Joey Wahler (Host): Human sex trafficking is an often overlooked issue, so we're discussing healthcare's role in helping its victims. Our guests, first from Southeast Georgia Health System, both Larisa Barnes, a registered nurse and coordinator of SANE, the Sexual Assault Nurse Examiner Program, and Haley Mitchell, Nurse Manager for their Emergency Care center. Plus, joined by Julia Martin, an advocate for sex trafficking survivors.

This is Health Matters from Southeast Georgia Health System. Thanks for joining us. I'm Joey Wahler. Ladies, welcome. We appreciate the time. First, what led each of you to choose your particular career, and what brought you to the area in the first place? How about you, Larisa?

Larisa Barnes, BSN, RN: I've been an emergency room nurse for 30 years. I had started the SANE training in New Jersey before we moved here to Georgia in 2018, and it always interests me, but due to life factors, I couldn't continue the training. We moved here and Southeast Georgia Health System was starting the SANE program. I interviewed for the job and accepted it and built the SANE program from the ground up. My background is in emergency room nursing, but also dealing with women and victims over the years and domestic violence has led me to do this as my full time job, which I love.

Host: That's great to hear. How about you, Haley?

Haley Mitchell: So growing up, my mom was an emergency room nurse. My father was a police officer in a small town. This was pre HIPAA. I would have to stay in the ER overnight when my mom worked overnight and my father worked overnight, and I would sleep in an empty room. But I got to see a lot of what they dealt with and I just loved it. I went to nursing school and knew that I was always going to be an ER nurse. It's just what I have a passion for and I love helping people.

Host: Also great to hear. And how about you, Julia? You have more of a mental health background, right?

Julia Martin: Yeah. My background is in trauma and addiction. I have a Master's in Clinical Mental Health and Rehabilitative Counseling. So, I primarily work with women who have suffered significant trauma, but who also want to become sober. So, we carry that through.

Host: Gotcha. So first off, what's the average number of sexual assaults treated at the Emergency Care Center?

Larisa Barnes, BSN, RN: Between 30 and 40 a year, which if you look at the statistics of that, it is a notoriously underreported crime. Many victims do not seek help. So, that is definitely a lower number than it should be.

Host: And obviously, that's one of the big problems here, right?

Larisa Barnes, BSN, RN: Yes. Absolutely.

Host: So, how does the health system work hand in hand with Julia and the fine work that she does?

Haley Mitchell: The health system works with law enforcement and folks like Julia and the Amity House and several other resources through meetings that we have. We have a quarterly collaborative meeting with mental health and law enforcement and EMS to help recognize these types of cases and get them off the street and get them the help that they need. We require continuing education for all of our nursing and clinical staff system wide, but especially in the ER where we are faced with it the most.

Host: And so speaking of which, why is it so essential for healthcare professionals to be aware of human trafficking?

Haley Mitchell: Well, for one, a lot of these people feel stuck and they are stuck. They need to figure out a way to get out, whether it's through labor trafficking or sex trafficking. A lot of them are taken into it at a very young age and have dealt with it for a very long time, and they don't know how to get out. So, they come to us a lot of times for help and are trying to figure out how to get away from that lifestyle so that they can have a safe, healthy lifestyle.

Host: So, what are the health system and law enforcement, which you mentioned, the law enforcement community doing to help recognize these victims in the first place?

Haley Mitchell: Like I said, we do continuing education with our staff so that we can recognize all the signs of a trafficked patient. We have a screening tool in our charting system. We teach our staff to be comfortable with these patients, be comfortable asking them questions, to do it in a one-on-one environment. And, Pray that these folks will tell us what we need so that we can then take the steps to reach out to law enforcement and whoever else we need to get involved.

Host: How about any particular experience you can share in encountering a potential human trafficking victim? What do you recall?

Larisa Barnes, BSN, RN: I've had several. I've had minors under the age of 18 that have been sex trafficked that I've taken care of in the emergency department. The thing you need to remember the most about this is they'll often seek healthcare. Eighty-eight percent of women who are being trafficked will seek health care in the emergency department, 68% in the emergency room. The thing with these women are is that either they don't recognize that they're being trafficked because they're in love. Often it's their family member. It could be their family member, a mother, father, brother or their boyfriend that loves them that is trafficking them out. So, they don't recognize it at first. And I have taken care of one girl who was in a safe home for girls that were trafficked, ages 12 to 17. And she ran away and she ran back to her trafficker. So when I took care of her, she was willing to go back to the home and oftentimes it's a revolving door. They want treatment, but it often can take seven to eight times before they actually leave that situation.

I have also had patients that had been labor trafficked. He was a migrant worker from Mexico, and he was terrified. So, I got him hooked up. He wanted to escape. He had to run away and make up an illness to come to the emergency room so that he could get away from his traffickers. Labor trafficking, they all seek services first, and then the sex trafficking, again, it's just very difficult. They don't want to leave their trafficker or they rise up through the ranks of they're the ones recruiting the girls that they started out at the very bottom being trafficked. And then, through trust with their pimp, they start recruiting girls and it raises them up and they no longer are trafficked.

