Broken Trust: Exploited Youth and Healthcare Access

Teresa Huizar: 

Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, Broken Trust: Exploited Youth and Healthcare Access, I speak with Dr. Amy Farrell, Professor and Co-Director of the Violence and Justice Research Lab at Northeastern University. Now on One in Ten, we’ve talked to numerous researchers over the years about commercially sexually exploited youth. Which kids are the most vulnerable and at risk, what are they running to or from, and most importantly, how child abuse professionals can help. But what we haven’t yet covered until now is the health effects that are experienced by youth that have been exploited. What do we know about their physical and mental health? What access do they have to health care in an ongoing way? And in what ways can healthcare systems and providers serve as a bridge to better health outcomes and healthy futures? Heartbreakingly, as you will hear, the biggest barrier to better healthcare access and intervention may be the ways in which these youth have been failed by the healthcare system and attitudes within it in the past. I know you’ll find this conversation as important and thought-provoking as I did. Please take a listen.

 

Amy, welcome to One in Ten. Let’s start with how did you come to this work looking at youth who’ve been commercially sexually exploited and their health care and mental health care needs?

 

Amy Farrell:

So happy to be here. So that’s a great question. I want to start by just contextualizing that this isn’t just my study; this is a study that’s done in partnership with myself at Northeastern University and my colleague Carlos Cuevas, who’s another faculty member here at Northeastern, and a great team of graduate research assistants, particularly Amelia Wagner, who was our lead research assistant, and some partners at Boston University, Emily Rothman at RTI, Rebecca Feather and Jacqueline Colnick and at University of New Hampshire, particularly Lisa Jones and Kim Mitchell and Jennifer O’Brien. And I say that at the outset to say this was a big team of people that came together that have all been doing research on commercial sexual exploitation and exploitation of children for a long time in a lot of different contexts. So we brought together researchers that are from public health, from social science and humanities, folks that are statisticians. And we were really interested in this question of, and I’ll also contextualize that we wrote this proposal actually in March of 2020. So before the COVID pandemic, right? Like as we were entering the COVID pandemic, we were actually writing this proposal, kind of going offline. So we almost had no idea of what was to come in the world in terms of health.

There had been quite a bit of research looking at how young people who experience exploitation have navigated the world post-exploitation. And much of that had focused on mental health. So we knew that young people who experienced exploitation had PTSD, were more likely to experience trauma, were more likely to have depression, anxiety, dissociation. But we knew very little about physical health consequences.

And most of the research that had been done on physical health and sort of physical well-being outside of mental health had been done on adults. And the research that had been done even on mental health and young people who experienced exploitation had been really limited samples. So small samples, lots of it was qualitative. The quantitative research tended to be in one place. and so we really thought this deserves a much larger robust study, right? To really understand the consequences of exploitation for young people in terms of health, but in addition to consequences, to really understand the needs of young people. And that is, I think, one of the most important things that came out of the study is, you know, we’re not able to say causally that exploitation causes all of these health problems, but we are able to really get a good contextual picture of the fact that there are significant health needs of young people when they enter situations of exploitation, and that those needs get worse as they go through periods of exploitation and those needs remain very unmet after periods of exploitation. So this study really lets us look at before exploitation, during exploitation, and after exploitation in I think a really unique way.

 

TH: 

Well, let’s talk a little bit about the research questions specifically that you wanted to explore. We’ll get to the findings in a minute, but what did you want to know and how did you set out to get the sample that you did in order to try to learn what you wanted to know?

 

AF: 

So we wanted to know what the health concerns were of young people who experienced exploitation. So what the physical health concerns were, what the mental health concerns were, and both self-reported and diagnosed concerns. We wanted to know how young people who experienced exploitation engaged with healthcare systems. So the different ways that they engage with healthcare systems and their experiences engaging with healthcare systems.

And we wanted to know what could be done to improve the health of young people who experience exploitation and better meet the healthcare needs of young people who experience exploitation. And part of that is that we wanted to be able to inform healthcare professionals about not only how to identify trafficking amongst populations of young people that they might see, but really how to actually better meet the healthcare needs of young people that they might identify as being exploited. And that we felt was a real gap.

