Renee Mallett:  Hello. My name is Renee Mallett. I am a healthcare attorney here in Columbus, Ohio. Prior to law school, I was a practicing nurse in the emergency department and the intensive care unit. After law school, I was hired directly by a hospital CEO in which he had asked me to develop a community-wide protocol and a hospital policy for any patients that experience violence. In working with the community this protocol was established for victims of domestic violence or human trafficking. This protocol impacted both child and adult patients. I'm bringing you today. My experience on victims of human trafficking. We will be discussing minor trafficking victims along with adult trafficking victims.

   I thank you for allowing me to share both my clinical background and also my legal background and providing this course on human trafficking. You just got off the phone with one of your major global corporate combines Claire Bear Toy Company. Claire Bear Toy Company is incorporated in Ohio and has manufacturing facilities and toy stores all around the world. Their CEO, Lucy wants to be proactive in ensuring none of her 90,000 employees engage in any human trafficking activities. This engagement extends from ensuring Claire Bear Corporation: A) does not procure a supplier of raw materials or distributor that violates human-rights laws by engaging in labor trafficking activities, B) forbids employees from viewing or receiving child pornographic materials whether it's on company or personal device, C) prohibits the purchasing of sexual activities while employees travel for work out of state or to a different country.

   Just as soon as you end that call you, you get a call from Rose Garden Health System located in Columbus, Ohio and then they are seeking advice with devising a community-wide protocol and health-system policy in responding to and aiding victims of human trafficking. They want to ensure their protocol hits input from: A) court appointed advocates, B) city and county prosecuting attorneys, C) legal-aid societies and immigration attorneys and D) other applicable community partners. You take a deep breath and then carve out your afternoon to begin researching the various state and federal laws and any relevant case law.

   Additionally, your two clients would like for you to assist in providing training to their executive leaders in management teams. You look in your files and seek to confirm the current definitions for human trafficking and the prevalence. You want to ensure you discuss the Trafficking Victims Protection Act, TVPA, The Preventing Sex Trafficking and Strengthening Families Act, Justice for Victims of Trafficking Act and The Stop Enabling Sex Traffickers Act and Allow States and Victims to Fight Online Sex Trafficking Act. Before counseling clients on human trafficking prevention and victim support, it's important to understand what it is. Human trafficking is the illegal use of vulnerable human beings to make a profit. The profit may be derived in the form of sex, other sexual acts or forced labor. Globally it is the fastest rising criminal market tied with illegal arms and second only to the drug trade. Now let's go into some definitions of human trafficking, human smuggling, commercial sexual exploitation, and consensual commercial sex.

   Human trafficking is exploitation base. It is the illegal trading of humans for the purpose of commercial sexual exploitation or forced labor known as modern day form of slavery. Human trafficking is a violation of someone's human rights. Human trafficking encompasses the perpetual exploitation of the victims in some manner to generate illicit profits for their traffickers. You may have heard the term human smuggling. Consider this transportation based. Human smuggling is the aiding of someone to legally cross international country borders often without identification or papers for monetary profit. Smuggling ends with the arrival of the migrant at their destination. Human smuggling is a violation of a country's immigration laws. A person can consent to being smuggled into the country. However, if that person is forced or coerced in two commercial sex or labor services, then he/she maybe a victim of human trafficking. So oftentimes the person is human smuggled across a different country. And then a trafficker picks up that victim and then forces them into sex or labor services.

   Let's now go to the definition of commercial sexual exploitation, which is defined as exploitation of children entirely or at least in part for financial or other economic reasons. Let's talk about what is the difference of consensual commercial sex. That's typically known as sex work. That's when a person willingly takes part in the sale of sex, it is consensual and does not affect their human rights. Because commercial sex is illegal it is more likely that law enforcement will stumble upon potential victims. The identification of the victim may be hindered as the minor may be instructed to say they are over the age of 18 and adult victims may conceal the use of force fraud and coercion. Victims exploited for commercial sex must be marketed or taken into contact with customers, thus increasing the opportunity for law enforcement or healthcare professionals to encounter the victims and preclude the crime. That describes sex trafficking.

   Now let's describe the differences of labor-trafficking. Labor-trafficking occurs in the context of a lawful business decreasing the number of encounters between law enforcement and individuals engaged in that industry thus making victim detection and identification more difficult. Labor trafficking victims include including victims of domestic servitude can be exploited in homes, fields, or factories with very few opportunities to encounter customers or other outsiders. Typically, these victims are working long hours at the work site and then go to a remote location to sleep for a few hours.

