know it's Saturday, but if there's people you haven't met yet, this is a good time to work together, network maybe a little bit, but we're hoping to do maybe just about four small groups, and just as a heads up, there's a couple cases that we'll work through during the talk, and so with each case, we'll kind of go back to It's there'll be a lot of interactive learning you're gonna learn a lot y'all are gonna be experts And we won't force you to talk if you don't want to but if you're if you're able to Particularly chatty they can be I think we can get started. Let's get started. Yeah. Awesome. Well, thank you so much for joining. Really appreciate it. This is something that's pretty near and dear to us, so really appreciate the interest. I think this will be pretty interactive, and I hope that we'll have a lot of discussion. Just a little heads up about kind of the overall outline, we'll have an introduction, we'll go into a case, we'll kind of discuss it among the small groups, come back, have a discussion about it, a little more content, and then a second case, and then a third case. But at any point, if you have any questions, anything that you'd like to discuss, anything that's happened sort of clinically, we're happy to talk about it throughout the talk. We don't have to wait until the end or anything. But just kind of starting off, anybody here a screen for trafficking in their clinical practice? Raise your hand if you do. Okay, we got one. Anybody else? Okay. How about if you've received formal training in identifying a survivor or victim of human trafficking? One? Okay. Cool. Awesome. Okay. I just wanted to get an overall kind of feel. And my name is Roberto Sanchez, I'm an addiction psychiatrist in Houston at Baylor College of Medicine. I have the honor of presenting with Molly Gordon and Jeremy Welliff. Huge thank you to both of them. I'll start off with the thank yous. Dr. Gordon was my attending when I was a resident, and the whole reason for this talk is because of the sort of screening and identification that I learned working on her inpatient team at our county hospital in Houston. So huge thank you. And thank you to Jeremy for encouraging us to present this and submit it. All right, we'll get started. Neither of us have any sort of disclosures or anything. And here are some of our objectives. So evaluate the intersection of substance use disorders and human trafficking. Identify how substance use disorders commonly develop or co-occur in survivors of human trafficking. Assess the prevalence of human trafficking, both globally and locally. And then apply the AMP model. So we'll talk a little bit more about what that means, and that's also on your sheet. And then lastly, apply validated screening tools to assess for human trafficking in the clinical setting. So I think there's a lot of misconceptions with trafficking, right? Or there's a thought that maybe, I think a lot of people think about sex trafficking and maybe ignore labor trafficking. Or maybe it's the opposite. Or maybe they think that we should be screening just children and we miss other demographics. One of the things that really stood out to me when I was kind of preparing this talk was that human trafficking is second only to the drug trade as far as criminal activity. It's massive. $150 billion are profited annually from human trafficking. And we'll go into several risk factors and what puts somebody at risk. But this is the American Academy of Addiction Psychiatry, so we know that people that use substances are at a higher risk for being victims or survivors of human trafficking. So it's incredibly important that we have a good understanding of what trafficking is, what puts somebody at higher risk for trafficking, and how we can screen and identify this. So knowing that, unfortunately, this is a problem that's growing, there's varying statistics, but at least 17,000 people are trafficked in the U.S. each year. With this number growing, we needed a federal sort of comprehensive law to say what is trafficking, but also something that helps us protect people that are victims of human trafficking, and also hopefully, you know, cut down on it, arrest the people that are doing this. So this definition was the first sort of comprehensive federal law in the U.S., and it states that sex trafficking, I'm sorry, human trafficking can be two of these. So sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person is induced to perform such an act and they have not obtained the age of 18, or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, coercion, for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. So it's a little bit of a tough definition to kind of remember, right? Understanding all that now. So the Polaris Project is an organization that created this, what we call the AMP model, which takes this federal definition and puts it in a way that hopefully we can implement it clinically and better understand if somebody that we're seeing may be a victim of human trafficking. So as part of the AMP model, a trafficker must take an action, employ a means, and there must be a purpose. So there must be one in each of the three categories, and action can be, as mentioned in the federal sort of definition, recruiting, harboring, inducing, transporting, or providing. There must be a means by force, fraud, or coercion, and, of course, for the purpose of commercial sex acts or labors and services. The next important point right there is if it's a minor and they're involved in the commercial sex act, by definition this is trafficking. So we're not now kind of having to look for a point in each of the three. If they're involved in commercial sex acts as a minor, this is human trafficking. That last bullet point I think was one of the most important for me. Data suggests that up to 88% of trafficking victims have come in contact with a medical professional and only about 1% are identified or provided with the necessary resources. So we know that this is a population that we're seeing in the emergency room on our inpatient units in the clinic, but we're not screening for it. We're not identifying these people. There was another study for children that were eventually identified as being victims of sex trafficking. I believe it was 41 children