Episode 14
This activity qualifies towards Michigan State Licensure requirements for Human Trafficking.
Featured guests: Andy Duncan, NP, and Bethany Mohr, M.D., Child Protection Team
Disclosure: Andrea Duncan was an employee of Phillips Healthcare up until 7/6/21.
Objectives
- Identify some red flags for human trafficking
- Identify potential assessment tools
- Develop pediatric specific assessment skills for the assessment of human trafficking
Resources
CME
Credits available: 0.50
Visit our CME course overview page for CME credit, or complete this survey for social work CEUs.
Transcript
Dr. Christina Cwynar:
Hello and welcome to our podcast Breaking Down Mental Health, with myself, Nurse Practitioner Dr. Christina Cwynar, child and adolescent psychiatrist Dr. Heidi Burns, and social worker Syma Khan. Unfortunately, today Dr. Burns was unable to join us. We are joined today by Nurse Practitioner Andy Duncan and Dr. Bethany Mohr to discuss human trafficking assessment. Andy Duncan is a pediatric nurse practitioner working with the Child Protection Team at CS Mott Children's Hospital. She has been a pediatric nurse for 30 years, and a PNP for over 22 years. Andy attended the University of Michigan for her BSN, and attended the University of Colorado for her master's in nursing. Andy has had the opportunity to work in a variety of healthcare settings, including a Spanish-speaking-only clinic, an LBGTQ health clinic, a juvenile homeless shelter, several school-based clinics, and private pediatric practices. She has also worked as adjunct faculty for a local university teaching pediatric content to FNP students, and was recently appointed as adjunct faculty at the University of Michigan School of Nursing. Andy loves what she does, and feels that her position at Mott has given her the opportunity to utilize all her skills and knowledge to do incredibly important and meaningful work, helping children and families.
Syma Khan:
Dr. Mohr is a clinical associate professor at the University of Michigan Health System, Michigan Medicine in Ann Arbor, and is the medical director since 2008 of the Michigan Medicine Child Protection Team. She's board-certified in general and child abuse pediatrics. Dr. Mohr evaluates suspected victims of child abuse and neglect in Michigan Medicine Suspected Child Abuse and Neglect, SCAN, clinics, including a telemedicine clinic in Northern Michigan. And the Child Protection Team is a designated medical provider for multiple child advocacy centers within the state of Michigan. Dr. Mohr is currently serving on the American Academy of Pediatrics Counsel on Child Abuse and Neglect executive committee, as well as the committee's policy subcommittee. Dr. Mohr is responsible for several pediatric policies within Michigan Medicine, with input on the suspected human trafficking guideline. Dr. Mohr is on the Professional Society on the Abuse of Children board, APSAC, co-chair of the Munchausen by Proxy committee, and expert member of the Abusive Head Trauma Policy Analysis Committee with an APSAC Center for Child Policy. She's the 2016 recipient of APSAC's Frontline Professional Award. Dr. Mohr was also an appointed member of Michigan's Governor's task force on child abuse and neglect. None of the speakers here today have any conflicts of interest or financial disclosures. Thank you both for joining us today.
Dr. Andy Duncan:
Thank you so much. We're so excited to be here.
Dr. Bethany Mohr:
Yes, thank you for the opportunity to be part of this podcast and discuss such a critical issue.
Syma Khan:
Last week, we met Dr. Munro-Kramer and Professor Carr to discuss the basics of human trafficking. We would love to pick your brains about the assessment for human trafficking of an individual whom a provider believes is being trafficked. Andy, what are some of the red flags that a medical provider should be assessing for in regards to human trafficking?
