Munoz - Lecture Slides

Sex Trafficking
and the Role of
the Emergency
Provider
Jessica R. Munoz
R.N, B.S.N, M.S.N, A.P.R.N- RX FNP- BC
Emergency Medicine Physicians- Pali Momi Medical Center, Oahu
Courage House Hawaii Project Director
Objectives
 Describe the problem of Domestic Minor Sex Trafficking
(DMST)/ Commercial Sexual Exploitation of Children
(CSEC) and the scope of the issue
 Describe Risk factors associated with DMST
 Discuss victim Identification, Red flags, and Indicators
 Explain how to approach a victim
 Describe role of the emergency provider
 Develop a plan for disposition and treatment after
identification
Human Trafficking Defined
“Exploitation of one
human being by
another for
personal/financial
gain
 In 2000 Congress passed the
* Labor, Sex, Baby and
Organ trafficking
 Force
Trafficking Victims Protection
Act (TVPA). To be convicted of
HT 1 of 3 elements used (29)
 Fraud
 Coercion
Sex Trafficking
Commercial Sex Act =
Any sex act for which something of value is given or received by either
person.
Value- money, food, drugs, shelter
1. Prostitution
2. Exotic Dancing/Stripping
3. Pornography
(29)
Domestic Minor Sex Trafficking/Commercial
Sexual Exploitation of Children- (DMST/CSEC)
• DMST/CSEC- Underage
children forced to engage in a
commercial sex act
• A minor cannot legally consent
to a commercial sex act
How big of a problem is this
really?
 UNICEF- 2 million children globally
 20.9 Million Estimated victims of human trafficking globally
 4.5 Million sex trafficking victims worldwide
 Between 50-60% of children trafficked are under the age of 16
 98% of Sex trafficking victims are women and girls
 Average age of entry into prostitution in U.S is 12
 1.7 Million children runaway each year only 375,600 reported
missing
(11,12,30,31,27,26)
Risk Factors
 Runaways- “throwaways”
 1/3 teens lured into prostitution within 48h
 History of violence and abuse
 28x more likely to enter into prostitution
 Younger girls are more vulnerable
 Family breakdown/violence/poverty
 Mental health issues
 Unaddressed trauma
 Substance abuse
 Sexualization of girls and young women
 Access to technology
100,000 per year newly
enslaved
Where do you find victims?
 Massage parlors
 Brothels
 Escort services
 Online
 Korean hostess bars
 Strip clubs
 Pornography
 On the street
 Hotels
 Juvenile Justice System
 Foster Care
 Emergency Rooms
and Urgent Cares
The Reality of Prostitution
Dr. Farley- prostitutionresearch.com

She was just 13 years old when she entered into the sex trade.

She is a victim of incest. (65% to 90%)

She is the most raped demographic on the planet. (80%)

She will die within 7 years after entering into prostitution.

She has a trafficker selling her as a commodity and keeping all or most of the money. (70%90%)

She is or has been homeless. (72%)

At some point she has considered suicide. (75%)

She is 40 times more likely to die than the national average.

She is two times more likely than a solider in a war zone to have Post-Traumatic Stress
Disorder. (68%)

She is classified by the US Center for Disease Control as having the highest HIV prevalence
in the United States
Stigma of Prostitution“perception of what she DID to get there”
Supply and Demand
Demand
 Pop Culture-
Demand for
Children

Rise in child porn

Open advertising on Internet
 Backpage.com
 Craigslist.com
 Myredbook.com

Can purchase a child in less than a minute
Recruitment
Kidnapping
Sold by family members
Forced or enticed into prostitution by boyfriends
or husbands.
Born in brothels and/or born to pimps and
prostitutes
Recruited from schools, malls, parties, bus stops.
Survival sex
Gang control
Types of Traffickers
Finesse Pimp
Gorilla Pimp
 Acts like boyfriend
 Minimal effort to sweet talk
 Treats them special
 Uses brutal force and threats
 Traps them in the
relationship
 Buys them gifts
The “Breaking In”
Process
1st Arrest
2nd Arrest
“The sooner you realize
that you don’t matter,
the sooner you stop
caring.“
3rd Arrest
4th Arrest
Breaking in Process
 Step 1 Seduction- “looks for needs and fulfill the void”
 Victim will look back on this phase when the relationship
turns violent and will do anything to get back to this phase
The Pimp Game
If the child wants love, they give them love and become
their boyfriend
If they need a place to stay they offer them a place to stay
If they are lonely they become their friend
If they don’t have a loving father, they become their
“daddy” and protector
If they are poor or have low self esteem, they sell them a
dream of a life status
Breaking in Process
 Step 2
 Isolation- create emotional, financial, mental reliance
on the pimp
 Brainwashing- no one cares about them like the pimp
 Safety net is removed
Breaking in Process
 Step 3
 Coercion/ Violence/ Control- manipulates to get the
child to prostitute as a display of love
 Payback
 Physical and emotional
abuse begins and is made
to be her fault
Breaking in process
 Step 4 Reframing





