HomeMy WebLinkAbout08-06-24 Public Comment - A. Nerlin - StatisticsFrom:A JTo:Bozeman Public CommentSubject:[EXTERNAL]Statistics part 1Date:Monday, August 5, 2024 1:29:54 PM
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.
As a pharmacy technician, I am required to get Continuing Education credits for my license. Here's my latest one. Gee, do you know how many tens of thousands of undocumented people are in thisvalley? Do you know how many problems you have exacerbated with this fallacy of a city government? No. You have zero idea. All you care about is $$$$$$$$$$. I will copy and paste my entire CElesson for you to read through. Welcome to BozeAngeles.
Introduction
Human trafficking is a crime that involves the exploitation of a person for labor, services, or commercial sex work and can impact anyone, including children, adults, and people of all
backgrounds and nationalities. It is critical to understand the difference between commercial sex work and human trafficking. Commercial sex work is that in which the sex worker is a
consensual partner with another individual(s) and engages in many activities and situations (eg, brothel and street prostitution, paid domination, stripping, sexual massage). Trafficking
is a broader term and is the illegal or illicit manipulation of people to perform certain acts by using force, coercion, or fraud.1 The word trafficking implies movement; however, current
federal laws do not require that victims or traffickers cross state or international borders or be otherwise transported. In 2021, 10,583 situations of human trafficking involving 16,658
individual victims were reported to the US National Human Trafficking Hotline, a contact site that finds social and legal services for victims and survivors of human trafficking, who may
choose to remain anonymous when they call..2,3 The hotline is available 24/7 for individuals seeking emotional support or resources for safety and has trained anti-trafficking specialists
who can converse with victims in more than 200 languages, including English and Spanish. The hotline also connects people who contact it with training and volunteer opportunities
across the United States and its territories. Although these numbers alone are staggering, they are likely an underestimate of the true prevalence of human trafficking in the United
States, as it is largely underrecognized and underreported.4 A 2014 study by the National Human Trafficking Resource Center indicated that 88% of human trafficking survivors reported
obtaining health care services, including 68% who indicated using the emergency department (ED) while they were being trafficked.5 This intersection of health care and human
trafficking presents an important opportunity for health care professionals to be alert to potential behaviors, injuries, or actions that may signal an individual is a victim of human
trafficking. Because of the ease of accessibility to pharmacy services, pharmacists and pharmacy technicians may encounter victims of human trafficking and should be informed
about approaches to safely and sensitively aid these people. Several studies have documented the limited recognition and knowledge of human trafficking among health care
professionals and the positive impact of specific training to increase awareness and confidence to act.6-9 The purpose of this continuing education (CE) program is to equip
pharmacists and pharmacy technicians with knowledge of human trafficking. This involves understanding the general legal definitions, types of trafficking, red-flag indicators, and
resources that can be used to help victims and support survivors of human trafficking. An important thing to remember about victims of human trafficking is this quote from Polaris, an
organization whose sole purpose is to help victims, “Adult trafficking victims and survivors need support, not rescue. Survivors rescue themselves.”
The Scope of Human Trafficking in the United States
Globally and within the United States, it is estimated that human trafficking prevalence is increasing. According to data compiled by the National Human Trafficking Hotline, situations
involving victims trafficked for sex and labor increased 20% from 2020 to 2021.2 Attention to this issue in recent years has seen health care professionals, including pharmacists, assist
law enforcement officials to measure these increases in human trafficking cases and successfully prosecute and convict traffickers. Between 2011 and 2020, human trafficking
occurrences reported to US attorneys increased 62%, and the number of individuals subsequently prosecuted for human trafficking increased 84%. Convictions for human trafficking
also increased from 2011 to 2019, with 1564 people imprisoned for human trafficking offenses as of December 2020.10 In 2005, the International Labour Organization estimated that
the human trafficking “industry” generated $32 billion annually, making it organized crime’s third largest income source.11 By 2014, it had grown to a $150 billion industry.12-14 The
clandestine nature of this crime makes identifying victims extraordinarily difficult, and the true scope of human trafficking in the United States is likely much larger. Human trafficking
cases have been reported in all US states, the District of Columbia, and US territories and involve domestic and foreign national victims.15 According to the National Human Trafficking
Hotline database, in 2021 the majority of signals (contacts received by the hotline via phone, text, web chat, email, and through an online reporting form) and cases received involved
California (10.29%), Texas (6.92%), Florida (5.67%), New York (3.25%), and Ohio (2.27%).16
STAR*
Would you recognize a victim of human trafficking who comes to your pharmacy, and do you have a plan to help?