   Next let's discuss the places where human trafficking occurs. Let's first talk about forced labor. You'll see these victims working in sweatshops, agriculture fields, and manufacturing facilities, at construction sites, landscaping, nail salons, restaurants, and the hotel industry and at carnivals. With domestic servitude, often these victims are working in private homes such as cleaning services. With commercial sex, the victims may be working in a brothel advertised on the internet and massage parlors, streets, in bars, nightclubs, private homes, and escort agencies. Let's further discuss what's considered illicit massage businesses. Per the Polaris project research depicts that more than 9,000 illicit massage businesses are open for business in the United States. Evidence suggests that many of the thousands of women engaging in prostitution are in illicit massage businesses. They are both victims of sex and labor trafficking.

   According to Polaris project and their research, these businesses are often organized into criminal networks with revenues around 2.5 billion a year. Polaris in 2017 analyzed 32,000 cases of human trafficking that encompass both sex and labor and classified 2,949 cases in relation to illegal massage parlors second in prevalence to trafficking and escort services. Many of the victims are women from China, South Korea, Thailand, and Vietnam speaking little or no English, have a high school education and their ages range from teenagers to 30 to late fifties with most struggling to provide for their children. These illicit massage businesses are in low income neighborhoods. Typically, they have bars on the windows and the doors and buzzards where customers ring the bell. Often the victims sleep where they work. Per the Department of Justice and Homeland Security victims of human trafficking are children under the age of 18 induced into commercial sex, adults induced into commercial sex through force, fraud or coercion and children and adults induced into performing labor through force, fraud, and coercion.

   Let's talk about the prevalence of human trafficking. The International Labour Organization estimates in 2016 globally that 25 million adults and children are victims of human trafficking. One in four victims are children, while women and girls account for 71% of the victims per The International Labour Organization. In the United States children that run away are homeless, kidnapped or leaving foster care are at elevated risk of forced prostitution and trafficking. Conservative estimates project yearly that 100,000 to 300,000 children are at risk for commercial sexual exploitation in the United States each year. In many instances, both minor and adult victims of human trafficking are isolated and have been coached to fear law enforcement or to lie about their circumstances. Victims of trafficking may fear law enforcement because of their participation in unlawful activity such as prostitution, drug possession, theft or in the case of foreign victims their undocumented status or experience with corrupt or violent authorities in their home country.

   Traffickers further exploit these fears by threatening the victim with violence, arrest, detention or deportation if they attempt to engage authorities. In some cases, the victim is attempting to escape other problems in his or her life that the trafficker exploits to ensure the victim's compliance such as an abusive family, drug addiction, gender identification, or extreme poverty. In 1995, The National Center for Missing & Exploited Children was created and is responsible for researching the commercial and sexual exploitation of children. In June, 2003, the FBI, The Federal Bureau of Investigation in combination with the justice department's criminal division of The Child Exploitation and Obscenity Section and The National Center for Missing & Exploited Children introduced the Innocence Lost National Initiative. Since 2003, the Innocence Lost National Initiative has created 86 FBI-led child exploitation and human trafficking task force. Since 2008, the FBI has recovered more than 900 children victims and arresting nearly 1400 traffickers.

   The following are vulnerable populations that are preyed upon by traffickers. Individuals who have encountered childhood abuse and neglect, children in the foster care and juvenile justice systems, runaway and homeless youth, individuals with disability such as cognitive or learning disabilities, low income individuals, native Americans, native Hawaiians, and Pacific Islanders, and also are lesbian, gay, bisexual, transgender, and questioning individuals, migrant workers, undocumented immigrants, racial and ethnic minorities, individuals with a history of chemical dependency such as substance abuse, depression, anxiety, families living in communities exposed to intergenerational trauma, victims of any form of a violence such as gang violence, physical or domestic violence.

   Children are susceptible to trafficking for a variety of reasons, including their age, developmental capacity, legal dependency on abuse of adults, family or community rejection and history of trauma, neglect, or abuse. Traffickers often seek to exploit children because they are perceived as easy to control and more profitable. Victims are frequently lured by offers of food, clothes, attention, friendship, love, and a seemingly safe place to sleep. Once a trafficker gains this control over a child, he or she will often use acts of violence, intimidation, and psychological manipulation to trick the child in a life of sex trafficking. Traffickers often target children at bus stops and train stations, at schools, strip clubs, casinos, group homes or through social networking and escort websites. A common misperception about human trafficking in all of its forms is that it involves kidnapping and physical restraint. The vast majority of women and men are trapped and tricked to stay by mental and emotional bonds built upon lies, shame, manipulation, and tear. This is referred to a psychological manipulation or often referred to as the trauma bonding.

   Victims are controlled to fear law enforcement. They often have threats against their family. They are shameful, [inaudible 00:15:18] debts that cannot be paid off and they fear deportation. Thus, it is as difficult for victims to leave or sometimes they remain as the trauma bond is holding them to be loyal to their trafficker. Next we're going to discuss a series of Federal Laws against human trafficking. The first one is the Trafficking Victims Protection Act. This is made a federal crime that involves exploiting a person for labor services or commercial sex.