Host: And you make a great point there, Larisa, that this doesn't just victimize women, but men as well, right?

Larisa Barnes, BSN, RN: Yes.

Host: So, what are the signs here? What specific indicators related to the victims you work with should healthcare professionals be most aware of?

Larisa Barnes, BSN, RN: Frequent emergency room visits for injuries, urinary tract infections, abdominal pain, multiple pregnancies, multiple sexually transmitted infections. The trafficker will bring them into the ER and stay with them. So, it's a delicate dance that we have to do to get their trafficker away from them so that we can have an honest and open conversation with them.

I'll also go over to Maternity. Maternity a couple of times has called me to come see a patient that they feel they've answered questions that they're not safe at home. And when they're not as comfortable dealing with the subject matter as I am, because it is my full time job, I'm also on the statewide trafficking task force, so they'll call me to come and see the patient.

I think the most important thing when they present to the emergency room, whether they identify as being trafficked or not, is that we listen to them and we offer them a safe alternative to go somewhere or help them somewhere.

Host: Gotcha. Now, Julia, your organization has worked with some 125 women identifying as sex trafficking victims or survivors. So, picking up on some of what Larisa touched on there, what are some of the common backgrounds these victims share, and how does that impact their recognition as victims?

Julia Martin: The majority of the women that I have worked with are local. They're from the surrounding counties and Glynn County. I've only had two out of the 125 who have not admitted to an early childhood trauma. And it may not have been a family member. At some point, the trauma picks up. It may not be the parent, it may not be a sibling, it could be a trusted family member.

What we have found out is the majority of the women we work with, in some cases, their grown children grew up with the very men that are trafficking them. And It's difficult to put it this way, but it's a very close-knit community. The majority of the women know each other, they know their traffickers in an intimate setting, whether it be growing up with their children or knowing them, but the number one common denominator we find is some sort of very early childhood trauma, whether it be physical, sexual, psychological, or a combination of all three. Once they're in, it becomes very, very difficult to move away from that. The majority of the women I have worked with have been on the streets in excess of 20 years.

Host: And so, how do you, in your experience, manage to fight through all that?

Julia Martin: You just build a trust with them. You start off just sitting down and having a conversation with them. Sometimes I'll take them to lunch. Sometimes I'll take them downtown for Coca Cola or a cup of coffee. I keep emergency hygiene and food bags in my car. And it's just a matter of building a trust. It does not happen overnight. Traffickers are very adept at manipulation. They are very, very good at convincing the people that they victimize that they are the only ones that really care about them. They're the ones that are going to feed them. They're the ones that are going to clothe them. They're the ones that are going to get them shelter. It starts out very slowly. It does not happen overnight. It takes several visits. But eventually, once you can get that trust in and break through that barrier, you can start to have almost daily conversations with them. And I've had quite a few that have managed to break through and get out of the area.

Host: And Julia, the health statistics among these victims highlight a public health crisis, don't they? One-hundred percent of victims, 100% report serious mental illness. Many are positive for hepatitis C as well. So, how does that affect their treatment in healthcare settings, would you say?

Julia Martin: When I work with a woman who says she wants to get out, she wants to get substance abuse treatment. We look for facilities that their specialty is working with this type of trauma. With a lot of the residential facilities, we've had a couple in Alabama and a lot up around the Atlanta area, they will include hepatitis C treatment in their programs. But there are very specific guidelines that you have to follow. But what we have also found is with fentanyl and methamphetamine becoming more and more combined uses of substance together and a very, very high rate of intravenous use as well.

Of course, our primary goal is to get them off the street, but we want to work with facilities that will incorporate that hepatitis C treatment along with substance use treatment, along with mental health treatment. It's a very specific type of counseling, because you're talking about years and years and years of abuse, very, very early onset of substance use, very little wraparound support. And if you can find a really good program that will kind of incorporate all of those together, kind of that trifecta of "We're going to take care of your immediate need first, we're going to take care of your body first, we're going to get you healthy, and then we're going to work on this," and people like Larisa and Haley are such a big part of this, recognizing that and kind of getting a jump on that health care as well.

Host: Yeah, no question. And speaking of Larisa and Haley, let me get back to the two of you, and how would you say Implementing risk assessment tools and electronic health records can help identify human trafficking victims?

