to teach some of the allied professionals that we work with of some of the things that are worth keeping an eye on. And it turns out that if people have a high ACEs score, they're more at risk for trafficking. But actually, the other way around, if you do an ACEs screen on victims of trafficking, most of them have an ACEs score of at least 7, but most of them are in the 7 to 10 range. So the point of this slide is to say that these things don't happen in a vacuum, right? It's not like your life has been perfect and you had all of your needs provided for, and all of a sudden you end up being trafficked, even though that could happen. Most of these things are being built, sometimes from the previous generation to the current generation. And this is especially for children, but for adults as well. You want me to? OK, I went to skip this. OK. I think one of the main things that is very hard to do in the emergency room, but hopefully for those of you guys who work in outpatient and have a chance to develop relationships with your patients, this is something that you apply more often. But it's really important to approach these situations with a true trauma-informed lens, not just asking people in a sensitive way if they've been traumatized, but really try to understand that trauma is happening at so many levels and can have so much impact on patients, but that there is potential for recovery. So if someone has been sexually abused, if someone has been trafficked, we kept using the word victim throughout this presentation so far. But if at some point they managed to get out of that situation, they become survivors of human trafficking. They become survivors of trauma. So it's really important to emphasize that. Signs and symptoms of trauma, we ask questions and we base a lot of our assessments on the answers. But there are also other signs and symptoms that we have to pay attention to ourselves, anything and everything from body language to the context that the person is presenting with, and respond not just to the client in front of us or the patient in front of us that we're seeing with a trauma-informed care, but making sure that our organizations, our clinics, maybe our residency programs for those of you who are trainees in the room, that we keep that in mind when we think of policies and procedures and practices. And the emergency room, especially for psychiatry, can be quite traumatizing for our patients. They're stripped of their clothes, like I was describing in the case of my patient. By the time I see her, she's always in gowns. She's always been changed. She's had her phone taken away. She's had her belongings taken away. For someone who has been trafficked, to have your things taken away again, that in itself is traumatizing. And we don't really think of that. We think that's a policy. Everybody gets changed into a gown. It's so potentially more dehumanizing and traumatizing. And just acknowledging that and realizing it for yourself and having a conversation with your patient can really help you build rapport. So actively try to resist this re-traumatization. Again, to the patient that I described, the vignette that I described, this lady ended up medicated multiple, multiple times during her visits because she would come intoxicated on crystal meth, would become belligerent, combative. All of those times that she was strapped down, injected against her will, occasionally restrained. We are contributing to the exact same things that she's being forced by her traffickers. So how do we then expect her in the morning to engage with us and be open and allow us to support her? Can she trust us? No. And sometimes we don't have an option, right? It's either she hits me or I medicate her. So it's this really tricky situation that we're in. But even having conversations about that and being real with ourselves, how we're contributing to this potential re-traumat, that potential actual re-traumatization can make a big difference. Let's see, a couple more slides. You want me to keep talking? Or you want to skip this one? We talked about interpreters earlier, right? But very, very tricky. Do not use family, do not use employers, do not use anybody that the patient is coming with. I mentioned earlier that for New York especially, and I think maybe this is federal, for anybody who we suspect to be a victim of human trafficking who's under 18, we are mandated reporters, either to the Administration of Children's Services and or to NYPD, depending on what exactly we're suspecting. I would say that ACS workers in general tend to have much more experience than a random psychiatrist in the emergency room or in the clinic for that matter. So sometimes just consulting with ACS as to what follow-up report needs to be done is really, really helpful. And then this slide has a bunch of resources. Some of them are federal, some of them are specific to New York. So for example, the Polaris Project is federal. They have an amazing website. A lot of the information that you heard today is from them. I strongly encourage you to look it up. I'm assuming you're here in this room because this is something you're interested in. The one right under it, Safe Horizon, is a local organization in New York, but they do have sister organizations in other states and they provide a variety of services for victims of human trafficking. The