   The Trafficking Victims Protection Act or known as TVPA was instituted in 2000. It defines human trafficking as a sex trafficking in which; A) commercial sex act is induced by force, fraud, or coercion and in which the person induced to perform such act has not attained the age of 18 year of old. B) it's the recruitment, harboring, transportation provision, or obtaining a person for labor or services by the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bond and slavery. In some adult human trafficking victims are forced, defrauded, and coerced. When it comes to children, any minor under 18 that's transported, facilitated or used for commercial sex is automatically a victim regardless of force, fraud or coercion is used.

   There is always an action and means and a purpose that traffickers take in committing human trafficking. Let's review a table that The Department of Health and Human Services has put together. So when we look at the actions that a trafficker takes, their actions are recruiting involves proactive targeting of vulnerable victims and grooming behaviors. Typically, the grooming behaviors is grooming them into the life. Harboring is an action taking that includes isolation, confinement, and monitoring of the victims.

   Another action is transporting, which involves the movement and arranging of travel. Providing includes giving to another individual. And the action of obtaining includes forcibly taking, exchanging something for ability to control. With sex trafficking there's also two additional actions in which it's soliciting includes offering something of value and patronizing includes receiving something of value.

   Let's discuss the means in which the trafficker takes it through force, fraud, and coercion, but let's be clear force, fraud, and coercion does not need to be present when it involves a minor, such as force which includes the physical restraint, physical harm, sexual assault and beating of a victim. Force also includes the monitoring and confinement are often used to control victims, especially during early stages of victimization to break down the victim's resistance. Fraud is defined as false promises regarding employment, wages, working conditions, falsifying that they're in a loving relationship, marriage or better life. Over time, there may be unexpected changes in work conditions, compensation, or debt agreements or the nature of the relationship. Traffickers use coercion. Coercion includes threats of serious harm to or physical restraint against any person, psychological manipulation, document compensation and shame in fearing inducing threats to share information or pictures with others or report to authorities.

   So let's discuss the purpose. What the traffickers intending to do. The trafficker is intending for the victim to engage in a commercial sex act, which is any sex act on account of anything of value given to or received by any person. Also, they're trying to engage in involuntary servitude, which is any scheme plan or pattern intended to cause a person to believe that if the person did not enter into or continue in such condition that the person or another person would suffer serious harm or physical restraint or the abuse or threatened abuse of the legal process. Also another purpose is debt bondage includes a pledge of services by the debtor or someone under the debtor's control to pay down known or unknown charges such as fees for transportation, boarding, food, or other incidentals, interests, fines for missing quotas or any changes of bad behavior.

   Typically, the length and nature of those services are not respectively limited and defined whereby an individual is trapped in a cycle of debt that he or she can never pay down. Peonage is a status or condition of involuntary servitude based on real or alleged indebtedness. And then the legal definition of slavery in the TVPA, slavery is defined as a state of being under the ownership or control of someone where a person is forced to work for another.

   Thank you for allowing me to demonstrate what the actions means and purposes that the trafficker takes in committing human trafficking violations. So let's discuss The Preventing of Sex Trafficking and Strengthening families act of 2014. This federal law seeks to reduce the incidents of sex trafficking among youth involved in the foster care system. The portion of this law specific to sex trafficking requires child welfare systems to improve their response to sex trafficking by screening and identifying youth who are sex trafficking victims, are those who are at risk for sex trafficking to provide appropriate services to youth who experience sex trafficking and report any missing children to The National Center for Missing and Exploited Children and also for child welfare agencies to develop protocols for locating missing and runaway children.

   Further State Child Welfare agencies are required to report instances of sex trafficking to local law enforcement and provide information regarding sex trafficking victims or at risk youth to the US Department of Health and Human Services. The Justice for Victims Act amended The Runaway and Homeless Youth Act by declaring youth who are victims of severe forms of trafficking in person are eligible for services. Through The Runaway and Homeless Youth Act it also supported street outreach programs that provided emergency shelters and long-term transitional living and maternity group home program to serve and protect runaway and homeless youth. Survivors of human trafficking have a wide range of basic human needs based on their age, type of victimization, level of trauma encountered, immigration status, health, family structure, education level, skilled level, criminal history, and many other factors. Victims must be classified as victims of trafficking to be eligible for services provided by government and non-government agencies.