in a hospital setting. Once identified, they sort of looked back, and I think it was about 80% of them had been in contact with some part of the healthcare services like the hospital, the emergency room, the clinic, but had not been identified up until that point. So we know that we're seeing them while they're actively being trafficked, but we're not identifying them. And this is a global problem. You know, a lot of statistics here, a lot of which are really important, and one thing I'll mention is it's really hard to get consistent numbers or to survey people that have been victims or survivors of human trafficking just because of the nature of it. So some of these statistics kind of vary. We think that some of them are probably more conservative just because we're not really able to survey as well as we wish we could, but in 2021, there was an estimated 50 million persons trafficked globally. That's about 1 in 150 people in the world. Labor trafficking was very high, about 28 million, 22 million in forced marriage. 71% of trafficking victims were identified as women, 25 as children, and then there's a human trafficking hotline. We'll go into detail on that a little bit more, but they've identified at least 100,000 cases in the U.S., and this was at the time of kind of us forming this presentation, so it's probably gone up much higher. And I mentioned Texas at the bottom, partly because we work there, but Texas, New York City, and California seem to have the highest rates, but human trafficking has been identified in all 50 states in the U.S. But in Texas, about 313,000 trafficked persons and only 18 prosecuted annually. So despite this federal law that's been around since 2000, we're still having a lot of trouble sort of identifying and prosecuting people that are trafficking others. A couple other quick statistics I mentioned earlier, between 14,000 to 17,000 people are trafficked in the U.S. each year. About half of those are U.S. citizens, and then a really large chunk of it is labor trafficking, and I think a lot of media attention and a lot of times that we've talked about trafficking, there's been an emphasis on sex trafficking, which is incredibly important, but we're missing a big part of it there with labor trafficking as well. And there's several misconceptions, right? There's the thought that maybe it only happens to people who are undocumented, but it happens to anybody. There's not one single profile person who is trafficked. It can be any background, any nationality, any gender. It can be absolutely anybody. So it seems like there's oftentimes an emphasis on maybe children, which again is incredibly important, but we're missing a whole lot of other people as well. And then, you know, this was just something I thought was a little bit interesting. Now we're kind of out of this a little bit as far as we're back to having large in-person gatherings and things, but during lockdowns and during the sort of height of the pandemic, there was a shift in where people were sort of being trafficked from. So there was a decrease in sort of the sites that were previously known for being higher risk, maybe foster homes, strip clubs, things like that. And the internet really became a really big place for trafficking and unfortunately social media, which many of us have, you know, a lot of adolescents, children are on social media, but the Polaris Project, the same people that made the AMP model found 120% increase in the proportion of potential victims of human trafficking on Facebook and Instagram. So again, I think there's these movies like Taken where you have this thought in your mind that, you know, trafficking is like you being kidnapped and you're held into a room and things like that, but this is starting on social media. Another misconception is that, you know, it's from somebody you didn't know, but oftentimes trafficking occurs from a family member, a romantic partner, somebody that was close to you that knew of a certain sort of need that had to be met and they kind of slowly through this process ended up kind of manipulating the person causing independence and eventually were being trafficked. So, you know, social media, that kind of freaked me out a little bit, just knowing how many of us are on there and how common this is. So we're going to go to case one here, and so I'm going to read the case, I'll keep the second slide of it up, and then at this point we're going to go back into our small groups and we're going to use that AMP model for this case and kind of figure out if we think this meets the criteria for trafficking. And this is a real case based on our work in the inpatient hospital unit in Houston. So a 35-year-old male admitted to the county hospital inpatient psychiatry unit for psychosis, reported working long hours as security for an apartment complex. He worked overnight shifts in an area he described as dangerous. Shifts increased and at times were as long as 72 hours. This type of work was different than the clerical work he was told he was going to do. His urine toxicology and admission was positive for amphetamines and opiates. He denied any intentional stimulant use but told us that his bosses often gave him supplements to be able to work longer hours. He was noted to be hypertensive and tachycardic on arrival to the hospital, and on admission he was experiencing auditory and visual hallucinations, limited sleep, paranoia, hypervigilance, mistrust for others, and exaggerated struggle response. The auditory and visual hallucinations improved with rest and without any antipsychotics. On day two, he developed diarrhea, muscle aches, chills, nose became runny, reported significant anxiety, and he told us he used a combination of opiates to avoid withdrawal and stimulants to stay awake to be able to do the work he had to do. He could only access more opiates if he worked. If not, he was forced to go into withdrawal. Although he was working these significant hours, he was not paid. Any complaints of lack of compensation and working conditions were met with threats of deportation. When he worked longer shifts without complaining, he was given extra supplements or heroin. He told us he was originally from El Salvador, but he crossed into Texas by coyotes who promised a better life. He