Dr. Andy Duncan:
Yeah, so I wanted to preface this conversation by saying that both Dr. Mohr and I specialize in caring for pediatric and adolescent patients, and approach human trafficking through a pediatric lens. So that being said, I think you can apply a lot of this information to assess and care for adult victims of human trafficking as well. So healthcare providers are one of the few professionals likely to interact with trafficked individuals while they're still being trafficked. So I think we need to keep our antennas up as healthcare providers. Estimates are that 43% to 88% of trafficked victims report an encounter with a healthcare provider while they're being trafficked. And there's some barriers for healthcare providers, including lack of education about human trafficking, which, hopefully this podcast will help with, lack of validated screening tools, which we'll talk about soon, limited knowledge of available resources, and uncertainty of next steps for providers.
And then also, of course, short time frame that we have allotted to see our patients, which makes it hard to assess these complicated issues. So to get back to the question about the red flags, there are some general indicators that could raise suspicion that someone is being trafficked. So it's just a list, but someone with a scripted or inconsistent history. Someone unwilling or hesitant to answer questions about an injury or illness. If the patient is accompanied by an individual that does not allow the patient to speak and refuses to allow privacy for the patient. Someone who presents as hypervigilant, fearful, has paranoia or anxiety. Unable to provide their address, unaware of their location, the date or the time. Sometimes they won't be in control of their own money, and they won't have their own identification documents. And then also, sometimes minors will have a large amount of cash, or expensive items or jewelry that just don't go with their developmental stage.
And then there's some red flags in terms of the exam and the history for victims of sex trafficking. So it could be things like bruises, scars, burn marks. In particular, if their marks are patterned. Missing or broken teeth, missing fingernails. Some may have branding or tattoos, but this is rare, actually. Certainly, they might have trauma to their vagina, rectum, or penis. And there can also be presence of cotton or debris in the vagina, which, girls, if they're menstruating, might put that there so they continue to be sexually active. And then there are some red flags of labor trafficking as well, to look for on history and exam. And often, people who are labor trafficked might be in agricultural jobs or labor jobs with poor working conditions. So, looking for those kinds of illnesses that might be from an unsafe environment. So things like heat stroke or stress, sleep deprivation, malnourishment, dehydration, water or sanitation related illnesses. Pesticide or chemical exposure, untreated skin infections or irritations, or musculoskeletal and ergonomic injuries. So this is not an exhaustive list, but definitely things to think about when you're assessing if someone might be trafficked.
Dr. Bethany Mohr:
So I just want to reiterate what Andy stated regarding that many children and youth experiencing trafficking and exploitation seek medical care. So healthcare professionals need to be able to not only recognize these children's needs, but respond appropriately to their unique needs. We need to ensure we're also identifying those patients who are at risk, and not just those who are already being trafficked, exploited.
Syma Khan:
Thank you so much for setting the stage of what we need to be aware of in medical settings. I think this points to the question of maybe who should be assessed for human trafficking.
Dr. Bethany Mohr:
Right. So just to go off of what Andy said, although red flags are important in our assessment, these red flags may be absent or present, but not reported by victims of trafficking and exploitation. So in terms of who to assess, this is largely informed by research done on various screening tools. Andy will provide further information later regarding the various tools. So validation research has included screening of patients age 11 to 17 presenting to various healthcare settings. For example, children, teens who present to a teen clinic with any chief complaint, to a child advocacy center with a chief complaint related to physical or sexual abuse or neglect, and to a pediatric emergency department with a chief complaint related to sexual violence, which includes sexual abuse and sexual assault, and one of several high-risk chief complaints. So in terms of who to assess, would fall within these chief complaints and where the child presents to.
So, one of these high-risk complaints includes vaginal, penile discharge. And many of these things are associated with child sex trafficking, so you can also have chief complaint of pelvic, genital pain, request for STI testing, or sexually transmitted infection testing. Request for pregnancy testing, intoxication, ingestion, suicide attempt, suicide ideation, homicidal ideation, acute sexual assault, traumatic assault, clearance exam for social services, as well as behavioral complaints. And basically, essentially any patient for whom the medical provider is concerned about high-risk sexual or social behavior, regardless of the chief complaint. I also want to add that I truly believe that offering families brief universal education and resources regarding violence, trauma, or worker rights is extremely important. Patients or caregivers may want help, but may also feel reluctant to discuss their situation with a healthcare professional. This approach has actually also been advocated for use with adults experiencing intimate partner violence and reproductive coercion.