  

TH: 

And so let’s go back to the sample. Where did you find these individuals and how did you get this information?

 

AF: 

Yeah. And this was really hard and made much harder because of COVID, obviously. And so the design that we started off with had to obviously be in some way changing. Right. So we got the grant, which, you know, the world had shifted entirely when we actually got awarded the grant. And so we knew we wanted to find young people who experienced exploitation. And so we began by partnering with agencies around the country in a lot of different geographic areas that served young people who experienced exploitation. So places that were connected with children’s advocacy centers, places that were providing pure mentorship and support, places that were non-governmental organizations or governmental organizations serving young people who had been identified as being exploited. And we partnered with those organizations, created MOUs, had them on the ground when we developed the instrumentation, the survey.

Design and then actually had them partner with us in recruiting young people that they worked with to identify young people who are really in a good place in whatever stage they were at, that taking a survey would not be disruptive to them and their journey that they were on, right? Like so if taking a survey would cause them harm, we obviously didn’t want them to take the survey. We wanted to ensure that people who were being recruited to take the survey had experienced exploitation.

We wanted to make sure we could target people who had experienced exploitation with these agency samples. So about half of our sample came from partnership with agencies where young people were recruited. We’re basically provided an opportunity. We’re told about the study, we’re kind of explained the partnership they had with us, and were offered an opportunity to take the survey and really have a voice in talking about their own health and their healthcare needs. And so part of the data from the survey came from that population. The other half of the data from the survey came from the fact that we wanted to target young people that might not be system involved. So might not be working with agencies that may experience exploitation. And so we created a series of a lot of social media ads that we targeted out on Instagram and that were about sort of health, young people in health generally. They were very basic. They were not specifically about commercial sexual exploitation. They were about young people in health.

And we had thousands of people that indicated an interest in taking the survey. And then when those people got screened, we then gave them a separate screener to determine whether or not they had experienced exploitation. And then if they passed through that screener, then they were told about the survey and particularly told about the remuneration. So we really felt like the sample that we got from the online recruitment were people that we felt more confident were either at very high risk for exploitation or had experienced exploitation.

So about half the sample then came from this population that was quite different than the young people who were working with service providers. And I’d be happy to talk about the difference between those two populations, but they were very different from each other. And then we did qu a qualitative part of the study where we, again, working with survivor networks, recruited adults who had experienced commercial exploitation as minors to do interviews with us, which were kind of longitudinal interviews where we talked about health experiences and healthcare engagement in these three periods of life, prior to exploitation, during exploitation, and after exploitation. And those interviews were really valuable and really critical for helping us understand the needs of individuals that experience exploitation.

 

TH: 

So we’ll pivot to the findings for a minute and just walk through these in a stepwise way. And first of all, I’d I’m curious about as you think about the overall study, your overall findings, how would you overall characterize the health of youth that are exploited?

 

AF: 

Yeah. So young people who experience exploitation have more health concerns than young people who are not exploited, right? And again, I want to be clear, we can’t distinguish that the exploitation is causing those concerns. It’s possible that those concerns pre-existed the exploitation and they relate to the adversity conditions that might make young people vulnerable to being exploited. But I think any provider that identified a young person as a victim of exploitation should be attuned to the fact that that young person is likely to be more vulnerable to these health concerns, right? And that should shape treatment options or practices of care. And so some of the places where we found that were, you know, incredibly high rates of commercially sexually transmitted infection. And one of the things we were able to do is compare young people to sort of general population numbers, but also within our sample, we had young people who self-identified in the sample as having experienced exploitation. And we had young people who had been recruited into the study or got screened in for being at high risk, but didn’t necessarily confirm being exploited. And so we were able to compare those two populations. So it’s a really interesting group of young people who are who probably experienced very similar adversity conditions and vulnerabilities, but one group has indicated being exploited and the other group has not. And so comparing those two groups, we found significantly elevated forms of health concerns across a variety of domains. So in reproductive health, we found much higher, about three times higher rate of STIs in young people who had confirmed commercial sexual exploitation. We found much higher rates of chronic pain, so headaches, stomach aches, backaches, chronic pain. We found much higher rates of asthma. We found higher rates of even things like high blood pressure. So, you know, finding this sort of sequel of health concerns, potentially related to stress, potentially related to some of the mental health issues, right? That there’s an interaction there. And we have some really interesting analysis that actually looks at the way that some of the mental health concerns impact the physical health concerns.