Given a new name
Branding
Shapes worldview and how world views them
Assigns shame, degradation, humiliation and guilt
Builds a sense of “family”/becomes daddy
Terminology
The Problem
The Players
The Game- prostitution sub-culture
Pimp- aka (P Daddy, P, Daddy, Boyfriend,
Her “Dude”)
Circuit/Track - area of prostitution activity,
route of cities a pimp and his stable
will travel
Ho-Line - loose network of
communication between pimps
(trading, buying or selling girls)
Kiddie Stroll - area of track with
underaged girls
Quota/Trap - amount of money girl has to
make
Gorilla- abusive pimp
Finesse- pimp who uses lover boy
approach
Johns/Tricks/ Dates/Clients- buyers of
prostitution
Squares- people not involved in the game
Terminology
Asset-Related Terms
Process-Related Terms
Stable- a group of prostituted girls
under the control of a single
trafficker or pimp
“Seasoning Process”- using physical and
Bottom Girl- the girl in a stable who
is tasked by the pimp with
supervising the others; she
helps impose punishment
psychological manipulation to break down
a girl's resistance and ensure she will do
what she is told; may include intimidation,
gang rape, sodomy, beatings, food
deprivation, drugging, threatening, cutting,
and isolation
Turn Out - to put a new prostitute out on
the track
Wifeys/Bitches- women in a pimp's
stable
To Sweat- to interrogate a prostitute
Out of Pocket - when a prostitute
leaves one pimp for another
To Timb - to stomp on a victim as
punishment;based on word
timberlands after the boots
Quote from Pimpology
 “You’ll start to dress her, think for her, own
her. If you and your victim are sexually
active, slow it down. After sex, take her
shopping for one item. Hair and/or nails is
fine. She’ll develop a feeling of
accomplishment. The shopping after a
month will be replaced with cash. The love
making turns into raw sex. She’ll start to
crave the intimacy and be willing to get
back into your good graces. After you have
broken her spirit, she has no sense of self
value. Now pimp, put a price tag on the
item you have manufactured.”
Why don’t they just leave?-
Why don’t they just leave?
 FEAR
 FALSE LOVE
 LIES
 They do not have anywhere else to go
 Brainwashed that no one wants them
 They will go to jail
 They may hope for the better future that was promised
What does this have to do
with me as an ER provider?
-Victims have an average of 9 HCP encounters while in
captivity
-They are rarely identified as victims of DMST/Sex
trafficking
-The physically traumatized are mistakenly believed to be
experiencing common domestic violence (by an
intimate partner)
Institute of Medicine/ National Research Council Sep, 2013
ED Provider Knowledge of
Trafficking
 Personnel in 2 emergency departments surveyed
 110 responses obtained




28% Attendings
34% residents
6 % PA’s
23% nurses
76% knew about it
29% thought it was a problem in their ED
*(Chisolm-Stike & Richardson, 2007)
ED Provider Knowledge of
Trafficking
 22% were confident in their ability to treat a victim
 6% had knowingly treated a victim in the ED
 13% felt confident they could identify
 Less than 3% ever had training on recognizing the
crime
Health Issues
Nutritional
Infectious diseases
Musculoskeletal
Gastrointestinal
Neurological
Dermatological
Gynecological
Psychological
Why is it so hard to identify
victims?
 Physically/psychologically controlled by pimps
 Trained by pimps to tell lies and false stories
 Victims distrust of service providers/LE (law
enforcement)
 No self identification as a victim (minimized abuse)
 Frequently moved from place to place
 Technology can help disguise the real age of the victim
 Easy to obtain false ID
Psychosocial Indicators
 False ID’s
 Lying about age
 Older boyfriend
 Hotel room keys
 School absences
 Restricted communication
 Wont make eye contact
 Large amounts of cash, jewelry, new clothes
 Multiple foster/group home placements
Physical indicators
Inappropriate dress
Tattoos on neck, lower back with man’s name or
initials/branding
Drug abuse/use
Multiple health care visits
Injuries in Assault Victims
 Perioral or intraoral injuries, especially erythema/petechiae
near junction of the hard/soft palate (voice muffling), forced penile-oral
penetration
 Neck Bruises or “hickies”
 Choke by hand or ligature, suction/bite
 Oval or semicircular bruises to neck, chest, breasts
or extremities
 Bite
Impact Bruises to face, body, especially lips, and eyes;
intra-abdominal hematoma or organ rupture due to
penetrating blow with fist