denied any history of any prior substance use. I'm going to go back. I think I'll kind of switch between the two maybe, but we can go back to our small groups here and maybe just have a discussion about it using the ant model. If you don't have that sheet, I can bring you one, but kind of look at it from that All right, we might kind of come back in. Love to hear what you think about the case. So maybe before we. All right, so maybe before we go straight into kind of talking about the AMP model, I would love to hear any thoughts, any questions, anything that came up. dependent, that means you have to be taking them every day at least. Yeah. So, I mean, there's a lot missing of who is this guy, and where did he come from, and why did he talk to you so much? Yeah, that's a great point. So one of the plugs I'll give, and we'll talk about this kind of in the latter half of the presentation, but as part of our inpatient psychiatric evaluations, we implement something called the RAF screening, which is a screening for human trafficking that's been validated. So we do this for every single patient that we see on our inpatient psychiatry unit. So oftentimes, you know, even if they've come in for something that seems to be unrelated or whatever it may be, we identify it just from the screening. And I think some of the papers and things that have been written about it have talked about cases where somebody came into the ER for a kidney stone, they were given the RAF screening, identified positive for trafficking, and then sort of given the appropriate resources. So part of it kind of came from that. We also have the benefit on the inpatient psych unit to see somebody over the course of a week or longer, and our initial evaluation is usually, I would say, about an hour at a minimum. So some of it was there. Some of it, of course, was consolidated for the point of teaching. So it's natural that there's going to be some gaps. But this was, I don't want to get too far ahead of myself, but for the point of the opiates, I think opioids are very commonly used in human trafficking as a tool for coercion because withdrawal is so miserable. It kind of leads to these rates of recidivism, right? Maybe somebody has actually gotten out of trafficking, but they know when they were in that situation, they were given opiates. And so they find themselves kind of coming back in order to not feel the withdrawal and then being stuck in this trafficking situation. I hope that kind of answers. Well, just if you don't mind me pushing you a bit. And that's kind of our rationale for having this presentation, I guess, is sometimes even when it's the last on our list, if we're screening patients that we know have the risk factors for it, which is everybody who has a substance use disorder, we may identify it and it's probably much more common than we realize. But great point, yeah, and obviously we changed some things about this case because I can't base it exactly on the patient that we saw, so some of it was for the point of discussion, but opiates are, I would say, more commonly given daily, right, and sometimes it's to the point of being able to debilitate somebody so that they're kind of stuck in the situation that they're in. So I didn't harp too much on the point of, like, how much he was given opiates, but totally understand what you're saying, yeah. Two comments about that, thank you, Dr. Koston, for those comments. The first is when it comes to coercion, so act, means, and purpose, force, fraud, and coercion, force is a physical element. Fraud is a lie, and coercion is a psychological tactic of control, and so not uncommonly weaponizing access to opiate use, not because the person's going to be intoxicated from the opiate, but to prevent withdrawal is a very powerful method of coercion. The second comment is, you know, we did talk about smuggling and trafficking, and I think Dr. Sanchez is going to comment on this briefly, but how does somebody who's not getting payment for labor pay for drugs or get access to drugs? So a question I not uncommonly ask is, this is an expensive substance use habit, so how is it paid for? Is it paid for by labor? Is it paid for by sex? Are you forced to do that? Are you doing that by choice? Is that a choice? And so that's something to also consider is the cost of addiction to our patients, and so how is that need being met? And so in this situation, sort of the substances are being supplied to him without payment in exchange for work. And so those are the only comments I would make. And I guess one other point is, you know, I think we focused on withdrawal a little bit, but we know that even when somebody's detoxed, they're still craving, right? If they were very recently... Yeah, exactly. I mean, some of the, like, they're after me, things that we may perceive as sort of paranoia. I know Dr. Gordon's kind of told me a story about a trafficker waiting outside of the hospital while the person was admitted to our unit. So, you know, in real danger, and it would be tough if we kind of attributed and not having it reported to somebody. Yeah, I'll just make a quick comment, and we'll talk about this more, I think, a little bit through the talk as well, but I learned recently that if somebody was smuggled and this crime was committed on them, bringing them to the country for the purposes of trafficking, they qualify for a trafficking visa, and so although they may be understandably really terrified about the thought of being deported, they're actually protected in that regard. And there's a lot to say. We kind of go towards this at the end, but a mandatory reporting, right, there's a couple states that do require that. There's a resource on the paper that kind of you can look up your state to find. But you know, some people are terrified about retaliation if it is reported and something happens to them, so it's a discussion that we have. I was gonna make a couple comments. Remember just by definition, smuggling is a crime against a border and trafficking is a crime against a person. And smuggled persons can be trafficked and trafficked persons can be smuggled. So you could be in a foreign country and trafficked and be fleeing the trafficking situation as a push factor for smuggling. And so a person may choose