   Under The Trafficking Victims Protection Act, child and adult victims are eligible for T visa. With the T visa designation international victims may remain in the United States, secure legal work authorization and qualify for public assistance programs. Victims are then eligible after three years to become a permanent legal resident. Under TVPA unlike adults, children are not required to assist with Federal Law Enforcement and prosecution to qualify for immigration relief and public assistance under T visa. The Justice for Victims and Trafficking Act of 2015 improves the US response to human trafficking. The Justice for Victims and Trafficking Act contains important amendments that strengthen services for victims. Among these amendments are charges in the criminal liability to include $5,000 penalty of buyers of all commercial sex from victims of trafficking. So the JVTA made a criminal liability for buyers to include a $5,000 penalty. It augments the TVPA's definition of trafficking by inserting patronizing and soliciting thus clarifying buyers can be prosecuted as trafficking offenders.

   The TPVA's definition contains anyone who recruits, entices, harbors, transports, provides, obtains, advertises, maintains, patronizes or solicits an individual over 18 by using force, fraud or coercion or any child or adolescent under 18 for the purposes of commercial sex. Let's talk about the Stop Enabling Sex Trafficking Act or known as SESTA and that they allow states and victims to Fight Online Sex Trafficking Act faster, which was enacted in 2018.

   These Federal acts institute a new criminal offense and that a website may be liable for the promotion or facilitation of prostitution and regardless disregard to sex trafficking. Websites that facilitate child sexual exploitation materials are that facilitate sex trafficking such as Backpage.com could be found liable. It is noted Backpage.com has been previously accused of facilitating child sexual trafficking and was shut down. Now that you're familiar with the definitions and prevalence of human trafficking, and you have reviewed the TVPA and various Federal Laws that prohibit human trafficking, you can now begin to assist Claire Bear Toy Company in developing their corporate policy against combating human trafficking.

   The two objectives of this policy are; one to ensure Claire Bear Toy Company does not engage or contract with suppliers or other third parties that may be involved in enforce labor activities. The second objective is to target the buyer. The buyer is the culprit that fuels the demand for sex trafficking. Your corporate client is attempting to prevent their employees from buying any sex through a minor or buying as they're traveling for work, whether it's within the United States or to a different country. You counsel your client: no buyer, no victim. You educate your client on an organization call called Businesses Ending Slavery and Trafficking known as BEST. In 2012 BEST did a study on Seattle based buyers and they discovered buyers are everyday men employed at local businesses. They range in age from 18 to 84. Buyers in the study admitted that they sex when they're traveling for business, when they are going to sporting events, or when they are in the military.

   The best study determine that web-based sex buying spikes at 2:00 PM in the afternoon, which means that these buyers are buying sex in the middle of a workday. You start drafting a policy prohibiting all forms of human trafficking, forced labor and sex trafficking. Now, we'll review what should be included in Claire Bears anti-trafficking policy so that you may be prepared to counsel a corporate client to prepare a similar policy. You title the policy anti-human trafficking policy. First, the purpose. The purpose should clearly explain why the policy exists, what it does and who is responsible for following its directives.

   For instance, the purpose could state why Claire Bear Toy Company is committed to a work environment that is free from slavery and any form of human trafficking, which for purposes of this policy includes forced labor and sex trafficking of children and adults. In the purpose, you want to talk about what Claire Bear Toy Company will not tolerate or condone human trafficking or slavery and any part of its global organization and who Claire Bear Toy Company employees, subsidiaries, contractors, subcontractors, vendors, suppliers, partners, and any others through whom Claire Bear conducts business must avoid complicity and any practice that constitutes trafficking and purposes in persons or slavery.

   Then part of the policy is going to have the definitions. So we'll just review through The Trafficking Victims Protection Act. Human trafficking is a Federal crime that involves exploiting a person for labor, services or commercial sex. For purposes of the policy, the TVPA definition of human trafficking will be used. Next, we'll talk about the scope of the policy. The scope could be written as this policy establishes the requirement for global conduct related to human rights and labor standards. This policy applies to all employees employed by or engaged to provide services to Claire Bear Toy Company, including but not limited to employees management team, officers, and independent contractors of Claire Bear Toy Company and Claire Bear US and International subsidiaries. It is noted contracts with independent contractors should have language against human trafficking. In fact, it is noted the American Bar Association has developed what is called a model contract clause to protect workers in international supply chains, version 2.0 is available.

   The model contract clauses, MCCs was devised to assist companies in implementing corporate policies in their supply chain that is legally effective against human trafficking.

   To further discuss the scope you can state in the policy that the above individuals are responsible for understanding and complying with this policy. Claire Bear Toy Company leaders are responsible for ensuring that employees who report to them directly or indirectly comply with this policy and complete yearly certification and training. Questions or concerns relating to this policy may be directed to the ethics and compliance, legal or human resource departments. In constructing this policy Claire Bear Toy Company considered the following, The International Labour Organization's declaration on fundamental principles and rights at work, the international bill of human rights and the United Nations guiding principles of business and human rights. Next, the policy will have a section titled prohibited activities in this is where the policy outlines, what exactly is disallowed.