Injuries in assault victims
 Impact bruises to extensor surfaces of upper/lower arms,
knuckles Defense injuries (victim tries to protect head with arms)
 Traumatic alopecia/subgaleal hematoma
 Hair pulling
 Numerous small (2-3cm) bruises on the shoulders, arms,
thighs, face
 Hand restraint bruises or grab marks
 Ligature marks to wrists/ankles
 Retrains with rope or wire
 Abrasion, friction injuries to body, prominences of back
Victims struggle while restrained in supine position or firm
surface
Indicators continued…
Psychosocial
Physical
--S/S of exhaustion
-Poor hygiene
-Change in eating habits
-Frequent pelvic pain
-Boredom with peers
-Dysuria
-Memory loss
-Fear of medical help
-Irregular menses
-Vomiting
-Sore throat
-Anxious to know where boyfriend,
daddy, or uncle is during exam
-Pelvic infections
-Answers multiple texts and calls
during a short visit
-Drastic weight loss
-S/S of PTSD
-Chronic headaches, pain
-Lubricant residue
-irritation, anger
-Recurrent injuries or burns
insomnia, flashbacks
-Untreated medical problems
SPECT SCANNING and
PTSD
 Normal Brain
 PTSD Brain scan
 No Meds
* Amenclinic.com
With MEDS
 ED trafficking documentary insert here
Case 1
A 12-year-old female was recovered one month
after turning 12, after having had 3 arrests in
another state for solicitation while she was 11. She
presented with chronic non-healing skin wounds and
lesions which were not resolving with repeated
courses of antibiotics.
 The child's diagnosis was determined to be malnutrition.
Although she was fed, she was subsisting on chips, Ramen
noodles, fast food and soft drinks.
Case 2
An 18-year-old female presents to the ED with complaints of right arm and shoulder pain
and pain in the right upper leg. The patient reports she was climbing over a railing when
she twisted her right arm and strained her right leg. She states she was trying to get
back into her apartment because she had locked herself out. The patient’s boyfriend
provides the patient’s ID and completes her paperwork for her. He repeatedly interjects
while the patient’s history is given and states she is clumsy and forgetful and forgets her
keys “all the time.” He is busy texting on his phone.
The patient provides short answers to questions about her history and keeps checking
the time. She is wearing a tank top with a sweater over it and jeans which are all kept on
during her physical exam. By exam, the patient has full range-of-motion in all four
extremities with no neurological deficits. Her gait is somewhat antalgic, but, otherwise,
her exam is normal. The examiner is paged overhead and must attend to another
patient. Ibuprofen is administered.
After some time, the patient is seen ambulating to the bathroom, and appears to be
walking more normally. Her boyfriend tells the nurse they want to leave. You write up
the paperwork and she is discharged.
Case # 3
A 16-year-old female was placed in detention home and
given a standard examination in the ED. No swelling or
bruising was apparent to the ED physician or the caseworker who observed the girl during her detention.
When the girl was released home the next week, her
mother called saying that she was complaining of face
pain. She was taken to another ED where she was
found to have 7 fractures to her face. It was elucidated
that she had sustained a beating from her pimp which
had occurred before she had been placed in detention.
Case 4
An 18-year-old female presented to the ED with a vague complaint of back
pain for several days. She arrived with an “older”man who appeared to be
her boyfriend. She was wearing a tank top and a short skirt. She had
several tattoos.
While she gave her HPI, the man she was with often interjected and
answered for her. It was explained that she had had this back pain before
and it felt like her normal pain. When the patient did speak, her speech
was pressured and she appeared to be in a hurry. She asked for a shot of
pain meds and Percocet for home.
Her PE was performed while she was in her clothes. There was no evidence
of neurological deficit. The medical record confirmed she had been there
before with back pain. The man was in the room for the entire history and
exam. The patient was given pain medication and sent home. She had no
PCP; she was given the referral line.
Case 4 cont
Two days later, the “boyfriend” drove an SUV up to the
ambulance bay, pushed the patient out of the car and
drove away. The patient appeared blue and was
minimally responsive. Resuscitative efforts were
performed, but she was unable to be resuscitated.
On coroner exam she was noted to have several bruises
to her low back, upper thighs and chest wall. She had a
retained “makeup sponge” in her vagina with a large
amount of pus present. She had a man’s name
tattooed across her lower left breast. There were