But that young people are presenting with these physical health challenges that need to be met when they seek out care.

 

TH: 

So one of the things that I was interested in, I mean, I don’t think it was surprising to me personally that, for example, that there would be higher rates of sexually transmitted infections in this population, right? That’s not only known, but also I think just would meet common sense. On the other hand, I was surprised about the increased risk for chronic health conditions, especially those that were not like back pain, headache, things that might be even psychosomatic potentially. You know, so, but then things like chronic, you know, something like asthma or something that is high blood pressure, some other what do you attribute that to? I mean, just in terms of even your own curiosity, if the study doesn’t answer that question, it just I was very curious about that.

 

AF: 

Yeah. So I think the study doesn’t answer that question. I think that’s a question that needs more work, right? We need to understand that. I think that there’s obviously there are some connections between some of the environmental factors that young people who’ve experienced exploitation may find themselves in that may exacerbate underlying conditions.

So things like asthma and high blood pressure might be un you know, might be exacerbated by the environmental conditions that a young person who experiences exploitation experiences. Right. So being in certain areas, living in certain areas, being housed in certain areas, having some of the conditions of exploitation themselves around violence, around nutrition, around being denied food around just the exploitation experience itself. You know, we attribute, again, like you said, the sexually transmitted diseases, some of the like physical injuries related to you know, the commercial sex acts themselves. They’re not surprising. These other pieces, I think, though, speak to the larger harms to the body that young people may experience. And for us, what we found to be really dramatic and came out in the longitudinal work that was qualitative was how much this stuck with people over their life course, right? That when you have high blood pressure as a young person, or you have asthma as a young person, or you have chronic pain as a young person who’s in their 16, 17, 18 year old, you know, what that’s doing to you when you get into your 30s, like how that actually plays out for the rest of your life course. And the ways in which the costs of those health concerns get born for a survivor of commercial exploitation over long periods of their life.

We think there’s also, you know, some really comorbid issues around substance use disorder and exploitation that also deserves like some really high usage of comorbid substance use issues that I think also should figure into this around that sort of environmental context.

 

TH: 

Interesting. You know, I wanna pivot briefly to the mental health aspect of this. I mean, I think that again, unsurprising that you would see higher levels of PTSD and trauma symptoms, those kinds of things. I was, I don’t know if surprised is the right word, but the levels of depression and anxiety were incredible.

I wonder how you think about that in terms of provider intervention and the supports that people need and how we should think about, you know, trying to meet these various needs because they’re quite significant.

 

AF: 

They are right. And so it absolutely demands having mental health providers as part of the response to young people and recognizing the associated ways that that symptomology is going to play out in terms of a young person’s I mean, talking about young people too, that are going through all sorts of other changes, right? But you know, very high levels of depression and anxiety have significant consequences around suicide ideation, around the way they’re going to navigate their life, their ability to re-engage with society, their ability to go to school, their ability to form pure relationships. So the things that we expect and anticipate should be normal for kids to be able to do and we expect young people to do sort of when they’re removed from a situation of exploitation are going to harder for young people to do without appropriate mental health supports.

 

TH: 

Very interesting that you also looked at disassociation. You know, recently I had Frank Putnam on One in Ten, who did so much groundbreaking work in looking at that issue with trauma survivors. And it also harkened back to this issue about how experiencing that can also make it in some ways more difficult to recognize the need for treatment and uptake treatment. And so I think that, you know, we sometimes forget about that as a significant factor, you know, we think about suicidality, we think about depression, we might even think about anxiety, but are we really thinking about disassociation as a piece of this? And I’m curious if that came up in the adult survivor conversations and just what you took away from that as something that we need to be paying more attention to or addressing more directly, or something else.