to engage in an illegal crime against a border to flee trafficking. For other reasons, people may engage in smuggling to the United States. And so they may pay for a smuggler to bring them illegally across the border and then be debt bonded in this situation to pay off the cost of the smuggler. And so there is an intersectionality of the two. If the person is smuggled on US soil, like Dr. Sanchez mentioned, they do qualify for what's called a T visa. Your comment is very relevant about disclosure. We are doing some research right now about barriers to disclosure because of the limitations of the prosecution model patients who have been exploited for labor or sex are hesitant to disclose to law enforcement. So then the question becomes, would they be hesitant to disclose to healthcare professionals as well? And so we're looking at the intersectionality of shame, resiliency and barriers to disclosure. The state of Texas just passed, I don't know if you got, who's from Texas here? Anybody here about what happened this week? Just this week. I'd have to say if they're documented or not at a screening for the hospital. Right, so now the hospitals have to ask a person, are you here with status? And so if you work in this space, there's a lot of concern, right? Number one, that a person could have extreme delays in medical and psychiatric care because of fear of deportation or fear of, what they don't know, what patients don't know is that we are required to ask, but they're not required to answer. And so we're really trying to explain patient rights that just, and I will often, we've been doing this and I've been disclosing, I have to ask you this question, you do not have to answer it. It will not change any access to your care. So I'm here to ask, if you wanna tell me, great. If you don't, I'm still gonna take good care of you. But there is a lot of concern about that. The second issue is about prevalence. About 91% of the patients we serve are Houston born and bred. A very small proportion of the patients we see are foreign born nationals. That has to do with access to care at the county hospital. And so it's actually quite uncommon to see people who are foreign born nationals in the county. And so this is a very domestic issue for both labor and sex. And so one of the things we wanna talk about is understanding what a trafficked person looks like. Yes, they can be foreign born nationals and this perception that it's all these people coming from other countries across the border, but this is the majority of the patients we see. And the majority of the data we have are boys and girls that were raised here in Houston. Or Texas. I just had a case. Yeah, I'm going to, so it's like you read my mind, that's a great idea, by the way, the Vivitrol, good tip there, I'm going to take that idea, we're writing a case series now about intellectual disability, we've had a lot of cases for both labor and sex trafficking, so we're here talking about addiction, but also if you have patients with brain injuries, cognitive limitations and those vulnerabilities to exploitation, we'll talk a little bit in the socio-ecological model about cognitive vulnerabilities and how easy it is to exploit somebody by manipulating addiction or by manipulating cognitive limitations. Yeah, and the other point I was just going to make is I think it's unfortunately fairly common where people in a situation like that are not, don't realize that Okay, cool, and we do have, so I wanna make sure we'll get to the next case as well. Revisiting a couple points, I think we hit all of these already, but certainly meets the criteria, right? He was transported, coerced, forced for the purpose of labor and services, and just to reiterate that point that Dr. Gordon said, somebody does not have to be transported to meet the criteria for human trafficking. That's just one of the actions, and that distinction between smuggling and transporting was really important. So this is a pretty busy slide. I'm not gonna read every single one of them, but there was a couple that I just wanted to touch on, and it's difficult. Like I mentioned earlier, there was that one case of somebody that came in for a kidney stone and then sort of identified positive for trafficking. So not everybody has to have all of these things, but these are some signs or kind of red flags for somebody that may be involved in trafficking. Of course, if somebody's kind of fearful, anxious, tense, they lack healthcare, right? Maybe they haven't had preventative care for a long time, no immunizations, no follow-up care. If they're malnourished, of course, if there's signs of physical abuse or trauma. The bottom left has a lot of important points. So if they don't have their identity documents, that comes up in some of the screening tools we discussed at the end. If they don't have any personal possessions, we know that when somebody's being trafficked, especially by a romantic partner or somebody that they're close to, they may have slowly kind of created this dependence on them, and so they have sort of little by little lost much of their belongings so that they're now entirely kind of dependent on this person. So those are some red flags. And on the right, not able to free, or not free to leave or come as they go. There was a really interesting article, it was in a New York paper, I can't remember which one, about somebody that came in with a trafficker who said it was a brother. They needed Spanish interpretation, but he insisted that he could be the interpreter for the person, said it was a brother. They insisted on having an interpreter. When they did, they found out it wasn't her brother, it was somebody that was trafficking her. So that point of just not being free to kind of come and go, or if somebody insists on being in the room, somebody that insists on speaking for them, that's something to look out for. Yeah, and these will come up through the talk. This is pretty, we kind of summarized it pretty short here. There's definitely much more, but physical injuries, higher rates of sexually transmitted infections, development of a substance use disorder. There's multiple angles here. Somebody may have a substance use disorder, and the trafficker may sort of use that to their advantage to involve