   For instance, Claire Bear Toy Company expressly prohibits activities involving trafficking in persons and slavery to include any form of forced labor or sex trafficking. Employees, subcontractors and agents will not engage in any practice that constitutes trafficking in person or slavery. This includes, but is not limited to the following activities; engaging in any form of human trafficking or modern day slavery, procuring commercial sex acts while working or on a company sponsored travel, or when using a company sponsored device such as a laptop or a smartphone. Securing or acquiring commercial sex acts or acquiring commercial sexual exploitation materials involving a minor child using forced labor, child labor or prison labor, destroying, concealing, confiscating, or otherwise denying access to any employee or contractors identity or immigration documents such as passports or driver's license, regardless of issuing authority.

   Using misleading or fraudulent practices to recruit employees or contractors such as lying about or failing to disclose key terms and conditions of employment including wages and fringe benefits, the location of work, any hazards involved, and the entire nature of the work. Using recruiters that do not comply with local labor laws of the country in which the recruiting takes place. Procuring services by charging applicants recruitment fees. If required by law or contract failing to provide an employment contract, recruitment agreement or other required work document in writing with all required information and in the language the employee understands.

   Next in the policy, we'll talk about the procedure. This clearly explains what employees are required to do. Example: Language is report any human rights violations or conduct that you believe to be a violation of this policy to Claire Bear's ethics and compliance, legal or human resources departments. Reports may also be made through the Claire Bear ethics hotline at 1800 Bear Cub or via the internet at the following website, www.clairebear.com, which allows anonymous and confidential reporting as permitted by applicable law. The hotline is available 24/7 and in multiple languages. Employees who fail to report actual or suspected misconduct may be deemed in violation of the policy. Now let's talk about disciplinary actions. An example text would be Claire Bear Toy Company will not tolerate retaliation against an employee reporting a potential violation and good faith or for cooperating with a compliance investigation even when no evidence is found to substantiate the report. Any violation of this policy may be grounds for disciplinary action up to including termination.

   Claire Bear Toy Company will participate fully with law enforcement investigations, including disclosure of any information obtained pursuant to an investigation of potential human trafficking activities. Thus, violation of this policy against human trafficking may also resolve in criminal prosecution of responsible individuals. Next, let's go back to our second hypothetical involving Rose Garden Healthcare System, in which they would like you to develop a community partnership protocol and also a policy specific to their organization. Since Rose Garden Health System is located in Columbus, Ohio we will use the state of Ohio as an example on how to locate your state laws in mandatory reporting requirements. Let's start first with Rose Garden Health Systems policy and then establish how we may partner with community resources. Interesting, in 2014, a study published in the Annals of Health Law found that nearly 88% of sex-trafficking survivors reported some kind of contact with healthcare providers while being exploited.

   A 2017 survey report from the Coalition to Abolish Slavery & Trafficking found that over half of labor and sex trafficking survivors surveyed had access to healthcare at least once, while being trafficked. Nearly 97% indicated that they had never been provided with information or resources about human trafficking while visiting their healthcare provider. Let's go to Rose Garden Health System's human trafficking policy. To start, let's start with a policy statement. This should explain why the document exists. For example, The Rose Garden Health System Human Trafficking Protocol has been developed to ensure that trafficked persons are identified in the healthcare setting and are assisted with victim-centered trauma-informed care and services.

   All medical staff and employees are to attend anti-human-trafficking training for healthcare providers and watch for red flags of human trafficking while working for Rose Garden Health Systems. Direct-care providers must refer to this policy when interacting and assessing a potential victim of human trafficking.

   If the potential victim is not a patient. For example, if you see a potential victim just walking through the walls of the Health System on the campus in the parking lot, you are to notify security or you can contact the National Human Trafficking Hotline at 1-888-373-7888.

   The policy should also include provisions that address how to access human trafficking activity with patients. So let's go to the assessment of patients. In the policy it states all licensed or certified healthcare professionals should assess all patients, particularly those vulnerable for sex or labeled trafficking concerns. Vulnerable patients may include at risk adolescents and children such as homeless or runaway youth, commercial sex workers, undocumented immigrants, homeless, any patient that has a form of addiction, drug or alcohol or any mental health concerns, migrant workers, patients lacking family or community support especially young mothers, foreign nationals and patients with learning our cognitive disabilities. Now we'll move into identifying victims of human trafficking.

   We'll go into the red flags and indicators in which has been provided by the National Human Trafficking Resource Center. You will list in the policy the red flags and indicators. So let's start with the general indicators of human trafficking. Shares a scripted or inconsistent history, is unwilling or hesitant to answer questions about their injury or illness, is accompanied by an individual who does not let the patient speak for themselves. Refuses to let the patient have privacy or who interprets for them. Evidence of a controlling or dominating relationship. Excessive concerns about pleasing a family member or [inaudible 00:39:50] partner or employee. Another sign might be the patient demonstrates fearful or nervous behavior or avoids eye contact. They are resistant to assistance or demonstrates hostile behavior, is unable to provide his/her address of where they are living, is not aware of his or her location, the current date or time. Is not in possession of his or her identification documents. Is not in control of his or her money, is not being paid or wages are withheld.