*S = Stop; T = Think; A = Assess; R = Review
Most reported cases of human trafficking in the United States involve women (85.1%). Regardless, men, women, adults, or children may be trafficked, and socioeconomic class is not a
factor.16 Roughly 24% of reported cases involve children.16,17 In the case of children, physical kidnapping is a possibility, but traffickers often lure naïve or unsupervised children using
online contact and social networks. In the United States, people with certain risk factors are more vulnerable to human trafficking (see Table 117). Human trafficking also increases in
the wake of a disaster when people are more vulnerable, and conditions are unstable.18
Table 1. Individuals With Increased Vulnerability for Human Trafficking17
Children in the child welfare and juvenile justice systems, including foster care
Runaway and homeless youth
Unaccompanied foreign national children lacking lawful immigration status
Individuals seeking asylum
Individuals of American Indian and Alaska Native descent, particularly women and girls
Individuals with substance use issues
Racial or ethnic minorities
Migrant laborers, including undocumented workers and participants in visa programs for temporary workers
Foreign national domestic workers in diplomatic households
People with limited English proficiency
People with disabilities
LGBTQ+ individuals
Victims of intimate partner violence or other forms of domestic violence
Types/Forms of Human Trafficking
Human trafficking can take on many forms and, in the United States, sex trafficking (72%) and forced labor (10%) are the most common types encountered (other/not specified reports
account for 13%).2 Readers may envision forced prostitution as a manifestation of human trafficking, but additional examples include demanding sex from a person who cannot pay his
or her rent, forced involvement in pornography, and forced marriage. Examples of forced labor include debt bondage, where a person is forced to work to pay off a debt, and child
labor.17 Other types of trafficking include forced criminal activity and trafficking for organ removal for transplant (which occurs in inappropriate venues and with poor aftercare), and, in
some countries, traffickers engage in ritual slavery, a form of slavery in which the trafficker takes young girls to atone for a family’s alleged sins.19,20 A growing form of human
trafficking is benefits trafficking (the exploitation of an individual for the purpose of appropriating their benefits or savings). This is a concern among the elderly. In this type of
trafficking, traffickers target adults who receive public benefits due to disability status or based on their age and may isolate them or force them to fill prescriptions for controlled
substances.21
In contrast with the United States, globally, more people are trafficked for labor, specifically agricultural or domestic labor, than for sex work.22 Experts often differentiate between 2
types of forced labor because they are widespread: domestic servitude and forced child labor.17 Exploitation of people who are forced into and held in these sectors is referred to as
modern slavery.23 Reports from the International Labour Organization estimate 40.3 million people were involved in modern slavery, which includes forced marriages, globally in 2016.24
Human Trafficking and a Critical Element: Exploitation
Human trafficking is an exploitation-based crime. It is different than human smuggling, in which the primary purpose is to transport or hide individuals who lack proper immigration or
residency documentation by evading officials without regard to immigration laws (a transportation-based crime).25 The people who smugglers transport often have chosen to engage in
the transport, whereas victims of human trafficking generally are held in circumstances against their will. Regardless, traffickers may also use immigration status and threats of
deportation as a means of coercion in both labor and sex trafficking, and smuggling may metamorphosize into trafficking.17,25
Many people confuse human trafficking and commercial sex work.17,26 A key differentiator between human trafficking for sex work and consensual commercial sex is that the
individual performing the sex work is doing so of their own free will. As with human smuggling, individuals who participate in commercial sex work have made a conscious decision to
do so; however, in some instances, individuals enter the commercial sex industry willingly and later become victims of human trafficking.27,28
Recruitment Techniques of Trafficking Perpetrators
Federal Laws and Institutions Fighting Human Trafficking
Human trafficking is illegal in all US states, and the federal Trafficking Victims Protection Act of 2000 established formal methods for prosecuting human
traffickers, protecting survivors of human trafficking, and preventing human trafficking.37 These 3 methods must be established and compose the 3P
paradigm. Prosecution refers to the ability to take legal action against an individual suspected of human trafficking. Protecting victims and survivors of
human trafficking includes the ability of health care providers and other individuals to provide referrals for a comprehensive array of services, including the
US National Human Trafficking Hotline. Governments and international organizations may also establish protocols to protect survivors of human trafficking
through emergency and long-term services as well as legal assistance. Prevention of human trafficking can be achieved through community intervention
programs led by health care professionals in collaboration with local organizations or law enforcement to expand awareness and build relationships with
individuals.38 Additional strategies for prevention and protection of human trafficking survivors are discussed subsequently.