 

AF: 

So definitely. And I think my clinical partners could speak to this more eloquently than I could, but the sort of like appearing okay at times or the ability to navigate. that was very strong in the adult survivors, right? Like the sort of like the the ability to just go numb, go through life. even to talk about, I mean, I think from a methodological standpoint, one of the things that was interesting, I’ve done lots and lots of these studies.

There were plenty of situations where we actually had to institute distress protocols during our qualitative interviews. And we have, you know, very firm distress protocols in place. So adults that were no longer in situations of exploitation and generally had fairly strong networks of support around them. We had many interviews where individuals we had to stop interviews, individuals became very upset. Not because they were talking about their exploitation, because the interviews themselves actually didn’t talk about their exploitation at all.

The only part of the adult survivor interviews that talked about exploitation was where we got age, put the three time points in place. All of our conversations were about health, right? We in fact only talked about exploitation if the person brought it up. Right. So we were really talking about their health of their family, their practice seeing doctors, the health concerns they had. And the experiences of people with healthcare systems was so traumatic that it was causing, right?

  

TH: 

It was triggering them. Interesting.

 

AF: 

It wasn’t their talking about their exploitation that was causing it. It was their talking about their experiences with health systems that was causing it. Because generally, now there were exceptions to this where people had really trusting, great, well-navigated relationships with health systems. But more often, people had relationships with health systems were very transactional and where, to be honest, they disassociated when they went to receive health care.

 

TH: 

And then I and then found it very triggering to talk about how bad that was. And I do want to get into that in just a minute because I think I found that personally some of the most interesting parts of the study was that issue about why they felt their healthcare experiences were so poor. But before we get to that, I want to talk a little bit about the health risk behaviors and that space and especially I thought it was very interesting the questions that were asked about basically exposure to adverse childhood experiences. And again, unsurprisingly, you had higher rates of that. But what was interesting to me is where it was very high, the types of things that they experienced, one of which was emotional neglect. So I think people sometimes imagine if somebody is commercially sexually exploited, what must have happened as their ace is that they were sexually abused. You know what I mean?

 

AF: 

Yeah, but we know that that’s not the case. That isn’t the case. Yeah. And so this research is confirming. And that was what makes it easy for people to coerce them, right? Like that’s what makes them vulnerable to the emotional coercion.

  

TH: 

It’s so true. And I think that it’s the heartbreaker because I think if we could get this message out to the general public more, it would be helpful. Because as you know, there are plenty of myths in the general public about child sexual abuse and exploitation. And I think this one-to-one relationship between sexual abuse and later exploitation is one of them. And it’s, I think, important to say emotional neglect, which doesn’t get talked about nearly enough, is such a powerful driver for a child to want some positive attention and sense of belonging, that it will even drive them into the arms of a trafficker or somebody who will exploit them.

 

AF: 

That’s exactly right. And it’s to some degree, it’s the part that’s so preventative, right? There are so many individuals who could become trusting adults in a child’s life, right? And we miss those opportunities. Right. So these are young people who no one has been there to fill that gap until an exploiter might have come along to fill that gap. And, you know, this is why people think it’s, you know, it doesn’t make sense that people, right? This is something we all know. Like, it’s not surprising that people stay with people who hurt them, who are in exploitive situations, because they give them something else, which is care. They see it as care, right? And they’re providing something for them that is filling a need.

 

TH: 

Maybe the only care they’ve ever had. You know, that and I think it’s an interesting thing that when you are talking about the fact that no adult has played that role in the life of a child, I think what this says is it’s also a community breakdown. It’s just, it’s not just a breakdown in the familial relationship. When you think about many of these youth are still in school, you know, and other kinds of things, how is it that the community at large hasn’t noticed that we have a child who’s been sort of lost to any kind of emotional support.

 

AF: 

That these are young people that largely have been in systems. Yes. Right. So we have had state systems involved in their life and they are still not having connections. Right. So our solution to this problem is not necessarily meeting their needs.