them in trafficking or keep them in trafficking. Somebody may have just had use, and within the trafficking sort of developed a use disorder. Somebody may have experienced significant emotional and physical trauma as part of their trafficking, and then began to use substances to cope. So there's many ways that substances can play a role in somebody who's been trafficked. And then, of course, depression, anxiety, PTSD, suicidal ideation and attempts. There's higher rates of eating disorders. Didn't mention here, but also there's some data for cardiovascular disease and neurologic diseases. So quite a bit that comes with trafficking. And then we've kind of touched on this quite a bit with the first case, but just to mention it, substances can be used to coerce a trafficked individual, can be used as a form of control or intimidation. It can be used to incentivize the individual to stay in their position, kind of in the same as in case one. Traffickers understand the fear of withdrawal and coerce individuals into further labor or sex trafficking for use, and substance use may begin or worsen to cope with the physical and mental trauma experience. There was a case in Massachusetts, I think fairly recently, of somebody who was targeting people that he knew were struggling with substance use disorders. I'm not sure if it was at a rehab or how exactly he knew that they were struggling with an opiate use disorder, but specifically targeting people that were more vulnerable to have them sort of in this position. So a year's survey found that 84% of survivors use substances while exploited. Alcohol, cannabis, and cocaine appeared to be the highest at the time. Heroin at the time was 22.3, but just kind of mentioning heroin and not fentanyl may sort of say how outdated this is, right? I think most of the country now, it's kind of been fentanyl, and there have been some studies to suggest higher rates of fentanyl use for somebody that was involved in trafficking. And then we made this point earlier, but debt bondage, right? If somebody's being given substances as part of the work that they're doing, but then kind of told that they owe that money for the substances that they were. So case two, 24-year-old female admitted to inpatient psychiatry unit for suicidal ideation and worsened depression. During the initial interview, appeared tired. With that, another 5-10 minutes, break into your groups, talk about the case, how you can separate. Sounds like a lot of great discussion. And I'd like to comment maybe on the intersectionality of commercial sex work and trafficking briefly. Commercial sex work is the voluntary exchange of sex for something of value. And when we think of value, we always think of money, but value could be food, shelter, housing, substance use, and then only about 10 or 11% of the time is, or drugs and alcohol actually used in exchange for sex. So it's usually more social determinants of health that are trying to be met in commercial sex work. Not all commercial sex work. Any commercial sex work of a minor is, by federal definition, trafficking. We'll talk a little bit more about that later. And then when we think about trafficking, that is always illegal. And so that is essentially forced sex work. When I was in training, we would call patients who presented to the emergency room sometimes child prostitutes, but that actually is a misnomer. Child prostitutes actually do not exist. Children can only be prostituted, so they can only be trafficked. The same when we think about domestic work or agricultural work. There are plenty of people who work in construction and domestic and agricultural spaces legally and without force, but it's forced labor that we're interested in or forced sex work. And so we not uncommonly will see patients who may have a history of childhood sexual abuse or commercial sexual exploitation as a child, and then as an adult engage in the illegal activity of sex work, and then sometimes then move into legal sex work, and then maybe be trafficked. So there is a lot of—we think about it as sort of a Venn diagram over time. There is a lot of overlap between these vulnerabilities and experiences, so we shouldn't consider a person who has been trafficked as all sexual encounters being trafficking. over here, because I attended a conference called Sex Down South, and it was a lot of professionals and also people that do sex work and kind of just seeing the intersection of that and trauma and really getting a better understanding of the world of sex work that, first of all, has such a wide range. You know, it's not just like sexual penetrative work. It can be like selling your feet online, you know, like that type of stuff. And it has such a wide range. And then also, some people, that is like a choice, and that is what they do for work. And I think, I remember just an Not always, so it is, you know, we know that there are sort of baseline vulnerabilities, so housing, food insecurity, we're writing a paper right now on food insecurity. And there's actually a very interesting literature on teenagers who have a lot of shame and that being a driving force for sex work to overcome that shame. So housing, food, access to healthcare needs, paying for other medications. So we don't think about those being push factors for labor and sex trafficking, but they are. Also in people who have had gainful employment and then may lose it or be in a transitional period of housing or employment or addiction. So if addiction. Substance use can actually be a push factor into sex work to meet. on ACEs and human trafficking. It's been a long year on this paper. So when I think about exploiting a person, it's much easier. children with high ACEs, if you're a child psychiatrist or a child addictionologist, if you have a child who has eight ACEs, maybe they're not being exploited, but could they be, and educating them, that's a harm reduction model, about their rights. that could mitigate trafficking for sex. And so there, that's a very, that's another hour conversation we can have and I'm happy to talk to you about it afterwards. But, but there, there are lots of reasons outside. We think about populations that have access. Just so you have some of the facts, and then we'll move on to the next case and other