various sites of what appeared to be cigarette burns to
her abdomen and inner wrists.
Case 5
 A 16-year-old female presents in police custody in need of medical
clearance for placement at a juvenile detention facility. The police
state she is being arrested on charges relating to truancy from
school and running away from home. She has not attended school
for several weeks and has reportedly stayed out intermittently with
friends rather than going home at night. Law enforcement agents
found the patient loitering outside an apartment complex near a
bus station. The police report she had marijuana in her purse
when she was apprehended, and that she has a prior history of
both marijuana and cocaine possession.
 During history-taking, the girl answers questions with one-word
answers, appears disinterested in conversing and prefers to stare
at a wall rather than maintain eye contact. She denies having had
any past medical problems. The patient states she has been
staying with her boyfriend at times, but is otherwise living “around”.
She says has a “stable” of girls she “runs with.”
Case 5 Cont
 No further social history is taken from the patient. The
police are waiting outside the exam room. The physical
exam is performed with the patient fully-clothed.
Oropharynx is clear, and examination of the heart and
lungs is normal. A urine pregnancy test is negative. The
patient is given medical clearance and discharged into
police custody.
Recap of the Case Studies
THEIR BODIES DO NOT LIE
Approach
Assessment1.Build RapportAlone/confidential
* Collect as much information as you can
* Separate from belongings and any “family members”
* Police custody- prime time for an exam
Terms to avoid when
addressing victims
-Call Girl
-Escort
-Ho
-Pimp
-Prostitute
-Sex Worker
-Trafficking Victim
-Whore
AssessmentGeneral Questions
- Where do you live, who do you live with?
- Who takes care of you?
- How did you meet your boyfriend?
- Do you feel like you are in danger?
- Are you being threatened in any way?
- What does your boyfriend do when he is angry?
- Do you feel trapped in your living situation?
Assessment
Direct Questioning
 Tell me about your tattoo.
 Has your body ever been used for money?
 Has anyone ever taken photos of you and put them on
the internet?
 Is there anything happening in your life that you want to
stop?
Approach to Victims
TEAMSTAT
-Tell them your agenda
-Express concern
-Assure normalcy of feelings
-Medical issues
-Safety issues (family hx, support, runaway
tendencies)
-Test and treat presumptively (STDs, pregnancy
prophylaxis, birth control)
-Access assistance (psychological and legal)
-Timely follow-up (injuries, STDs, birth control,
drug/alcohol use, psychological issues)
Trauma Bonding
 The victim becomes emotionally attached to the
trafficker even though they have been abused
 Emotional attachment creates a sense of hesitation
or lack of desire to leave trafficker
Why is it so hard to get help?
 Understanding her mindset
 Captivity- frequently guarded/ accompanied
 Fear
 Shame/ self blame
 Debt bondage
 No personal ID
 Distrust of law enforcement
 Isolation
 Lack of knowledge
 Hopelessness
 Threats to loved ones or family
 Dependency on pimp
Once I identify,
then what?
 Mandatory reporting for children under 18 who are being sexually
exploited
 Police, sex crimes Squad, CPS, FBI
 Work with Hospital admin to establish a policy/protocol
 Find out what your community is doing in this arena
- Social worker, justice advocate volunteers specializing in this population
- National Human trafficking resource center (888-373-7888)
- Local San Diego FBI- Becky Moreno- becky.moreno.ic.fbi.gov
Physicians/Nurses
Law Enforcement
Multidisciplinary
Approach
Mental
Health
Specialist
Social Workers
The #1 Need in the US…
 Licensed AFTERCARE FACILITIES providing longterm restorative care!
 As late as 2009, there were only three homes for minor
victims of sex trafficking in the United States with a total
of 32 beds. Today, that number has grown to
approximately ten homes totaling over 150 available
beds. We have a long way to go to meet the need
 (sharedhope.org)
What would you do?
Hippocratic OathAMA
 “VI. Work freely with colleagues to discover, develop,
and promote advances in medicine and public health
that ameliorate suffering and contribute to human wellbeing.
 VII. Educate the public and polity about present and
future threats to the health of humanity.
 VIII. Advocate for social, economic, educational, and
political changes that ameliorate suffering and
contribute to human well-being.”
You Can Make a Difference
Resources
 Sharedhope.org
 Traffickjamming.org
 Courageworldwide.org
 Nationalcenterformissingchildren.org
 Polarisproject.org
 Gems.org
 Notforsale.org

*See Document with full Reference list
Questions
 Contact:
 J.munoz@courageworldwide.org