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PAGE 11 July Issue 2021 PAGE 09 July Issue 2021 cycle of harm isn't continued within their walls, they need to be educated on trauma and equipped to navigate it. Victims often have urgent needs, especially if they are currently facing exploitation, and the first priority should be ensuring their safety, comfort, and confidentiality. Victims are more likely to engage and display trust if these needs are met. Identifying immediate needs can be guided by Maslow's hierarchy : ● Physiological: Does the patient have low blood sugar? Are they dehydrated? Are they exhausted? ● Safety-related: Do they feel safe? Are they triggered? Are they angry? ● Relational: Are they in need of connection? Do they need to feel validated/seen/loved? Olson recommends pausing and considering what the patient has just experienced prior to coming in and [how] they will be engaged. "When they do not feel seen or heard, that's when the lid is flipped," she said. "When a doctor or nurse doesn't listen to them, that's what prompts that anger and sends them into fight or flight." Trauma takes a physical, mental, and emotional toll. It can affect memory and behavior, slow thought processes, cause difficulty making decisions or solving problems, and lead to withdrawal and silence, or extremely talkative behavior. Emotions can be irritable, anxious, depressed, helpless, hopeless, overwhelmed, guilty, confused. According to a study on childhood trauma , the number of children in the U.S. exposed to trauma within one year exceeds four million. Those that experience or witness trauma or grooming through sexual abuse are at greater risk for profound emotional, behavioral, physiological, cognitive, and social problems. Those who don't understand trauma may ask why a person who was being exploited or abused didn't leave, but victims often form a trauma bond with their trafficker. According to Green, brains develop schema over time and if a child is traumatized repeatedly, the belief that this is the norm is established. For example, if a child is sexually abused by a parent for years, consistently forced or motivated into keeping quiet or being told it's because they're "too attractive", a trafficker exhibiting the same behavior will feel familiar. Attachment bonds are formed extremely young and establish schemas surrounding relationships. When victims experience a form of "love" or attachment similar to the abusive relationship they had with a parent figure, they may develop a similar attachment to their trafficker. "If something happens once, it may be a fluke, but if it happens over and over and over again, it builds a pathway and an outcome we come to expect over time," Green said. "So when we have these children, where a dad or partner has done it and now a trafficker has done it, it reinforces the schema with themes of "other people will hurt me" and feelings of helplessness." Over time, the chronic trauma exhausts the neural pathways by constantly triggering fear and panic sensors, causing slowed development. Trauma and related dissociative disorders are often misdiagnosed as attention deficit disorders or anger issues because some symptoms may be present while trauma may be unrecognized or unacknowledged. Misdiagnosis can worsen existing issues, especially if medication is involved. Rushing a diagnosis without understanding the bigger picture counters a whole-person or trauma-informed approach. Assessing Trauma To prepare to assess trauma in a potential trafficking victim, the webinar demonstrated that providers must first apply the pillars of trauma-informed care: ● Safety: Meet immediate patient needs to ensure they feel safe, stable, comfortable, and are aware of confidentiality. Repeat short statements such as "You are safe" and "I am here to help" – patients experiencing severe trauma may not be able to process complex sentences. Repetitive, calming validation can help de- escalate. Provide food, drinks, breaks, tissues, a place to regain composure, and the reassurance that they can ask for what they want or need. Never conduct interviews with the trafficker nearby. ● Trustworthiness/transparency: Explain all procedures in terms they can understand and inform them how long procedures will take and what to expect. Describe their rights, the interview process, and roles of everyone involved in their care. Employ interpreters if their first language is not English. Ask consent before touching them every time. ● Peer support: Enlist help of victim specialists when possible and connect survivors with social services. Be mindful they may have had negative prior experiences with health care professionals and may be afraid or distrustful. ● Choice: Frequently remind the patient they are in the driver's seat. They have the option to choose what kind of care they receive and to speak up if they need anything. ● Collaboration: Encourage the person to ask questions and make decisions about their