As previously described, though the word trafficking implies movement, current laws do not require that victims or traffickers engage in actual movement
across state or international borders. It only requires that the trafficker has met the criteria for the 3 elements of “act,” “means,” and “purpose.”27 These
elements are defined as the following39:
ACT implies that the trafficker has recruited, transported, transferred, harbored, provisioned, obtained, patronized, solicited, or received a victim
MEANS indicates the trafficker has used threats, force, coercion, or fraud to deceive, abuse, or otherwise compel an individual to engage in nonconsensual
sex acts or labor
PURPOSE is very simple; the trafficker’s sole purpose is to exploit the victim
Consider a landlord who forces a woman to have sex with him because she cannot pay the rent. During the pandemic, this type of situation was reported
more often than previously.40-42 In this case, law enforcement might interpret act/means/purpose in this way42:
The ACT is that the landlord has recruited and harbors the woman in his property
The MEANS is that the landlord has coerced the woman with the implied threat that the family will be homeless if she does not comply
The PURPOSE is exploitation of people experiencing economic hardship
The International Trafficking Victims Protection Reauthorization Act of 2022 will continue established policies to combat human trafficking, including
expanding international trafficking prevention efforts and protections for international workers and visa holders. This act includes resources to promote
knowledge of their right and identifies countries to receive additional assistance or take action against those failing to meet standards.28,43
In December 2022, the US Senate passed legislation to reauthorize the Abolish Human Trafficking Act, originally passed in 2018, which has 2 primary
focuses44: (1) eradicating human trafficking and (2) supporting survivors. It reauthorizes funding at the Department of Health and Human Services and
Department of Homeland Security and extends important programs that combat human trafficking through 2027. Its components include far-reaching
actions:
Confidentiality protections for victims
Cybersecurity enforcement
State-level funding if states include trafficking prevention and treatment in their foster systems
Assistance to victims whose traffickers have stolen their documentation
Improved data collection
Funding for forced labor investigations
This reauthorization also extends the life of the Department of Justice Domestic Trafficking Victims’ Fund. The fund receives fines pursuant to conviction of
human traffickers and sexual predators and receives an annual allotment from the Community Health Centers Fund.44
Health and Quality of Life Impact of Human Trafficking
Victims of human trafficking often lack access to quality preventive health care services or sufficient methods of hygiene. Lingering, chronic health issues
can stem from poor living conditions or inadequate access to food and water. Poor growth and dental problems can be signs an individual experienced
human trafficking at a young age. Repeated pregnancies, sexually transmitted infections (STIs), or infertility from chronic or untreated STIs or dangerous
abortive medical procedures may be indicators that a person is a victim.
Because traffickers often restrict the victim’s movement and activity, victims may find treatment adherence and follow-up difficult, if not impossible.
Traffickers often use threats of physical violence to control their victims, often around the clock, and prohibit victims from contacting family or friends. They
may have no free time, lack access to money, or be kept from speaking when directly addressed.
Aside from immediate physical health concerns, the trauma associated with human trafficking can cause post-traumatic stress disorder or other mental
health conditions in survivors. Some victims may have preexisting substance use disorders that increase likelihood of coercion by a trafficker.45 In other
circumstances, traffickers may force victims to use addictive substances to alter their cognition and make it easier to be controlled.17 Survivors of human
Human traffickers are nefarious individuals who often use force, fraud, or coercion to exploit and control their victims. Traffickers may use force with threats of physical violence,
restraint, or imprisonment. It should be noted that force, fraud, and coercion are not necessary to be established if a victim is younger than 18 years old. Instances of fraud may include
deception and withholding pay or identity documentation. Coercive acts may include controlling the individual through emotional manipulation, isolation, or cult-like spiritual or cultural
practices to ensure the victim’s obedience.29 Traffickers may also use physical or mental manipulation through illicit, addictive substances that can alter an individual’s cognition to
control their victims.17 In the case of benefits trafficking, the criminal offers housing, care, and protection; though this is common among older adults, individuals of any age can be
targeted for benefits trafficking. Once ensconced in a new setting, individuals are forced to sign over their benefits; identity theft often follows.21,30
Numerous researchers and public health groups have tried to understand the motives behind human trafficking, with the thought that understanding such motives may help identify
anti-trafficking interventions. Many organizations cite financial gain as the primary motivation.31,32 As noted previously, the profits associated with human trafficking can be enormous.