broader questions. But of course, trading sex work for substances or money increases the risk of trafficking. So this is both ways. Survivors of commercial sexual exploitation often require sometimes as part of a treatment program, but maybe not. Good job. We're two-thirds of the way through. You made it. So we have a case here of a young male, a 16-year-old male, who presented to the emergency room for symptoms concerning for an STI and worsening wrist pain. Notice he did not present to tell us he was being trafficked. About 64 percent of patients seeking health services who are trafficked do so in emergency room settings. While gathering his social history, it was noted that he was recently unhoused. He said he was growing up, he was exposed to domestic violence in the home, and his father struggled with an alcohol use disorder and was physically abusive towards his brothers and the patient while father was intoxicated. The patient told the team that father would force him to leave the home when he came out as gay to his brothers, who then told the father that he was in the LGBT community. The young boy was then unhoused and approached by an older male. When we think about older male, that doesn't necessarily think, you know, as I get older, I think older males are like 80, but so if you're 16, right, an older male could be a 22-year-old who could appear to be somebody trustworthy, appear trying to help somebody out, who offered a room in his home. He was living with this legally adult male and then forced to clean and care for the home in exchange for housing and then was eventually forced to engage in sex acts with the young male or older man, depending how old you are, to receive needs in housing and then would escalate to engaging in sex acts with other people for which money was exchanged. The older male would receive the money, not the young boy. Attempts to leave the situation were met with physical force and threats and he got into a physical altercation, was pushed, landed on the outstretch arm, and presented to the emergency room with a wrist injury. Okay, so again, is there an action, means, and purpose present to meet the criteria for trafficking? Remember, when we think about act, it's defined as recruiting, harboring, inducing, transporting, and provision of services, but what that really is is the attachment of a vulnerable person to somebody who's going to exploit them, whether that in, well, I won't give it away, but is that present? Does harboring and movement and transportation have to happen or is there an act here? What sort of force, fraud, and coercion elements are present? And then what purpose is happening? So, I'll let you guys talk. All right, any thoughts? Anybody who wants to sort of share what they thought for this case? Yeah, sure. All right, it looks like we have about 15 minutes left, so we want to make sure we'll get through everything. But any thoughts about this case? What stood out? Do you feel like it met the criteria? Anybody want to show? I have thoughts. So we agree that it fits the AMP model, and he's 16. So there's that. But we're like really. Great. So the answer is, this is actually a trick question, because there are means of forced fraud and coercion in this case, but do there need to be for a 16-year-old to engage in sex work for housing? So even if he met this older male, they hit it off, and he assented to engaging in sex work with him or others for housing, the assent of sex work is, by federal definition, commercial sex exploitation of a minor, because a child cannot consent to sex work, even if they engage in the behavior and agree to do it and aren't being forced, frauded, or coerced. Not uncommonly, though, those elements are present. It's one of the reasons, because there's no need for means, when we're talking about minor sex trafficking, that when it comes to the prosecution space and you're a lawyer, is it easier to prosecute a case of forced, fraud, and coerced labor trafficking in an adult person, or sex trafficking of a minor? What would you think if you were a lawyer, if you don't need to prove forced fraud and coercion were present? Right. It's a lot easier to get prosecutions for sex trafficking of minors, which is fantastic, but it leaves a largely vulnerable population once they turn 18. And so sometimes they can get a prosecution for commercial sex exploitation of a minor or sex trafficking when that individual was 14 and 15, but then if that individual was trafficked at 18 and 19, it's harder to prove means. So just think about that. Any other comments? Yes, in the back. So it's different when it comes to labor and not sex of minors. Is it familial? So are you working on a family farm, doing chores around your house? You know, anyone have teenagers? So the expectation rape, charge, sex trafficking? That's a good question. clothes jewelry Yeah, so that's great. So in this situation, you may not be able, well, you should be able to prove trafficking, but it may end up being a rape case against the minor and then whoever was prosecuting the case may not even bring charges of sex trafficking or labor trafficking to the table. They could just try it as a rape case. That's the decision of the courts. There is a term called initiation sex where traffickers will use sexual violence, well, either first as a sexual relationship and then escalate to sexual violence and then trafficking to illustrate control in that dynamic. And so sexual violence can be used, that's your force, right, so physical or sexual violence as your means. And so there can be rape and then secondarily exploitation. All right. Where are my slides? So the answer is yes, it meets the criteria for the ANT model, but because it's a minor, it does not need to. So we talked a little bit about this earlier. We talked about adverse childhood experiences as a vulnerability and risk factor for trafficking for both labor and sex. We know that youth who are survivors of trafficking are involved in this juvenile system. This becomes sort of a ethical issue when it comes to disclosure because if we treat children as perpetrators of a crime as opposed to a victim of violence, what does that child think of the adults who are put in place to protect him or her or them? So they may be manipulated