treatment. ● Empowerment/voice: Trauma-informed care seeks to answer "what happened to you" versus "what's wrong with you". Consider body language and nonverbal cues. Ask if there is anything you should know prior to a procedure or if they have any preferences or difficulties with certain procedures. Once a safe environment and trust has been established, a screening can be conducted to spot signs of trauma and exploitation. Screenings for children, like the one mentioned in the previous example, focus on identifying potential signs of abuse, exploitation, and patterns in their history that could be red flags. At Children's Mercy KC, Olson and other SANE providers will assess screenings for exploitation for all acute sexual assault victims and on a case-by-case basis. Social work services are immediately involved, and the following agencies are notified for child trafficking, exploitation, or pornography suspicions: ● Child Protective Services hotline in the state where the child lives ● Missouri: 1.800.392.3738 ● Kansas: 1.800.922.5330 ● Local law enforcement where the crime occurred ● Missouri State Highway Patrol Trafficking Unit ● National Human Trafficking Hotline ● Call: 1.888.373.7888 ● Text: 233733 ● National Center for Missing and Exploited Children Adult screenings ask similar questions, usually including a more balanced emphasis between sex and labor trafficking. Screening questions for adults, other than those related to sexual acts, include inquiring about being tricked into jobs that don't exist or situations they never wanted, being forced to commit acts to pay off a debt they can't afford, or not being allowed to keep legal or identification documents, or talk to friends and family, among other things. If adult patients answer yes to any screening questions, it's a potential red flag for trafficking, especially if other signs are present. If they seem to be at-risk, Olson and Green recommend discussing referral options to specialists trained on human trafficking. Mandatory reports of abuse must be completed for minors and eligible adults. Unfortunately, some patients may not disclose any information, especially if they don't identify as a victim. It's critical to continuously remind all patients, "I am a safe person for you and this is a safe place to receive care." Trafficking in Missouri According to Phillips, the most present forms of trafficking in Missouri are labor trafficking (domestic services, agriculture, factory and farm work) and exploitation of migrant populations. Sexual exploitation in Missouri falls mostly under prostitution and escorting. 9000 illicit massage businesses were identified around Kansas City, St. Louis, and resort areas. Massage businesses highlight an intersection of sexual exploitation, forced labor, and taking advantage of someone's migrant status. "A lot of these types of trafficking overlap," said Phillips. "Where you see labor trafficking, you will likely see sex trafficking, and vice versa." Missouri has a landscape prone to trafficking – unfrequented rest stops, gas stations, and hotels along desolate truck routes are hot spots for traffickers to transport victims. According to Phillips, the opioid crisis in rural communities throughout Missouri also plays a role in familial trafficking. Familial trafficking occurs when a parent sells their child in exchange for having needs met, including receiving drugs or money. In areas with high rates of poverty and homelessness, instances of familial trafficking and running away are often higher. To combat human trafficking in Missouri, Phillips recommends turning to grassroots activists in your community before turning to government representatives. "Representatives come up with their own solutions. The people with boots on the ground doing the work every day – they know what kind of legislation we need and are very rarely asked." The Attorney General's Office is also working on a training program in partnership with Missouri Hospital Association with hopes of rolling it out this summer. A toolkit will be available with screening tools, hospital policies, resource guides, among other information. Complement to the toolkit will be a video training module series of 15- minute videos discussing what trafficking is, screenings for minors and adults, survivor experiences and their interactions with hospitals, working with law enforcement, and more. Anyone can be a victim of human trafficking. For anyone with questions or concerns regarding trafficking, the National Human Trafficking Hotline (1.888.373.7888) is available 24/7 and offers additional resources and information in 200 languages. The Missouri Coalition Against Trafficking and Exploitation (MOCATE) offers a statewide resource guide organized by county and can assist with finding resources including housing, advocacy opportunities, and substance rehabilitation programs. Learn more about the webinar series and access recorded presentations of each session here. PAGE 10 July Issue 2021