Many interventions are used to try to identify traffickers and can include strategies that “follow the money,” such as tracking large quantities of cash and suspicious banking patterns.
Recent research has found that in some cases, traffickers do not make significant amounts of money. Sometimes traffickers are motivated by ideology, religion, or cultural norms that
place little value on human life. In addition, many traffickers were themselves trafficked as children or young adults. Some examples include youths who are forced to become child
soldiers and grow up to believe that forcing young men to fight is not only acceptable but manly and necessary. Or, after years of sexual exploitation, a grown child may be convinced
such behavior is normal. Some traffickers simply have pathological tendencies.30
Traffickers can be strangers, acquaintances, or even family members, and they prey on vulnerable individuals.33 In some cases, community leaders may serve as recruiters for
vulnerable individuals within their immediate community. Common human sex trafficking fronts can include modeling agencies, babysitting or au pair services, or massage
parlors.25 For sex trafficking, traffickers look for reliable access to hotels, motels, or truck stops. Many traffickers keep their victims mobile, moving them from place to place in
“circuits,” to prevent attracting undue attention and minimize risk of being caught; pharmacy staff need to know that interstate movement is not a required element for human
trafficking.7
Like most businesses, human trafficking operations have increased their use of technology, and the nature of this problem has changed over time. Law enforcement reports that while
traditionally trafficked sex workers walked the streets, increasingly traffickers use online methods to attract clients, making the internet the primary location for solicitation. In addition,
traffickers can reserve and pay for rooms at hotels online, making the hospitality industry somewhat complicit.34 This has made it difficult for law enforcement to act. One thing has not
changed: sex trafficking is primarily an urban problem. Further, human trafficking and the drug trade often occur in tandem.35,36
Traffickers can recruit vulnerable children and youths at a variety of venues, several of which are key locations in the child’s community, including schools, shelters, shopping malls,
movie theatres, public transportation, libraries, parks, and parties.2,7 In recent years, the trend has been for traffickers to build online profiles to attract victims, especially in the Southern
United States.7 In many instances, the trafficker will accompany the victim and display actions signaling control over the victim, such as not allowing the victim to speak or venture out
of their sight.7
STAR
Is human trafficking a problem in your area? What types of human trafficking are likely to occur, and who is most likely to traffic people in your area?
Many traffickers are well known to the victim and could be intimate partners or family members. Polaris tracks recruitment relationships if the information is available or if the victim is
willing to provide it. In 2021, that information was available for 4010 cases (38%), or reported cases, of which 33% were linked to a family member or caregiver and 28% were linked to
an intimate partner.2 The numbers are higher when the researchers look at sex trafficking alone (removing other forms of human trafficking).2 A warning sign might be that a family
member showers a relative with money, gifts, or presents an offer that seems too good to be true. Increased vigilance from responsible adults is called for when a person becomes
involved in a fast moving and asymmetric relationship (ie, 1 partner is considerably younger or less financially stable than the other).33
trafficking may continue drug use to suppress psychological trauma stemming from the experience of being trafficked.46 These complex psychological
effects contribute to survivors’ difficulties with focusing on tasks and forming/maintaining relationships.46 Without job-specific training, survivors of human
trafficking may experience economic difficulties that can impact their long-term employment and financial stability.46
Clinical Settings Where Trafficked Individuals May Seek Care and Challenges
The exact percentage of human trafficking victims who visit health care settings is unknown, and no data are available about their use of pharmacies;
however, it is known that these individuals most often present to community clinics or EDs, and accessibility makes pharmacies an ideal place for victims of
sexual trafficking to seek care.8,47 Limited data have shown that trafficking victims tend to use complaint-based, episodic acute care services (eg, minute
clinics, urgent care centers, and EDs) more often than long-term, comprehensive primary care services.46 Health care providers may have missed
opportunities for intervention on behalf of trafficking victims; the majority (87.8%) of human trafficking victims in 1 study reported having any contact with a
health care provider, with the greatest proportion (63.3%) receiving treatment in a hospital or ED setting.48
Identifying Victims of Human Trafficking
The signs of sex or labor trafficking differ, and the signs also differ for adults and children.33 Victims of sex trafficking may have history of multiple
pregnancies or abortions; STIs; and pelvic, urinary, or rectal trauma. Indicators of physical abuse may not be overt and may be hidden or isolated to body
parts that are less visible (ie, lower back). Victims of forced labor trafficking may present with more severe injuries due to unhealthy or unsafe working
conditions and lack of protective gear for the job. Working for long hours, lack of benefits (health insurance, sick days), and limited finances may be
indicators of forced labor. Victims of human trafficking who have been forced into domestic labor may experience a combination of these signs and may be
unable to schedule or attend appointments unaccompanied.33,49 Indicators that a child is a victim of human trafficking can be similar to those mentioned
for adults but can also include lack of parent or guardian presence, missing school or working during school hours, lack of friends or playtime, dressing
provocatively, or drinking or using illicit substances as minors.49 Health care professionals should be familiar with immediate physical concerns that may
indicate that an individual is a victim of human trafficking. Victims of human trafficking can present with multiple injuries, sometimes comorbid injuries,
chronic and untreated conditions, STIs or trace of sexual violence, and mental health or substance use issues.50
Health care professionals should heighten their awareness of potential abuse and human trafficking and look for “red flags.” A key red flag is delayed care,
although many patients have reasons to delay care (eg, lack of insurance, no transportation, or difficult access to care). Delayed care in conjunction with
other flags may indicate an individual is in trouble.51,52 Figure 18,51-54 lists potential signs and signals of human trafficking in adults and children.