 

TH: 

I want to pivot for a moment and talk a little bit about access to healthcare. And I have to say I was a little surprised by the high level of insurance coverage that youth who are commercially sexually exploited had and the fact that it wasn’t at all uncommon for them to have had fairly recent care of some kind or, you know, attempted to or did access the healthcare system. Now, you all as researchers may have already known that, but I have to say when I read it, I sort of imagined them as more disconnected from the healthcare system than they actually are, which I don’t know, I take as hopeful. Like there’s an opportunity. We may not have maximized it yet, but there’s an opportunity for intervention and prevention here.

 

AF: 

And I’ve there’s a few pieces of this that should be unpacked, right? And so then we did see regional differences and that I think we’re at a tipping point where also this could go downhill really fast. And I think it is going downhill really fast because we’re removing many of the safety nets that Obamacare and the other state systems that put in place insurance programs for families had. So we certainly saw regional differences. So places in the Northeast were much more likely to have insurance even in their family systems usually through state systems, through state insurance. I mean I live in Massachusetts. There’s very few uninsured people in Massachusetts because of state systems. I say that is not the case across the country and that’s definitely what we heard in interviews. Right when we talked to adults in Massachusetts and Rhode Island and New York, we didn’t hear people saying I don’t I can’t get care ’cause I can’t afford it. When you talk to people in Texas, that was something people talked about a lot. I’m making decisions about care ’cause I can’t afford it. And those were adults, right? Like for kids.

You know, nationally we have a much better safety system for care for kids. It really did surprise us at first to see how often kids had primary care, how often they’d been to medical facilities. In some ways that’s not completely surprising when you think about it a little bit more. So for example, if a young person is in a state system, they probably have been medically cleared recently, right? Like if they’ve run away from a state system, they’ve just been medically cleared coming back into that system. So they see healthcare providers actually probably quite a lot if they’re in state systems. So that made more sense to us. It was actually hopeful. We found that people had connections to healthcare systems, even to dentists or to other folks are usually good barometers of a healthcare safety net. So while that can be improved, one of the things that we found is that during active exploitation, young people got most of their care in emergency rooms, which is not necessarily but in the times when maybe they were not in active exploitation, they may have been back in state care, or they may have been in a foster family, or they may have been like out of a situation of exploitation for some time, they were engaging with more traditional healthcare systems. And I think there’s some important differences between emergency care and like long term care that need to be addressed. But we did find as people went through exploitive processes, they became more and more wary of healthcare systems because they had more and more negative experiences with healthcare system, more and more stigmatizing experiences with healthcare systems.

 

TH: 

One of the things I was thinking about as you were talking is the fact that one of the great challenges of commercially sexually exploited youth is that while they may have various touch points with various systems, they’re very wary touch points and they’re very uneven and they’re highly unlikely to be really consistent. And so, you know, even in the Children’s Advocacy Center, a kid might be coming to group or whatever for a while and then drop out and then come back and that so there’s this there’s this influx nature to some of that makes it a particularly challenging group for consistent interventions, which, and I think this kind of pivots to your point, is why it’s so critical that when there is a touch point, that it’s a good experience. Because otherwise it’s too easy to d disconnect from that system or that touch point and be essentially lost to it for a period of time. So now let’s talk about this sort of perceptual barrier to healthcare that exists because people have had, as you were describing, what was interesting in the report, let me just say, is that it wasn’t just that they had an unpleasant experience. That’s not how it’s described. You know, lots of people have had an experience with healthcare where either because of the procedure or whatever, it just wasn’t something you were looking forward to going back to, right?

But this isn’t what you’re describing. You’re describing discrimination, stigma. So talk about that because these were strong words, you know, used for the experience that these youth were having with healthcare settings.

 

AF: 

Yeah. And so in both the survey and in the qualitative interviews, we assessed this. And the survey focused on discrimination in healthcare and not only discrimination by characteristics, but also things like being treated like you’re less intelligent, not being listened to, perceptions that you weren’t being listened to, process terms you’re being ta talked down to. So young people, I mean, also we know young people may feel that way about authorities, sort of in general, but young people who experience commercial exploitation, even in this really vulnerable group.