by traffickers or coerced into other criminal activities. So to give you an example, drug muelling, running drugs, weapon exchanges, other thefts, criminal activities that are not related to sexual violence or labor trafficking. Trafficking, like we mentioned, we know is linked to substance uses which can increase the child's risk of drug-related charges. We wanna consider substance use as a form of coercion in children and the risk of a child then being charged with substance charges. We know that gender and sexual minority youth are particularly vulnerable to trafficking. They have underlying social determinants including higher rates of abuse in the home, rejection or shame around their gender or sexual orientation, food and housing insecurity, and a higher relationship to the foster care system. And we know that sex trafficked persons, at least in the United States data, may be more likely to be boys and girls of color. In a study looking at 41 child survivors of sex trafficking found that 88% used substances. Other work has reported lower numbers that about 70% of commercial sexually exploited youth have had experiences with substances. So if you're working in a, anyone working in child and adolescent substance use in the room? Just curious, do you screen for commercial sex ever? Okay, so I always think about kids as dependents because I'm a parent, right? So how is a child paying for their substance use is always my first question. And if they say, well, I'm working for it by having sex and that's how I get money or I'm working for it by having sex and that's how I get my substance, is that commercial sex exploitation? So it seems like a logical next step when it comes to access to substances. Commercial sexually exploited youth may be subject to substance use to create dependence or to aid and coercion like we talked about in the other cases. It's much easier to manipulate a child than an adult for lots of reasons. So substance use may be a response to exploitation to cope with trauma related symptoms, anxiety or mood symptoms. In children that are unhoused, we know that about a quarter of them experience commercial sexual exploitation. The majority of them had exposure to a substance use and 75% met criteria for a substance use disorder. So housing and security and the intersectionality of commercial sex and substance use should be considered. This is one of my favorite slides, the Swiss cheese slide. So that to traffic a person, multiple things have to line up multiple vulnerabilities or holes. And so there are definitely individual risks that we talked about in these cases, social demographics, socioeconomic status, specific race or gender cultures status. But there's also relational issues that we talked about briefly with regard to ACEs, violence in the home, the Philadelphia ACEs study that looked at violence in the community, relationships with peers, partners and neighborhoods where trafficking for other elements like drugs and arms may be present and so not uncommonly there is organized crime rings or individual vulnerabilities and a demand for trafficking for labor or sex. We know that what we call bottom boys or bottom girls are recruiters who are peers who can exploit other classmates in schools or neighborhood friends. So that is a tactic that's often used in individuals who are brought into trafficking and then can offset some of their labor or sex quotas by recruiting others to work. And so there's a benefit for that. And so then the question becomes if you were a child who was trafficked and then you recruit other children, are you a perpetrator or a victim? So it's a difficult question to answer today. So we know that there's community resources that may not be available for all populations. We should think of our homeless youth population and young adult population, people who work in Covenant House or with homeless youth as having vulnerabilities that may be higher. We know that social norms, my favorite story, if you've ever heard me talk before, is what do you call it when you're teaching a med student or a resident by asking them a lot of questions until they don't know the answer? What do we call that in academic medicine? Pimping, right? So we talk about sexual violence pretty casually. And so what does society say? We just passed Halloween. So if you want, you can actually sex, you can dress up as a sex trafficker. That's what I see when I see somebody dressed up as a pimp costume for Halloween. So the normalization in our culture and in our society of sexual violence. I could go on and on about that. Maybe I'll give a talk next year on that. Again, in schools and neighborhoods that are vulnerable. And we know about the laws and policies. Just to give you an example of those numbers, I think Dr. Sanchez mentioned, somewhere between like 18 and 30 prosecutions in a good year happen in the state of Texas when it comes to trafficking. That's a good year. It's very hard to get prosecution results and takes a lot of time, sometimes five to 10 years. The systems that are put in place from the prosecution model are great, but they have limitations. So our beds are, we have a 20 bed unit on the inpatient unit where we work. And we identify somewhere between 100 and 150 people a year in our tiny little unit. So imagine if every ER and hospital across the city or state started to screen for trafficking compared to the prosecution model, what we can do to help move those prosecution numbers forward or at least identify and respond to trafficked persons. So the idea about scaling the screening into the patient population you serve, if that's the only thing you learn, then we've done our duty today. Okay. All right, so in summary, trafficking impacts patients who see our emergency rooms, our outpatient clinics and on our inpatient units. We know that substance use is common in those who are trafficked or dealing with the physical and psychological sequel of exploitation. Survivors of trafficking interact with healthcare providers, especially you guys, substance use disorder clinicians. And so consider screening. There are barriers to getting into treatment that we need to address. That has to do with cost and housing and access to care. We know that gender and racial minorities may experience