Additionally, a common flag worthy of emphasis is the presence of tattoos (ie, bar code tattoos or branding marks) that imply possession by a pimp or a
trafficker. These often appear on the neck, arms, or groin areas.55
Figure 1. Red Flags That Should Trigger Suspicion of Human Trafficking8,51-54
STI, sexually transmitted infection; UTI, urinary tract infection.
Because of victims’ lack of preventive care, they may present with advanced or chronic conditions that could have been prevented or managed if discovered
sooner. If they have access to patients’ medication histories, pharmacists can examine prescription filling patterns. Prescriptions filled in different clinics for
STIs or emergency contraception may indicate an individual is being trafficked for sex work.8 Within the community pharmacy, another red flag for sex
trafficking may be individuals who frequently purchase condoms or emergency contraception.25 These examples pose a challenge because these patterns
alone do not necessarily indicate that an individual is a victim of human trafficking.
STAR
How can you recognize a possible victim of human trafficking and intervene?
Pharmacy Staff and Health Care Professionals’ Roles
As of 2023, only 2 states require human trafficking CE for health care professionals, including pharmacists and pharmacy technicians. Additionally, schools
of pharmacy are trying to raise awareness of human trafficking in their curriculums.
Need for Adequate Education and Preparation
Health care professionals who are alert to potential behaviors, injuries, or actions that may signal an individual is a victim of human trafficking can leverage
that opportunity to help the victim. However, surveys consistently report health care provider knowledge of human trafficking as below average; in 1 survey,
less than half of participants reported receiving formal human trafficking training.6 In a study of health care professionals working in an ED, just 2% had
training on clinical manifestations of trafficking, 5% reported receiving training on treatment of victims, and 6% reported having ever cared for a victim of
human trafficking.56 Unfortunately, the data indicate that health care professionals were the initiators of only 2.1% of signals or alerts reported to the
National Human Trafficking Hotline between January 1, 2020, and December 31, 2020.57
Additionally, some reports have found that health care providers may be hesitant to act even if they suspect human trafficking. Their hesitancy often stems
from unfamiliarity and lack of confidence about possible and specific actions. One study reported 77% of patients were not identified as victims of human
trafficking when health care providers did not ask questions and took no action.58 As EDs and community clinics are sites where human trafficking victims
may be seen, it is paramount that formal training on identifying and caring for victims of human trafficking be provided to health care professionals in these
settings. Ideally, organizations should develop protocols and provide education to guide health care professionals in their employ in the identification of
human traffickers and their victims. This can ensure that health care providers are prepared to appropriately and compassionately respond to incidences of
human trafficking. Additionally, established protocols can facilitate rapid responses and can allow an individual to remain calm while following a process.
Employers should also detail optimal and safe responses should victims disclose their situation.9 Establishing organized, proactive responses to suspected
cases of human trafficking can ensure the safety not only of the individual but also of the health care provider.
Pharmacy staff can use the Stop, Observe, Ask, Respond (SOAR) framework to identify and appropriately respond to suspected cases of human trafficking
within their pharmacies, health systems, and communities. Through outlined culturally and linguistically sensitive interactions, the SOAR framework
provides trainings for health care professionals to design interventions for victims of human trafficking (Figure 259). A key component of the SOAR
framework is coordinating care among members of the multidisciplinary team. Note that this step follows patient engagement. In all suspected cases,
health care professionals need to remember that adult victims must rescue themselves. Supporting victims and providing the tools they need to reach
safety is the first essential step. Helping victims who are children or in protected classes is different, but also requires care and discretion.