Dr. Christina Cwynar:
Now, Dr. Mohr, you just referenced some universal recommendations and education that you could provide patients and families. Could you give us a little bit more information about what that may look like? What would you specifically talk with?
Dr. Bethany Mohr:
So it's essentially anticipatory guidance, so not knowing that families have issues or have concerns about trafficking or other forms of exploitation. So just giving broad information regarding all types of interpersonal violence, anticipatory guidance about prevention of sexual abuse. And there's actually a lot of great information for parents, as well as medical providers through the American Academy of Pediatrics.
Dr. Christina Cwynar:
Thank you. Now, you referenced this just a few minutes ago, Dr. Mohr, about how do we make sure to capture these patients, and is there standardized tools about that. Do you guys think that you can talk about what standardized tools are out there, if they're proven in any way, and if they can help guide an assessment?
Dr. Andy Duncan:
Yeah. So, interestingly, there are very few validated screening tools for human trafficking available for healthcare providers. So I actually saw a study yesterday that was published in Public Health reports in July. It was a July issue. And the researchers did a literature review, and found only six validated screening tools for human trafficking in a healthcare setting. And three of those were actually versions of the screening I'm going to talk about. So, really, there's just a few. And the other interesting fact is that only one of the validated tools screens for labor trafficking, so labor trafficking does not receive as much attention. So the tool that has been validated in the pediatric setting, as Dr. Mohr mentioned, well, it's called the short child sex trafficking screen for the healthcare setting, or CST. This sex trafficking screening tool was validated for use with children ages 11 to 17. And the studies they did to validate it, they included youths that were seen in several different settings, which Dr. Mohr mentioned. So I do think it's a little narrow in the applicability in terms of age ranges. Although, I think most trafficking cases probably do occur in that 11 to 17 age range. So I was just going to read a little bit of the questionnaire.
So, they do have a suggested introduction that just says, "We want to make sure we assess you appropriately. This is confidential, unless you're at risk of harming yourself or someone else," or if they're mandated by law to release the information. And then it's six screening questions. So it can either have the child or the patient fill the questions out themselves or they can verbally be read to the patient, and then most of them are yes/no questions. So the first one is, "Have you broken any bones, had cuts, stitches, or been knocked unconscious?" And that's a yes/no question. And then some kids have a hard time living at home. It asks about, "Have you run away from home? Have you had drunk alcohol or done drugs in the last 12 months? Have you had problems with the police? And then how many sexual partners have you had?" And that one, it's not a yes/no, it has zero, one to five partners, six to 10 partners, or over 10 partners, and a positive on that one would be over five partners. And then, "Have you have ever had sexually transmitted infections?" So two yes answers is considered a positive screen. And then if there is a positive screen, then it indicates that you should ask some more open-ended questions to get more information.
Dr. Bethany Mohr:
So I just want to highlight in what Andy had said, but highlight that a positive short screen for child sex trafficking identifies trafficked persons and those at risk. We obviously want to identify those who have not been trafficked yet, if that's a possibility, and they're at risk, because both groups need the option of services.
Dr. Christina Cwynar:
Now, we just talked about a very structured type of interview for these patients, but these questions, even in a structured format, are really sensitive and sometimes really difficult for providers to ask. Do you have any tips for asking these questions and how to complete these with our pediatric patients?