more ACEs and exploitation for labor and sex. And that it's a very difficult sometimes relationship when a patient is exploited by a loved one, a friend in the community, a romantic partner, or they even have children with people who harm them and the complications of the dynamic of separating somebody from the person who's harming them. I'm gonna talk briefly about some screening. There are two validated screening tools that do exist. When we first started in this space in 2017, there were none so we were coming up with our own questions and using clinical and DECA, but there are now two. One is called the raft. Have you ever worked on things in a place that made you feel scared or unsafe? You'd be surprised how many people say yes to that question. Have you ever been tricked or forced into doing work that you did not wanna do, afraid to leave or quit work due to fear of violence or threats to harm of you or your family or loved ones? And have you ever received anything in exchange for sex, including things like food, housing, shelter? And then we'll move into things like money or substances. This is validated in 2021 by Dr. McKinney Chisholm Straker. She is an emergency room doctor out of Mount Sinai, if any of you know her up in New York. So if we go back to some of the cases we discussed earlier, I got like 30 seconds, so I'm gonna talk fast. We do know that a lot of these questions would, the raft questions, the patient would say yes to. This is one of my favorite things in this space. This was developed by Dr. Jordan Greenbaum in 2018. She is a forensic pathologist out of Emory. She now, she was the medical director for the International Center for Missing and Exploited Children and works in a group called ISCAN, the International Society for the Prevention of Child Abuse and Neglect in the international space. And so she and her team developed a screening tool for kids in emergency rooms. If you answer yes to two of the six questions, there's about an 80 to 90% chance that you were trafficked. If you say yes and you're not trafficked, there's a good chance there was something else that happened to you that could be treated. So maybe exposure to substances as a minor or sexual or physical abuse. And they're very quick, easy questions. So if you're in an ER, you can ask these questions in 15 seconds. Ever use drugs or alcohol? Ever run away from home? Ever been involved with the cops? Ever had an STI? So you can ask all those questions very quickly. And those are the kind of screening tools that we're looking to develop for labor trafficking and in adult populations and in non-emergency room settings. We're working on an emergency room QI project now where we're implementing these questions as of last Monday in our emergency room, just in our low-hanging fruits. If you come in and you were a victim of sexual violence or physical violence, or you screen yes to an abuse screener, we should probably then follow up with the raft questions. We're not screening everybody who comes in for asthma or an MVA, but if there's suspicion that there may be an overlapping risk, we should ask. So again, if we had used the short screen in the emergency room, this young boy would have screen positive. There are other screening tools, the TVIT, that's. as well as the, excuse me, the CUIT. So this is used in research, and then the CUIT is used in the homeless youth population. So this is only validated in working with children who are unhoused. Keep in mind, I'm preaching to the choir here, it's a room of addiction psychiatrists, but the trauma-informed interview, dissociation, depersonalization may impact the ability to tell their story and experience, develop a therapeutic alliance, avoid. you are, if it is a minor, you are a mandatory reporter. So we do not have state laws that require us to report unless the adult is incapacitated or if it's a minor. And at the bottom of your handout, there's something called the Jones Day Toolkit that was developed by a law firm. Jones Day is a national law firm and it's updated every year with state mandatory requirements for education and training around human trafficking as well as reporting. So in this situation, you would tell you a social worker you would call CPS and they would escalate it to state and federal authorities. And again, you know this of working with patients with substance use disorders. Be cautious about asking questions because you're curious if it doesn't have clinical decision making. Sometimes patients will ask that you use an Elias. Be cautious about what you put in the chart. Be cautious of your own safety. And this is a harm reduction model. So educating the patient about their vulnerabilities and risks and their access to resources is important. Again, we already talked about mandatory reporting. Okay, so just make sure when you're talking to children that you let them know that you are a mandatory reporter and that you're working for them and offering them a service. It can be very distressing for sort of an adolescent to be sort of forced to engage with CPS, social work, or the police. And if you have questions, you can always talk to your own risk and legal team. These resources are also on your handout. The Polaris Human Trafficking Hotline is easy to remember, 888-3737-888. It's a palindrome, you can say it backwards. 888-3737-888. Text be free, that's what that says. 23-3733 is actually be free. And then you can, there's a teletext you can access. Heal Trafficking is run by Dr. Hani Stoklosa out of Harvard. She's an ER doctor up there. It's a public health NGO related to intersectionality of health systems and human trafficking alliance and then migration networks. All right, so keep this on your differential diagnosis. Be mindful of your screening tools. And if you ever have questions, you know how to find us. This is the peer-reviewed literature. Thank you for spending the beautiful afternoon with us today. And we'll stick around for questions, comments, if I know people have other things.

substance use disorders

human trafficking

interactive learning

small groups

real-life cases

prevalence

risk factors

screening tools

AMP model

demographic vulnerabilities

trauma-informed approach

mandatory reporting

National Human Trafficking Hotline