Those that experienced exploitation compared to those who reported that they didn’t were more likely to have had healthcare experiences where they felt like they had been treated as they were unintelligent, that they felt like they had been talked down to, that they felt like they had had these other experiences. And when we got into the qualitative interviews, what really became important was this question of stigma. So, right, the idea that they felt this discriminatory.

Or behavior that they saw from healthcare was linked back to their identity as someone who was engaged in commercial sex or someone who was using substances, right? And maybe both. And over and over again, interviewees talked about just being perceived that they were worthless by healthcare providers who treated them like they weren’t human, who seemed not to care about them, who seemed just and these were like really emotional conversations where what they experienced was what we would expect to have people talking about when they talk about other authorities like law enforcement or other people that we more normally expect young people to have negative interactions with. And that was everything from emergency rooms to clinics to sometimes reproductive health care, where there was just this sense of not only that that they didn’t get their healthcare need met, they didn’t actually come out of it with their healthcare need addressed, but they felt terrible about themselves as a person. And they felt like it was related to their identity as being a person who was exploited.

 

TH: 

They felt judged and shamed ultimately. What you’re describing. And I think that it’s just heartbreaking. You know, that part of it, reading that section, it’s just heartbreaking because this is the last thing that we want kids to feel like who have already experienced these terrible experiences that you wouldn’t wish on anyone. And so I was thinking about

 

AF: 

And they often had legitimate healthcare needs like they weren’t like they had a broken leg or they had like a right. They weren’t coming and part of it is that they didn’t necessarily want someone to take them out of that situation of exploitation. They were very open about like, yeah, I wasn’t gonna leave that situation of exploitation at that time. Like I didn’t need somebody to rescue me at that moment. I probably wouldn’t have accepted help. But I just needed somebody to be nice to me. I just needed somebody to be human to me. Because then later when I was ready to get help.

I would have gone back to those people. If somebody would have been nice to me in healthcare or somebody would have seen me as a person in healthcare, maybe when I was ready to get out of that experience, a nurse or somebody would have been somebody I disclosed to. I would have looked to them for help. But now I’m not gonna look to them for help because I don’t feel like I trust them.

 

TH: 

One of the things as you were talking about that, that I was thinking is how familiar this feels to domestic violence work in terms of the fact that often people feel ashamed and judged about that. And on the other side, there’s this lack of understanding sometimes on the part of providers about the nature of readiness as a factor in intervention and judging a person’s lack of readiness for an intervention in some way. And so I think that there’s just a real opportunity to do some education and training with healthcare providers around some of these things. I’m wondering though, when you think about the recommendations for healthcare providers, can you talk a little bit about what those are, especially as it relates to building trust with these kids?

 

AF: 

So we have recommendations that are at a few different levels. So one is we saw particularly from the interviews that we mapped out these life courses that look at the three different time points and then let kind of tagged each experience that they had with healthcare providers as like positive, negative, or neutral. And what you can see in that early intervention, early like pediatric, like before exploitation, right? When a young person’s going to see their pediatrician, right? That the experiences tended to be fairly neutral. Doctors did what they were supposed to do. I got shots, like they were fine. You know, I talked to them. I didn’t really ever disclose anything to them. I didn’t really dislike them. Sometimes they were really negative, sometimes they were okay. But they were very transactional. And one of the things that we make a recommendation about is a pediatric recommendation that before someone is exploited, right? Long before someone is exploited, that pediatricians have an opportunity to create foundational trust in the healthcare system with people before they become victims. That isn’t transactional, right? Because they’re transactional is what they’re going to experience in the exploitation, right? That is that’s agency building that creates trust, that it helps people learn to take care of their own health, that gives them agency, that creates a partnership with a provider.

You know, all that work that you can do nurturing that relationship so it’s not just this neutral transactional relationship will help set you up for the second phase, right? Cause during active exploitation, if you have no foundational base to trust healthcare.