National Human Trafficking Hotline on the left side is a federal number. This is the one that I was telling you we changed from 888 to 000. So instead of calling it the National Human Trafficking Hotline, we just said, oh my God, I'm trying to remember, counts, not counselor, but anyway, something completely not related to human trafficking and we changed the 888 to 000 and we didn't say one dash, we just put 000. And I would want to believe that this is helpful. And on that note, I actually wanted to add the picture to this slide, but I didn't have a chance. I flew in last night, got to the airport and went to the restroom. And in the women's restroom, as I closed the door to the stall, there's this big blue sign about this big, which is asking, are you safe? Do you need any help? With the phone number of the National Hotline. And it's in Chinese. I don't know if it's Mandarin or Cantonese because I can't read that, but it was also in Spanish and Russian. I want to say in Korean, maybe six, seven languages on this little blue sign. And I found that really scary on one hand, but comforting on the other hand, right? So we have these things in the airport in San Francisco, I'm assuming in a lot of other border cities as well. I would hope that they're in Texas. I would hope that they're in New York in hopefully every restroom where people might go. Definitely high traffic areas like airports. This one has our emails and we are happy to answer any questions you might have. We're also on the APA app. So feel free to connect with us. We have uploaded the slides, but we have many, many other resources as well as literature research articles for whoever wants to know more. And we have a very, very big team that we're grateful for from all over the hospital. Emergency medicine, social work, pediatrics, professional affairs. This has been a hospital-wide initiative to train everyone to distribute these cards and pamphlets throughout the hospital. And I would like to believe that it's made a difference. And we have about six minutes left for any questions you guys might have from the audience. So this one is built into the EMR in English because the EMR has all of the questions in English. So it's a similar thing to let's say the Columbia Suicide Severity Rating Scale, right? But we do have, because of the patient population where we are, we do have interpreters in-house who speak both Mandarin and Cantonese as well as Spanish. For other languages, we would just have to have the interpreter translate it. How many of you are working with or treating potential human trafficking victims? Any questions you have or experiences you might wanna share with the audience? That happens so often. It's like we would ask a question, the interpreter says, blah, blah, blah, blah, blah. The patient says, blah, blah, blah, blah, blah. The interpreter says, blah, blah, blah, blah, blah. The patient says, blah, blah, blah, blah. And then the interpreter says, he said no. Yes. So yes, it happens a lot. We educate our interpreters a lot. The ones in-house, and again, because of where we are, we have this huge army of volunteers who speak Cantonese and Mandarin from a local Asian foundation from Kaipa. So we're very lucky to have them. And then we have a lot of staff who speak Spanish as well as patient representatives who speak Spanish. So for those two languages, it's a little bit easier. For almost everything else, I don't know if you wanna share any experiences, but I've had to educate interpreters so many times. Actually, not so much when it comes to human trafficking, but they would give me these very coherent, clarified stories from people who are completely disorganized. So I have to educate them to translate ad literum what the patient is saying, yeah. It's tricky. Not a lot of interpreters are trained specifically in mental health. Yeah, yeah, yeah. That's a tricky situation and very sad. But it is, the cravings question is a really good one, right? And I think we often ask people, what do you use, how often? Do you have any withdrawal symptoms? What do we don't ask them? What does it do for you? Does it help you with anything? So I think if we change our mindset a little bit, not just with victims of human trafficking, but in general, we might find out someone who's street homeless might use just because they don't wanna have to feel what they have to endure to sleep on the street, yeah. Polaris Project has a lot of resources. They're also actually, interestingly enough, a lot of resources from the Labor Rights Organization, I wanna say is the name, particularly for Nepal, Bangladesh, Pakistan, India. There are a lot of human labor trafficking situations in Emirates, Saudi Arabia and such. So that area has a huge, huge trafficking problem. And it's specifically young men with professional degrees who are going to Arab countries for better jobs and higher wages and end up being exploited over there. So I would look specifically into that. I think it's called Labor Rights Organization. It's an international. All right, any parting comments from you? Thank you all for caring. We really appreciate it. Thank you.

human trafficking

healthcare sector

trafficking victims

screening strategies

trauma-informed care

red flags

risk factors

emergency room

case studies

National Human Trafficking Hotline

Polaris Project