Dr. Bethany Mohr:
So that's a great question, Christina. And it's not only applicable to assessing for human trafficking, but also in evaluating patients for all forms of violence and exploitation, including what Andy and I do every day in terms of evaluating for child abuse. So it's especially important, because these screening tools that Andy was talking about oftentimes involve asking a patient or a caregiver to provide answers to questions, and these answers and the effect of the screening tool relies on the accuracy of the information provided. So if you have a patient or a caregiver who is not open and is not relaying any information or inaccurate information, then your screening tool is not going to be very useful and you won't know to provide specific services. So how we conduct the screening is just as important as the content of the screening tool. So the key, really, in asking these sensitive questions in potentially traumatized patients is to use a trauma-informed approach. Meaning, recognizing the potential impact of trauma on a patient and their family, and making efforts to build trust, decrease anxiety, limit re-traumatization during the visit, foster resilience, and empower the patient.
That being said, that may be very difficult, as Andy mentioned earlier, in a short period of time. So this is not something that can probably happen quickly. So, sometimes we may do these screening tools and then have to come back and slowly ask the questions. They might not disclose any information that's important on that first visit. So, essentially, an overall screening for exploitation can only be effective when embedded within a trauma-informed, culturally appropriate context with trust and openness. So building rapport prior to screening, using normalizing language, and a nonjudgemental, empathic approach makes it much more likely that patients and caregivers will feel comfortable to share their concerns and be open to resources. And I feel that just to... It sounds like a lot. It takes practice. Even getting and obtaining a social history when you're doing an evaluation for a sensitive subject like human trafficking or abuse, it really takes a lot of practice to feel comfortable. Because if you feel uncomfortable, the patient and caregivers are going to pick up on that.
It's also really important to monitor body language while speaking with a patient and caregivers. So if there's any signs of discomfort, that those are identified immediately and addressed. I also want to highlight that trafficked and exploited persons often experience considerable barriers to accessing appropriate medical care and mental healthcare. And many of these barriers are around a lack of trauma-informed attitudes and practices by clinicians, and oftentimes healthcare facilities are not trauma-informed in terms of their policies and procedures. So I just want to highlight one more thing, that I don't have to list all of the key principles, but the Substance Abuse and Mental Health Services Administration actually has created guidelines on trauma-informed care, and creating a trauma-informed organization, which is based on these six key principles.
Dr. Christina Cwynar:
Dr. Mohr, I truly appreciate you bringing up the trauma-informed care. And for our listeners, if you tune back into some episodes a few weeks ago, we talk a little bit more in detail about trauma-informed care, and you can reference that back and learn how to apply some of these principles in this setting. And honestly, all settings where we were working with patients and don't generally know what their trauma history is, and may not know until we ask in the right way. Thank you.
Dr. Bethany Mohr:
I also wanted to mention about documentation, not only with regard to suspected human trafficking, but with regard to abuse. Many times, patients, caregivers don't want to report information because they're concerned that it will be then in the medical record. And then for various things, concern about having being biased and discrimination against them by providers. Also breaches of confidentiality. They, especially with human trafficking, might be concerned that information may get back to the trafficker and put them at risk of even being killed. And also repercussions from authorities. So it's a common theme among different types of abuse and exploitation, but especially true with human trafficking. So, really taking care to preserve the patient's confidentiality, and respect their choice about what information is in the health record is really important, but also be extremely honest about what information has to be in the medical record. And I think it's important, even if they don't express concern about that, to bring it up, because it's probably somewhere causing anxiety.
Dr. Christina Cwynar:
Do you think you could provide us some detail, given that our audience is mostly medical providers, about what we should and shouldn't put in the medical record?
Dr. Bethany Mohr:
So, there are varying opinions. So my opinion and how we document is, I feel for ongoing medical care, whether it's documentation about trauma, about abuse, exploitation, that it's so important for caregivers and medical providers in the future, to be aware of that history just in case the person is not comfortable disclosing it as time goes on. And so, I always document as much as possible. If it's something that really is not going to have an impact moving forward, in my opinion, and it's just in there because they said it, I don't put that in there. And I also feel that we can redact information. If release of records is requested, there's many times where we can redact information.