   Specific indicators of labor trafficking are the person may have been abused at work or threatened with harm by an employer or supervisor, is not allowed to take adequate breaks, food or water while at work, is not provided with adequate personnel protective equipment for hazardous work, was recruited for different work than what he or she is currently performing, is required to live in housing provided by the employer, has a debt to the employer or the recruiter that he or she simply cannot pay off.

   Let's now discuss specific indicators of sex trafficking. The patient is under the age of 18 and is involved in the commercial sex industry. The patient might have tattoos or other forms of branding, such tattoos may say daddy, property of, or for sale. It may actually be located on the person's body. The victim may report an unusual high number of sexual partners. Perhaps they don't have appropriate clothing for the weather or the venue, and they're using common language in the commercial sex industry.

   Next, the policy should have health indicators and consequences of human trafficking. As legal counsel you may direct your healthcare client to the national human trafficking resource center website for a listing of health indicators and consequences should they want to utilize an assessment tool? Their own medical director or chief of nursing may recommend other assessment tools. Let's now move into the recommendations or best practices when conducting the assessment. You should allow your patient to decide if they feel more comfortable speaking with a male or female practitioner. Minor female victims should be examined by female healthcare professionals and minor male victims by male healthcare professionals. Take time to build report with potential victims or if you do not have the time yourself, find someone on staff that can develop rapport with the patient. Building a trusting relationship by opening the conversation with because violence is common in our society, rescreen all patients for abuse. Ensure that the patient understands confidentiality policies and practices, including mandatory reporting loss. Use multidisciplinary resources, such as social workers, sexual assault nurse examiners, behavioral health counselors, when and where available.

   A trauma informed approach includes understanding the many effects of trauma and recognizing and appropriately responding to signs of trauma. For example, victims of human trafficking may appear to be submissive, fearful, hypervigilant, or even uncooperative. Recognizing that a person's behavior and choices may be influenced by prior trauma enables a healthcare professional to better understand and provide compassionate care and services to that person. Refer to existing institutional protocols for victims of abuse, sexual abuse. If the patient requires interpretation, always utilize professional interpreters who are unrelated to the patient or situation. You may contact the national human trafficking resource center hotline for assistance in conducting an assessment and determining next steps. The National Human Trafficking Resource Center offers confidential round the clock access to a safe space to report tips, seek services and ask for help.

   The National Human Trafficking Resource Center is operated 24/7 has access to 200 languages through tele interpreting services. All communications with the national human-trafficking resource center are strictly confidential to the extent permitted by law and callers need not disclose a personal information in order to access services through this resource center. The goal should not be rescuing or gaining a disclosure from the patient. The goal should be creating a safe nonjudgmental space to build rapport, educate this person on his or her rights and options and offer assistance. If the trafficker is with the victim, it may be safer for the patient to allow that individual to remain in the room. If the trafficker believes there is a threat, the victim may leave against medical advice or there may be a risk of future harm to the victim by the trafficker. The decision of whether or not to continue to push for separation may include evidences of aggression, agitation of the trafficker, overall health and safety of the patient, opportunity to schedule follow up visit, presence or absence of prior assault or abuse.

   Safety planning varies on how the patient views their situation and whether the patient wants to stay is in the process of leaving or has left. Strategies to interview the victim alone may include assess the power dynamic between the patient and accompanying persons, assess patient's ability or desire to speak freely about things that may be bothering them. If possible, have the company persons wait in a separate area. You may provide the following reasons; diagnostic test in another area, I'm taking the patient to clinical hospital policy, requires us to interview the patient alone, ask the potential controlling person to step outside the examination area to assist with any paperwork.

   In the policy, have a section about mandatory reporting. Mandatory reporting refers to the legal requirements to report to authorities, including local county and state agencies such as child or adult protective services and law enforcement. Legal requirements regarding mandatory reporting of human trafficking may differ from state to state. And the situation may require mandatory reporting under related statutes even if the situation is not human trafficking. For example, the reporting of child abuse or in some states if domestic violence is a mandatory reporting option. The justice is for victims of Trafficking Act amended The Child Abuse Prevention and Treatment Act by adding human trafficking and child pornography as forms of child abuse. Child abuse is always a reportable offense in which licensed healthcare professionals are required to report when assessing or examining an individual 17 years or younger. Child abuse includes all forms of abuse such as physical, emotional, sexual and neglect cases are always reportable.