Figure 2. The Stop, Observe, Ask, Respond (SOAR) Framework59
Strategies to Recognize Victims and Have Effective Conversations
When victims of human trafficking have contact with health care professionals, an important opportunity presents itself; however, starting and maintaining
conversations with victims can be challenging. Safety of the individual should be the primary concern. Before engaging with individuals who may be victims,
it is important to be mindful that the trafficker may be present or nearby. In many cases, human trafficking operations involve multiple traffickers and
victims of both sexes.60,61 The trafficker may remain close to control and scare the victim and could prevent the individual from answering truthfully. Direct
questioning may place the individual in additional danger, so health care providers need to be careful when conversing with a potential human trafficking
victim, both for the safety of the individual and their own.62 They should ask sensitive questions and discuss personal information only if they are able to
assess the patient alone. Some questions and examples of compassionate language to use when addressing a victim of human trafficking can be found in
Table 2.63,64 Pharmacists can use their position as medication experts to explain the need to privately counsel patients about new prescriptions. Once they
have some privacy away from the suspected trafficker, they can talk privately, share concerns about the individual’s safety, and seek aid from appropriate
resources.8
Table 2. Examples of Compassionate Language Preferences 63,64
Instead of…Preferred
Prostitute Victim or survivor of sex abuse; trafficked
individual, commercially sexually exploited
child (CSEC)
The term “prostitute” conveys criminalizing
nature and stigmatizes trafficking victims.
Rescue or save Leave, exit, or assist Trafficking victims may not feel the need to be
“saved,” or “rescued”; and this terminology
reinforces a power structure and disempowers
trafficking victims.
An individual was trafficked This person trafficked the individual Emphasizes who is doing the action and
removes blame from the trafficked individual.
An additional and powerful step pharmacists can take is to call out implicit bias.65 Most people in the United States know little about human trafficking and
often have some preconceived notions. Among health care professionals, attitudes, whether they are positive or negative, or stereotypes about victims of
human trafficking can affect their actions and decisions unconsciously. This is called implicit bias. It causes us to form ideas and make judgments about
people without completely understanding their situations. Health care providers have an ethical obligation to be aware of their potential biases and the
effects of implicit bias when they provide care. By examining one’s biases and the biases that are observed in coworkers and colleagues, health care
professionals can take steps to combat implicit bias and improve patient outcomes. Addressing bias is an important step when dealing with human
trafficking. In other words, when dealing with victims of human trafficking and the entire issue of human trafficking, pharmacists and pharmacy technicians
need to be able to sort their beliefs from the facts of the matter.65
Victims of human trafficking could be racial or ethnic minorities; migrant laborers, including undocumented workers and participants in visa programs for
temporary workers; and people with limited English proficiency. Mismatched languages between patient and provider are barriers to good health care
because, often, patients or their untrained interpreters miss, omit, or revise portions of the provider’s discussion. In addition, without training, the person
doing the interpreting may think that the pleasantries and kindnesses of the patient’s natural language are unnecessary and can be dropped, but
pleasantries and kindness are necessary to build rapport. Health care professionals need to know that for patients, the provider’s efforts to establish rapport
may be more important than the health-related information. Trained interpreters know these facts and treat patients accordingly.66 Making professional
interpreters available ensures statements are translated and documented accurately. Individuals may feel more comfortable speaking in their native
language.2,52,66
Trauma-Informed Care
Trauma-informed care is crucial for trust building and communication when working with victims of human trafficking. This approach, promoted by the
Substance Abuse and Mental Health Service Administration, is used to identify, question, and intervene when human trafficking is a concern. This approach
acknowledges trauma’s widespread impact and integrates knowledge about trauma into practice while minimizing re-traumatization. Health care providers
who use this approach are aware of potential paths for recovery, recognize trauma’s signs and symptoms, and respond to patients thoughtfully,
nonjudgmentally, and with empathy.67 The trauma-informed approach has 6 principles: safety; trustworthiness and transparency; peer support;
collaboration and mutuality; empowerment, voice and choice; and cultural, historical, and gender issues. Key points for pharmacists and pharmacy
technicians include the following:
Frontline health care workers need training and education, and it is not a one-and-done activity. It is essential to stay current with findings and changes as
evidence develops
Involving the community is critical to changing how trauma manifests as an event, an experience, and an effect (3 components of trauma)
Many people who experience trauma will recover and be well, but most will not unless they have significant help from qualified professionals
Experts recommend using strength-based, nonjudgmental language to avoid victim blaming (eg, replacing the phrase “child pornography” with “child sexual
From:A J
To:Bozeman Public CommentSubject:[EXTERNAL]Statistics part 2Date:Monday, August 5, 2024 1:32:09 PM
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.