We’re already behind the we’re already it we need to set the foundation, right? Like so there’s a really strong recommendation we make for pediatricians. And we understand pediatricians have less time. All these parts are on the healthcare system, but we think they’re good for every kid. This isn’t just about exploitation. This is about pediatricians creating a foundational trust for the future when kids have a hard time with healthcare systems, when kids need healthcare systems. And then we make these set of recommendations about sort of like, during the time young people are experiencing exploitation. And one of the things we really point to is that in healthcare training, we’ve largely seen that healthcare providers have been sort of trained to identify exploitation. So they can refer people to other sorts, like so that they can call the police, so that they can make a 51A referral, so they can call child welfare services. And that’s helpful. But what we haven’t trained them to do is to actually treat the things that they arrive with, right? Like so knowing like, a young person who’s exploited is more likely to have these conditions. So if you suspect exploitation, how about we ask some additional questions about sleeping and insomnia? And why don’t we think about STIs and why don’t we think about pain and all of the other things that this study finds are issues? Maybe we should test for asthma. Maybe we should like it’s not just STIs. It’s not just the sort of traditional stuff. It’s a whole bunch of other stuff. It should be shedding off a red flag, just like it would be if a child had high blood pressure, or a child was overweight, or a child other things that were red flags. This should just be a red flag that maybe other tests need to be run or other questions should be asked. Not about their exploitation. I mean, yes, if you feel trust and you could do that, but your job is to treat their physical health. And maybe you can make referrals, but don’t neglect treating the physical health project. And that’s the part that we see really getting neglected. And then at the after stage, we make a recommendation for navigation. The service providers need to have healthcare navigators. There need to be people that help survivors navigate healthcare systems and find doctors that understand exploitation, right? That get to the right clinic and the right provider. Because we had these great stories from survivors who had found the right person and it was life-changing for them.

Either they and normally they’d found that right person because another survivor had given them the name of this doctor and said, This doctor gets it. This doctor is young and hip, or this doctor went to this training, or this doctor is so good at you know, they understand addiction and they understand exploitation. And over and over again, the thing that survivors said is that I don’t want to have to educate. I wanna see that my doctor knows about exploitation. Like if they could just signal to me that they understand exploitation without me having to explain everything, I would feel more open about talking about it. Like they need to send me the signals that they’re an expert so that I could feel open to talking about it. But if I think I’m gonna have to explain everything to them, I don’t wanna go down that road. Like I don’t wanna educate anybody else about this. In a moment that I need healthcare. And so getting to that right provider, though, was just transformational for some people.

And that that we think navigation could be a big piece of that, helping them navigate insurance, helping them navigate specialized, and then also to train clinics and doctors and staff, like to having a well-trained community of health providers is actually something that we need to think about in the service delivery needs of survivors and communities.

 

TH: 

One of the things that I was thinking about as you were talking were about the programs within Children’s Advocacy Centers that many have working with these youth. And I think it’s well recognized that they’re going to need lots of advocacy services and case management ongoing. I don’t know in the if there’s the equivalent recognition of medical services ongoing once they’ve been physically cleared, you know, that you don’t have a current health concern. And so I think that for Children’s Advocacy Center staff that may be listening to this really keen in on this need for an ongoing positive healthcare relationship, I think is a critical one.

 

AF: 

Yeah. Because people, even as you said earlier, even if a person has an experience with a provider like a nurse or someone who they’ve said, you know, treated me like a human. And we have all these examples. We have quotes like they gave me a blanket. They just asked me how my day was. And that that just moment of humanity, human connection, made them more likely to talk to somebody later on. Like to reach out to a nurse at a different time, you know, when they’re having a SANE exam. They’d had a really nice nurse in the emergency room five years earlier. And so they actually disclosed something, right? Those points of connection are just so instrumental. So whether or not it’s about meeting the needs immediately, they’re all setting foundations for trusting health systems, which to be honest, are something that I think this study shows. And I mean it would be great to do this longitudinally, right? To figure out what are the long-term consequences. But our study seems to indicate that there’s a need for that research because it’s it certainly seems like the physical health challenges that young people experience and that may be exacerbated by exploitation follow people through their lives. And so people are going to need healthcare through their lives that may always need to be attuned to the fact that they’ve had this experience, right? So, you know, there’s things like if they got hep C when they were exploited, if they got another STI, if they have other types of trauma that come back and create recurring health problems and for people to be able to be honest about that with their health providers and have plans for that throughout their life that are non-stigmatizing and that are just about health is so critical.