Syma Khan:
One thing I really appreciated in that reflection was being empathic, being curious, which I think really ties into when we think about asking sensitive questions in other settings. So I think the importance of using that trauma-informed lens, being mindful about those experiences and how we ask about them may trigger trauma. So we want to really create a setting that people feel safe, that they feel like their confidentiality is being respected, that it won't change the care that they receive, is really important. And I think, right? When we talk about suicide and things like that too, we want to be thoughtful in that similar way, and I think these themes carry across on different sensitive conversations that we have to have. When we talk to a child about whether they've experienced any kind of abuse or neglect as well, how can we ask it in a trauma-informed way that won't re-traumatize them, but the information that we have to get is really necessary to provide the medical care in a healthcare setting.
Dr. Bethany Mohr:
Exactly.
Dr. Andy Duncan:
Yeah, I agree.
Syma Khan:
So one thought I have is recognizing that we see children from infancy, all the way to young adulthood, and then obviously we see patients on our adulthood side as well. How do we change our assessments based on the age of the patient?
Dr. Andy Duncan:
Yeah, that's a great question. I do feel like you have to take a different approach when you're working with younger children. So, obviously with adults, you can ask more direct questions and get to the point a little more quickly. Whereas with children, you often have to build rapport and talk about other things first, and get to know them a little bit. And it just might take a little bit longer with children. And you also have to be sensitive to their developmental level, and make sure they understand what you're talking about. So when you ask them about, "Have you been sexually active?" They don't always know what that means and they might think it means something else, so you have to be very clear about what you're actually talking about. And then using open-ended questions with children. So, letting them do some narrative, and often that gets you to another place where you can start asking more directed questions.
And then with the examination, we haven't really talked about that yet, but just in general, I think assent is critical. You have to make sure that they are willing to do the exam and feel comfortable with it. And with younger patients, you want to give them choices, and give them control to make them feel more comfortable. And a choice could be whether they want their parent to be in the room or they prefer not to have their parent in the room. And sometimes, it surprises you. Younger kids might not want their parent, whereas older kids might want their parent. And then explain everything you're going to do before you do it, and then making sure you undress your patients.
So they might be there from abdominal pain, but it's really important to do a full, head-to-toe assessment, and do a really close skin assessment. Because, again, we want to look for pattern marks or bruising, or bruising in unusual places. And then doing a thorough genital exam. And we do external exams, especially on children. And then also, just thinking about whether it's reasonable to get an evidence kit or a sexual assault kit. And our kind of cutoff is that if they've had contact with a perpetrator less than 120 hours ago, then that would be indicated. And then it's important to document the finding. So any injuries, genital or bodily injuries. And then offer STI, pregnancy testing, prophylaxis and treatment as needed.
Dr. Bethany Mohr:
So I just wanted to add one thing to what Andy said about the examination is very true about assent. And even in cases where children may have vaginal bleeding or anal bleeding, in those situations we would take them, pediatric surgery or pediatric gynecology would take those children to the operating room under anesthesia to examine them. We never recommend giving them any kind of sedation or anything like that so that we can perform an exam. And just to add a little bit, too. Initially, we were talking about the standardized assessments, the screening tools, there's very limited information on appropriate screening questions for children under 11 years seeking healthcare. And especially with populations such as American Indian, Alaskan Native youth and immigrant refugee patients. So the screening tools that have been validated were looking at children who are older than this age group. So we sometimes will recommend, based on someone's medical practice or the patient population, that they may just ask general questions about possible risk factors for child labor and sex trafficking and exploitation.
Syma Khan:
Thank you so much for highlighting that a lot of these tools and the interventions and the assessments that we've developed really don't meet the need for diverse populations. Are there any other reflections that you have about human trafficking with Black, Indigenous, people of color?
Dr. Bethany Mohr:
So one of the things that's really important, I just wanted to talk a little bit about prevention. So we think about primary prevention, and obviously someone who has already been victimized, preventing further abuse or exploitation. So, essentially, with regard to, say, medical providers, there are some things that they can do. I already mentioned the brief universal education. They can talk about healthy relationships, family and dating violence, internet safety, which is a big one, especially with regard to trafficking. Worker rights, labor exploitation, and human trafficking. But you can also have providers or others, even mental healthcare providers, put up education in the form of informational posters, videos or brochures in the waiting room, or screening for vulnerabilities at the individual relationship and community levels.