Conclusion
Human trafficking is, unfortunately, a very real and regular occurrence both internationally and in the United States. Marginalized people are victimized
because they are vulnerable, and health care professionals, including pharmacists, should be aware of red-flag indicators that place both children and adults
at risk for human trafficking. As individual states have different laws concerning mandatory reporting for children and adults, participants in this CE program
are cautioned against using the information presented as legal advice. Organizations and health care settings also have unique policies that must be
followed when reporting suspected cases to support survivors. Pharmacists are central in combatting human trafficking. They can help establish or revise
existing procedures within their practices that address implicit bias for potential victims of human trafficking and support comprehensive, trauma-informed
actions when red flags present themselves.
ADDITIONAL RESOURCES
RESOURCE Link
National Human Trafficking Hotline English: https://humantraffickinghotline.org/en
Spanish: https://humantraffickinghotlin...
1 (800)-373-7888
Text 233733
Chat at https://humantraffickinghotlin...
abuse materials” and defining sexual acts during captivity as “exploitation” rather than “prostitution”).68 When health care practitioners use language
carelessly, they raise the risk of re-traumatizing the victim; each time the victim tells the story of his or her captivity, re-traumatization can occur. Health care
providers also need to let the victim decide what to tell and when to tell it and respond calmly without sensationalism or tone that implies judgment.69
Making assumptions about an individual’s situation is unwise, as some may not see themselves as victims and may take offense to suggestions of human
trafficking. Trafficked individuals may be unwilling to share their experiences due to shame, stigma, disbelief, or judgement resulting in blame. Pharmacists
and pharmacy technicians should remember to use compassionate language, as victims perceiving judgment, cultural insensitivity, or other biases may be
less likely to accept or ask for help.9
Traffickers use fear as a weapon to keep and control victims of human trafficking. Fear is 1 reason victims hesitate to report or disclose their situation.
Physical and psychological abuse from their traffickers prevents victims from reporting their situations. In some cases, victims develop “trauma bonds” with
their traffickers and may not see themselves as victims.7 Expressing concern for individual safety while respecting their choices and not pressuring them to
seek help is a balancing act. Pharmacists who are familiar with motivational interviewing to encourage medication adherence and disease management
can use that skill to connect with and help victims of human trafficking. Building rapport may take time, and Figure 359,70 describes the usual cycle. First
developed by Prochaska and DiClemente, the cycle can be applicable to many situations and patients with psychological and interpersonal conflicts.
Victims of human trafficking may be wary of overt efforts to distance them from their trafficker; therefore, health care professionals should consider
providing information that promotes empowering the individual to choose to report their situation during the contemplation stages to prepare them to act.
Providing such resources is essential for the maintenance stage as well to ensure the victim receives ongoing support for their decision—immediately after
and continuing into the long term—and prevents a relapse or a return to their trafficker.71 Victims may progress or regress through the stages; as with all
patients, the process of building rapport is not linear and waxes and wanes as patients consider any new knowledge or encouragement they receive, their
values or conflicts, and their trust in the pharmacy staff.59
Figure 3. The Cycle That Drives Rapport Building59,70
Considerations for Reporting Obligations and Implications of Law Enforcement Involvement
Pharmacy staff need to know what to do once they discover a human trafficking situation or victim. A concept that pharmacists and pharmacy technicians
need to explore in the state(s) where they practice is requirements of “mandated reporters.” Mandated reporters are professionals, including social workers,
school personnel, health care workers, and law enforcement officers, who are obligated to report known or suspected abuse or neglect relating to children,
elders, or dependent adults.72 Federal law does not clearly define a “mandated reporter” and does not require health care providers to report trafficking
victims, the Federal Child Abuse Prevention and Treatment Act delegates this issue to individual states. It requires states to define provisions or procedures
requiring specific individuals to report known or suspected instances of child abuse and neglect.