   Per Ohio law, healthcare providers must report child abuse in any suspected trafficking of a minor to the County Child Welfare Office or to local law enforcement. Elder abuse generally refers to the abuse, neglect, or exploitation of a vulnerable adult over the age of 60. And this falls under mandatory reporting guidelines to adult protective services. Many states require elder abuse to be reported. Elder abuse also includes physical, sexual, verbal, emotional abuse, neglect, including abandonment or financial exploitation. Required reporting is also for those with a learning cognitive or physical disability and typically this reported to adult protective services. Per Ohio law Section 2921.22 of the higher revised code, healthcare professionals must also report any gunshot or stab wounds or burn injuries such as second or third degree burn injuries. In some please check your state's manage for reporting requirements for healthcare professionals.

   Let's talk about adult patient's consent for treatment and collection of evidence. When working with adults who have been trafficked, it is important to gain permission and consent from the patient before disclosing any personal information about the patient to others, including service providers. Adult patients 18 years and older will have to consent to the medical forensic examination and to any video or photograph documentation.

   They may consent only to the examination collection of the evidence, photos of their body, but they may decline to have photos taken of their genitalia. An adult may not agree to talk to local law enforcement after the examination or days after. The adult patient may decline to participate and assist local law enforcement in investigating the crime. Unlike a true sexual assault victim if there was an exchange of money for sex, law enforcement may view it all as a participatory person in prostitution. The victim has been severely threatened, abused, manipulated by the trafficker, and they may be fearful in cooperating with local law enforcement. When we talk about minor or child patients, let's talk about consent for treatment and collection of evidence. We know under Federal Law, any minor engaged in commercial sex is a victim of sex trafficking, regardless of force, fraud or coercion. And this constitutes child abuse.

   Child abuse is any intentional harm or mistreatment to a child under 18 years old. Child abuse takes many form, which often occurs at the same time. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person. Sexual child abuse is any sexual activity with a child such as fondling, oral genital contact, intercourse, exploitation, or exposure to child pornography. Emotional child abuse means injuring a child's self-esteem or emotional wellbeing. It includes verbal and emotional assault such as continually belittling or berating a child as well as isolating, ignoring or rejecting a child. Child neglect is failure to provide adequate food, shelter, affection, supervision, education, dental, or medical care. Medical child abuse occurs when someone gives false information about the illness in a child that requires medical attention, putting the child at risk of injury or unnecessary medical care. For sexual abuse and assault patients 17 years or younger the sexual assault evidence collection kit and toxicology samples for drug facilitated sexual assault will be given to local law enforcement and may be tested at the state crime lab.

   Likewise, minor consent laws are very open such as a minor does not need the consent of their parents or guardian to be examined or evidence collected. In many states minors may consent for treatment involving sexual assault, rape, sexually transmitted infections or if they are suicidal.

   Let's explain confidentiality. In the protocol you will explain the limits of confidentiality. If the patient is a victim, contact hospital registration to place the patient as confidential in the hospital directory. So if their trafficker or others working for the trafficker attempt to locate them, they are listed as confidential and their location will not be confirmed. For adult confidentiality you can tell the adult patient, everything you tell me is confidential unless you tell me someone has harmed your children or if you intend to harm yourself or someone else. For children and teens, the healthcare provider may say everything you tell me is confidential unless you tell me someone is harming you or if you intend to harm yourself or someone else. Depending on your age, there are instances where I may need to report sexual contact or conduct to local law enforcement.

   The policy and protocol should include discharge planning in a compassionate manner, arranged for a follow up visit by a community provider or next appointment if possible. Provide resources discreetly such as writing resources or numbers on a prescription pad and a sanitary napkin or on any product samples. The national human trafficking hotline has shoe cards. These cards can be offered to patients, particularly any person who is suspected to be a victim, but declines assistance. The shoe card is a small plastic card that can be broken down into three smaller sizes. Each of which has the national hotline printed on it. The hotline is 1-888-373-7888 or text 233733 BeFree. These cards are available in different languages from the Blue Campaign, which is a resource center created by the department of Homeland Security. Along with other resources for discharge billing should be a list of food banks, housing, legal services, rape centers, and clothing donation facilities.

   Evaluate the need for mental health services for the patient. Now that you established a policy for Rose Garden Health System, let's talk about developing a community partnership community protocol. When providing advice on how to develop a community partnership plan, it is important to think creatively about all agencies, organizations, businesses, and individuals who might be able to support victims of human traffic or contribute to its eradication. Partnership will depend on what is available in your community.