Larisa Barnes, BSN, RN: So, the hospital uses Cerver, that's our documentation system. And last year, last October, the hospital said, you know, "We screen for domestic violence, but we don't screen for human trafficking, so let's see what we can do screening-wise." So, they go to Cerner, their gold model was what they presented to us. And if you're not comfortable answering and asking these questions, they can sense that you're uncomfortable with the subject matter. So, I took the questions that they utilized in that medical record. And I created a little bit of a cheat sheet for the nurses up on the inpatient unit who are not comfortable. It's called the RAFT tool. It's Rapid Appraisal for Trafficking. And just by those four questions on that, the nurses are more comfortable than reading off 10 different questions from the form in the chart that they don't know the answers to so that we incorporated that, we went live with that last-- I want to say last November, and I did educational on that. I had the CJCC come in. We rolled out another training for human trafficking in conjunction with the CJCC so that the nurses are more comfortable with it. And if you're not comfortable, just that simple RAFT tool can help you identify, "Hey, wait a minute, maybe I should call Larisa and have Larisa come up and see this patient. And I could reach out to Julia. "Julia, she's in a tight spot. Could you come have a conversation with her and give her some resources?"

Julia Martin: Right. And if I can jump in on that really quick, we try to do that. I worked with a local mental health and trauma counselor, and we wrote up questions that we can reach out to law enforcement, especially probation officers who become jaded. You see the same person coming in and out of the jail over and over and over again. "They're just a junkie wanting a fix. They're doing this." So, we teach them to have a conversation with the ladies rather than an interrogation, and asking questions that you can kind of go through the weeds and get the answer to rather than, "Is this happening to you? What are you doing? Tell me who this is." to teach them to have a conversation, not an interrogation.

Host: Yeah, that sounds like an important distinction between those two. How about, Haley, emergency care nurses play a vital role in the recognition and rescue of human trafficking victims, so how can they improve that approach to suspected human trafficking cases?

Haley Mitchell: To kind of touch on what Julia was saying, with law enforcement becoming jaded, it's easy to do in emergency room nursing as well because, like Larisa mentioned, these patients have a lot of ER visits and it's for usually the same thing, a UTI or an STD. So, we have to teach our staff to be sensitive to the subject and to these patients, that it's a very delicate topic and it can be uncomfortable to talk about. But thankfully, we have the RAFT tool in place and the questions so that we can approach it in a much more compassionate way, as nurses are supposed to, and to not have that jaded feeling towards these patients. We too try to build a rapport, which is much harder to do when we're doing it in a very short time span, unlike repeated visits that Julia has, because when you come to the ER, you're not always going to have the same staff. So, building that rapport and that trust with that patient for them to say, "I need help and I want help" is very important and we continually teach our staff and reiterate that to them.

Host: Yeah. You mentioned there, Haley, both compassion and trust. I'm sure both of those are crucial in what we're talking about here. Just a couple of other things. How about resources that are available for healthcare workers seeking further training on human trafficking?

Haley Mitchell: Sure. As healthcare workers, we are mandated reporters in all areas. So, we have lots of resources. Our number one resource that we always use obviously is Larisa because she is very well versed in this subject, and helps us tremendously. The CJCC, we have resources around town such as the Amity House that we can set them up with, and Julia that we can reach out to for help if we don't know where to turn.

Host: And finally, in summary here, perhaps each of you could chime in on this. If you or someone you know is being trafficked, who can you call? Where can you go?

Larisa Barnes, BSN, RN: To tie it up as far as the compassion, I just want to add one more piece to it. So, in dealing with victims of trauma and those ACEs, the adverse childhood events, the main thing that you need to keep in mind is dealing with them in a trauma-informed way and come to their level and realize where they're coming from. So, it could just be a matter of how you're phrasing your question, "Why are you here today?" And instead of saying that, say, "What happened to you?" So, that can help them feel more comfortable. There is a Georgia hotline. It's 1 866-END-HTGA or 363-4842. There is also Tapestry, which deals with labor trafficking. They're Spanish speaking. They're available 24/7. And then, Frontline Response in Georgia deals strictly with kids from 12 to 17.

Julia Martin: We work really closely with an organization in Savannah called SWAT, which they have an annual trafficking-- it's called the Traffic Jam in Savannah. We work very closely with an organization in Atlanta that deals specifically with women 18 and over who have substance use disorders, mental health disorders, and are victims of both labor and sex trafficking. We try to keep the channels open for that, and keep our doors open because if you walk out, you can walk back to us, and we'll do it as many times as it takes.

Host: That's great to hear. And how about you, Haley? What's your best advice to people in this situation?

Haley Mitchell: In all honesty, to just be open minded about it. Don't just put blinders on and shut down and close these people out. There's a lot of it around that is happening, and I do feel a lot of people get jaded to the fact of the situation. So, we have to be open minded, again, compassionate. That's what we're in health care for. We took an oath to take care of everyone, and that is our number one duty, to get these people the help they need. If it was my family, I would want somebody to do that for them.

Host: Absolutely. And folks, we trust you're now more familiar with human sex trafficking. Larisa, Haley, Julia, the passion you have for this work comes through. Keep up all your great work and thanks so much again.

Larisa Barnes, BSN, RN: Thank you.

Haley Mitchell: Thank you.

Host: And for more information, please visit sghs.org/sa-er. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for being part of Health Matters from Southeast Georgia Health System.