 

TH: 

You know, it’s especially critical with these kids, but I was just thinking about the degree to which it’s this vital, period. That, you know, all children and all teens and all adults need a trusting relationship with their health care providers. And I think the more that we can help foster that in our little circle, you know, our little circle of concern that we have, I think the better, because I think we see the effects when that’s not the case and that trust is broken and people feel that.

Instead of reaching out to medical professionals for medical advice, they’re asking Chat GPT or they’re doing all kinds of things that may be unhelpful or turn up unhelpful and inaccurate information.

 

AF: 

And we saw some of that, right? And again, we were even doing these interviews long I mean, we did these interviews, you know, two years ago, or a year and a half ago. Like so well, yeah, two years ago almost that we were doing the interviews. That was before Chat GPT, you know, but was over there. So I’m sure this is just exacerbated, by people Googling health and also people going to like, you know, more spiritual practices. some really concerning practices because people were so fed up with healthcare systems. And also, I mean, I think exacerbated today is also the cost. I mean, what years ago than today is the critical decisions people are having to make in families about where they can afford health.

 

TH: 

Well, the report was far longer than we’ve had the opportunity to talk about today, and I wish we could cover all of it because I just found it fascinating and really adding to the literature and our understanding of these youths. But I’m wondering, is there anything else that you wanted to make sure that we talked about today or any question that I should have asked you and didn’t?

 

AF: 

I do. Yeah, actually, one thing we didn’t talk about, and I think is really important, is that there are some really unique health challenges that young people experience depending on some differences that young people experience, particularly around gender identity and being LGBTQ. And we were only able to scratch the surface of that in this study. And I think there is a lot of work to be done with that because it was something that was a major issue for individuals who identified as LGBTQ in our interviews. And we had a small pool of interviews, not a pool focused on LGBTQ youth, but their healthcare needs and healthcare experiences were greater and they had more opportunities for stigma. So I think there are sort of like avenues to go down here that deserve more sunlight and attention.

You know, this report was only able to signal some areas where there were some really unique needs, particularly with trans youth or youth that experienced gender identity, had different gender identity issues that they, you know, were trying to navigate through as a young person and really experienced a lot of stigma on top of the exploitation stigma. So I just wanted to put out there that that was something that I think is really important.

 

TH: 

One of the areas that sort of ended your report had to do with areas for future research, aside from the things that we’ve talked about so far, were there other areas of future research that you wanted to make sure that we highlighted today?

 

AF: 

I mean, I think that there is a lot more research that’s needed to help us understand the sort of mechanisms through which people create trusting relationships with healthcare providers? Like how do we do that? And I say this because healthcare providers’ time is so limited. We know that this is a pressure on healthcare providers. So what are the mechanisms that actually help providers create those trusting relationships?

Do trauma informed care better, specifically for this population. So I think research that could help providers not say, like, I’d love to do this, I just don’t have the time, or we have all these pressures on us. And this is one more thing we’re being asked to do. I just think it’s so critical we provide really concrete resources to providers who are busy and who have a lot of pressures on their time about what actually works. And we could again this study could begin to scratch the surface about what would might could work, but it isn’t an evaluation study about how specific models work. And I do think that work would be really helpful.

 

TH: 

Well, I think from a research perspective you have your work cut out for you because you’ve talked about several things that are worth exploring. Thank you so much for coming on to the podcast and talking about all of this. This is just I think a vital area for us to honestly do better by these kids. So appreciate all the work that you’re doing ongoing.

 

AF: 

Thank you, thanks for highlighting the study and highlighting the issue.

 

TH: 

Come back anytime.

 

AF:

Sounds good.

 

TH: 

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