So there's a lot of things also in terms of what you had mentioned, Syma, talking about the fact that if we really want to prevent human trafficking, it's not so much in a neighborhood level or a house level, individual level. It's really on a community level, or even larger, at a nationwide level. This is an issue, obviously, that's global, and not something that's just in the United States. And essentially taking a stand against systemic racism, homo and transphobia, xenophobia and ethnic discrimination, really could help reduce the vulnerability, not of individuals, but entire communities. And then one last resource that, again, I mentioned, the American Academy of Pediatrics, but they actually have a child trafficking and exploitation toolkit that provides a lot of practical information, not only for pediatricians, but other medical professionals and staff. It's really helpful, has many articles, and the screening tool that Andy talked about.
Dr. Andy Duncan:
And then I just wanted to mention that I think in terms of African American or minorities, I think in general they might have less access to healthcare, and that way we may not be catching them either, because they're just not coming in. And so I think that that is a problem and that needs to be fixed. So as much as we as healthcare providers want to get information and then fix the problem, the goal in this situation is actually not to get a disclosure. It would be ideal if we could, but the most important thing we can do is to assess risk and then try to meet our patient's needs and offer resources or referrals, such as mental health services, homeless shelters, LGBTQ resources, food pantries, and other things. Also, you don't have to get a disclosure of trafficking to make a report to law enforcement or CPS if you are a mandated reporter. So this is actually a quote taken from the screening tool that we discussed, "Mandatory reporter laws do not require the provider to be certain the child is being trafficked, but typically require a reasonable degree of suspicion. That is why assessment of risk level is important, whereas a disclosure of trafficking is not necessary." So I think as healthcare providers we don't have to have all the answers, but we need to know when to be suspicious about trafficking and react accordingly.
Syma Khan:
Thank you so much, Andy, for reflecting that many minority individuals don't access healthcare. So it's really important when they do come through our doors, that we're really thoughtful and mindful in providing that comprehensive assessment, and that we're creating a setting that's welcoming and safe for them to share things that may be traumatic or distressing to them. I think it's also really important to recognize as a mandated reporter that it's important for this to be part of our practice. And the reflection that we don't have to have a disclosure, but if there's enough of those red flags, we do need to make that report to ensure that that child is safe.
Dr. Bethany Mohr:
And it would be on a case-by-case basis, but I believe it's very important, if it's not going to pose an increased risk, to inform the patient, depending on the developmental stage and the caregiver, that we are filing a report, so that they don't have distrust that we did something and didn't tell them.
Dr. Christina Cwynar:
Any additional thoughts that you, Dr. Mohr or Andy, would like to share with our audience before we wrap up today?
Dr. Andy Duncan:
Yeah. I just wanted to mention the fact that... We talked about how screening tools are really limited, and we don't know how much screening is actually going on, but if we don't screen, we don't find out what is going on. So I don't think we have a true sense of how much trafficking is actually happening. So I think that it would be important to start considering screening universally, even at well visits and things like that, so that we do have a better sense and we can try to nip this in the bud.
Syma Khan:
And I think we've reflected that sometimes putting in that front-end work really helps prevent future harm to patients and families. And so, maybe something to consider is really, "How can we further integrate assessing and recognizing the signs of human trafficking with the patients that we work with?"
Dr. Christina Cwynar:
We really appreciate your time and your expertise. Thank you to our audience for tuning in this week. Nurses, social Workers, and physicians can claim CMEs and CEs at UofMHealth.org/breakingdownmentalhealth. You're able to do this anytime within three years of the initial air date. We hope that you join us next week.
Listen to more Breaking Down Mental Health podcasts - a part of the Michigan Medicine Podcast Network.