   Consider the following local state Federal Law enforcement, local and state child protective services and custody and welfare systems, local county, juvenile justice systems, child advocacy centers, rape crisis centers, domestic violence, shelters, and service providers, civil legal service providers, legal aid societies, immigrant serving agencies with immigration attorneys, youth and mentoring programs, court and juvenile diversion programs, judges and court appointed guardians, the attorney General's office, human trafficking, prosecuting attorneys, city and county, prosecutors and public defenders, human trafficking service programs, hospitals, pediatrician, and primary care offices, nurse practitioners, urgent care clinics, chemical dependency and mental health counselors, psychologists, psychiatrists, schools, especially school nurses, resource officers and guidance counselors, service organizations such as the Rotary Club, Kiwanis and Chamber of Commerce.

   Faith-based organization such as churches, mosque, temples, and synagogues and business leaders. Multidisciplinary teams need to clearly define their purpose, addressing all types of trafficking victims; child, sexual, or labor trafficking so they can engage the appropriate people. It is important that communities identify in their protocol one or more centralized points of contact to coordinate care for the survivor. For example, a survivor who is involved with the juvenile court and it's also being served by child advocacy center may become that central point of contact. In some communities without child advocacy center, a human trafficking victim service provider may be that point of contact. If the child is already involved in the juvenile justice system with a State Safe Harbor. Court diversion program, the court diversion program may serve as the point of contact.

   Let's now develop a community-wide protocol using Ohio as an example. You might have in the protocol, what to do if there's a missing child. So if a child is missing, you're going to instruct the community provider or the parent to immediately file a report with law enforcement. Instruct the child's parent to limit access to their home until investigators can collect evidence and to not touch anything in the home. Instruct the parents or guardian to provide investigators, all requested information including a complete description, photos, facts related to the disappearance, social media accounts, cell numbers, and any other requested detail to include providing fingerprints, dental records and DNA so they might find their loved one. In your community protocol you will have what to do for a minor human trafficking victim. You will have them call 911 immediately. We know it follows under Ohio's child abuse mandatory reporting laws. You'll have The Childhelp National Child Abuse Hotline available 1800 for a child, the National Human Trafficking Hotline and also National Center for Missing & Exploited Children at 1-800-THE-LOST.

   Further when screening for human trafficking, we know rapid reporting is critical as there is typically is a 72 hour window and which healthcare providers are trained for examiners can collect biological and other evidence to assist in the prosecuting the trafficker or the buyer. Typically, if a minor child is screened for sex trafficking, the child welfare agency and local law enforcement will be con contacted, who will contact the County Juvenile Court. The juvenile judge or magistrate will whether the minor is to return home or appointed a guardian ad litem or made ward of the state in which the child welfare agency will determine placement of the child.

   We know a guardian ad litem is typically an attorney or could be a lay volunteer appointed by the Juvenile Court to assist in the child's best interest. A guardian ad litem will examine all factors within the child's life and present the court with recommendations for the child's best interest. Unlikely we will counsel for the child who represents the child the guardian at litem presents their observation for the child's best interest. The public defender's role, as we know many human trafficking victims are charged with criminal offenses directly related to their trafficking experience. Thus, they need a defense attorney to avoid criminal conviction or juvenile disposition.

   Many states have saved Harbor Laws for minors engaged in commercial sexual exploitation. This was an attempt, a paradigm shift from treating victims and survivors of commercial, sexual exploitation and sex trafficking of minors as criminals to understanding and recognizing commercial sexual exploitation and sex trafficking of a minor as a form of child abuse. Thus say proper laws were enacted to guide young victims of commercial, sexual expectation and sex trafficking from the juvenile justice system to court diversion programs. If a child qualifies for court diversion, the court places the child in advance for a period of time in which the child is provided trauma-based behavioral health services or educational activities the court finds appropriate. The court may extend this abeyance. If the child is successful in achieving this program their records will be expunged or sealed per applicable offense. If the court denies the case for abeyance or the child no longer wants to participate in diversion, the complaint will go forward in the Juvenile Court system.

   For adult victims, court diversion is a restorative program consisting of therapy, counseling, and behavior modification. For adult individuals charged with a crime, courts may accept an adult's request for intervention in lieu of a conviction. If the victim was a human trafficking victim at the time of the fence and that victimization was a factor leading to the offender's criminal behavior. The state attorney county prosecutor, defense attorney, or public defender may jointly decide whether to refer or divert the case out of the court's system to the court diversion program. Participants may take responsibility for their actions by entering a guilty plea or no contest plea. The participant signs a contract or an agreement agreeing to the terms of the diversion program. The program is usually up to one year if the provisions of the program are adhered to.

   Upon accessible completion of the program, the state attorney or prosecutor is notified and the criminal charge is dismissed. But depending on the state and offense, the participant's records are either sealed or expunged. As far as victims' compensation goes, victims of human trafficking can pursue several damages against their trafficker per higher revised code 2307.51. The Ohio Department of Job and Family Services may administer compensation to identify trafficking victims through the victims of human trafficking asset seizure fund through Ohio revised code 5101.87. Thank you for taking the time to listen to this course on human trafficking.