Reporting requirements for victims of human trafficking are inconsistent between states.73 The American Hospital Association, the law firm of Jones Day,
and the Health, Education, Advocacy, Linkage Trafficking network have collated state-specific reporting requirements for health care providers on the
Health, Education, Advocacy, Linkage Trafficking website (https://healtrafficking.org/wp-content/uploads/2021/01/Human-Trafficking-and-Health-Care-
Providers_Legal-Requirements-for-Reporting-and-Education-02_25_21.pdf).74,75 For minors, health care providers are legally obligated to report the incident
to their state’s child protective services; the responsibility to report child abuse cannot be delegated to others. Reporting abuse is also mandated for
persons older than age 65 years and adults living with disabilities as well. Reports should be made as soon as possible; however, some states provide
specific time windows in which reporting must be made within 48 hours of initial encounter if there is reasonable cause or suspicion of child endangerment,
abuse, or neglect.76 For an individual who is younger than 65 years and without disabilities, providers must obtain the individual’s permission to report
instances of abuse; should the individual not give consent, providers may report human trafficking without sharing identifying information. Although the law
requires all health care providers to ask permission before releasing an adult’s medical information, pharmacists can contact the national 24-hour, toll-free,
multilingual National Human Trafficking Hotline at 1-(888)-373-7888 or via text (233733) to report a suspected human trafficking incident.62,74 In these
situations, the reporter must take note of the individual’s or trafficker’s details, such as clothes, physical features, or car make/model if witnessed. They
should also document concerns for potential human trafficking or visible/reported injuries in the individual’s chart to inform other care providers. It is
difficult to provide more specific guidance on documentation, as the medical-legal issues surrounding human trafficking are complicated.75 Pharmacy staff
who are employed in health systems should be familiar with their organizations’ policies and procedures on suspected abuse or human trafficking. Those
who work independently can consult with local victim advocacy organizations, prosecutors, or attorneys to determine what needs to be included in the
documentation. Documentation of human trafficking must balance the need for comprehensive information with medical-legal concerns. It is, however,
always appropriate to document:
Acute injuries, and include photographs
The care provided as documented for any other patient
The resources provided to the patient
If the victim is not in a protected class, providers often struggle with how to proceed, especially if their organizations have no policies or procedures. It may
be unsafe to attempt to help a trafficking victim directly and could increase the danger for the victim. In an emergency, call 911 to notify law enforcement
and ask for help. Providers can call or help the victim call the National Human Trafficking Hotline. The people who staff this hotline can help providers
develop a plan to respond safely, and, once the patient’s safety is assured, providers can help the patient access other services they need using the same
approaches used for all patients but incorporate sensitivity and victim-centered care principles. The National Human Trafficking Hotline provides
connections to several organizations where the victim can receive shelter, medical care, legal assistance, and other critical services.3
Victims of human trafficking may be engaged in illegal activities or have had their identification documents withheld by the handler. For these reasons,
although many law enforcement departments are trained to assist in these situations, mentioning the “police” may cause the individual to feel unsafe and
reject help.47 Fear of law enforcement may also stem from threats made by the trafficker warning victims never to seek help from law enforcement or other
officials. Readers should note that most state and federal laws do not penalize or prosecute victims of trafficking for the unlawful acts traffickers compelled
them to commit.77 However, it should be explained to victims of human trafficking that law enforcement officials can provide additional aid to victims as
well as protection against threats of retaliation or further intimidation. Should a victim of human trafficking or a witness to human trafficking events not
want to be identified, law enforcement involvement can support measures to keep the individual’s identity confidential and can protect their privacy.78
Community and Other Resources for Survivor-Centered Care
Pharmacists can contribute to multidisciplinary standards of care and train other health care professionals within health care organizations and the
community to identify victims of human trafficking. Several state-level and national organizations have been established to protect and provide aid for
victims of human trafficking, and pharmacists should be aware of available resources within their specific communities.50 Pharmacists can be important
players in creating a trusted local network of advocates to identify and assist victims of human trafficking. Pharmacists can provide victims with
information on how to contact community, local, and/or state resources, such as the National Human Trafficking Hotline. If an individual does not express
interest in leaving the trafficker, pharmacists can ensure they are aware of available resources and organizations, such as The Center for Prevention of
Abuse or the National Human Trafficking Hotline, that can provide safety or assistance should they choose.
National Human Trafficking Training and Technical
Assistance Center.
https://nhttac.acf.hhs.gov/
Polaris Project https://polarisproject.org/
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gee. wonder how many homelss, children, elderly, or mothers in tough situation are being trafficked in Bozeman?
Ashley Nerlin