Prison and sex-traffic victims: A place for help but not a safe zone

By Megan Fredericksen | 09/08/2016

Nurses and other healthcare providers also at risk.

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During my time as a graduate student, I developed a passion for working with individuals who have experienced sexual trauma, specifically those who have been victims of sex trafficking. I wanted to focus my doctoral work on development of sustainable system changes to improve screening and care of this vulnerable population. When I was presented with an opportunity to partner with a local correctional health system, I was unsure if my interests matched the population’s needs.
 
Mean FredericksenI knew that people who are incarcerated suffer a disproportionate burden of chronic health conditions that include hypertension, diabetes, asthma, mental health disorders, infectious diseases, and drug dependence, but I was unaware of the prevalence and impact of sex trafficking. Upon investigation, I found that many of the risk factors that bring individuals into the corrections system, such as substance abuse, poverty, homelessness, and child abuse, overlap with the same risk factors that make them susceptible to being trafficked, both inside and outside of prison. And just as health problems follow former inmates as they return to their communities, so too do risks of falling back into “the life” of sex trafficking with its sexual trauma and victimization.
 
Some victims unaware
Individuals in the correctional justice system are more likely to be victims of child abuse, incest, rape, and sex trafficking than the general population. Often, they have never received medical care or been screened for this history and may not even identify with the reality that they have been victimized. The corrections system has been identified as an opportune setting to diagnose and treat health conditions of those who have never received healthcare in the past. It makes sense, then, that prison is a place where first responders, including healthcare providers, may encounter and identify victims of sex trafficking and connect them with appropriate resources.
 
Identifying trafficking victims upon entry into the corrections system goes beyond addressing past victimization, however. Although imprisonment releases trafficked individuals from the captivity of their exploiters, the new setting can also threaten their safety and health. Incarcerated individuals, especially those with a prior history of sexual violence—as is the case in trafficking—are at increased risk of suffering prison rape.
 
Consequences of rape within the corrections system are well-documented and involve both physical trauma (including injuries from violent physical attacks, sexually transmitted infections, HIV and AIDS, and unwanted pregnancies) and psychological trauma (including depression, post-traumatic stress disorder, stress response syndrome, rape trauma syndrome, altered behavioral and cognitive functioning, and suicide attempts). Research shows that a person who is sexually attacked once is at increased risk for repeat victimization, which can exacerbate physical and psychological problems. Detecting trafficking victims at risk of sexual violence within the prison setting is critical in preventing these devastating consequences and supporting best outcomes for this vulnerable population.
 
Specialized training needed
Learning about these vulnerabilities highlighted for me the need for training that increases healthcare-provider awareness, knowledge, and skill in delivering trauma-informed care to victims of sex trafficking. Evidence shows that this victim-centered awareness and training can prevent or mitigate physical and mental health consequences in incarcerated individuals who have experienced sexual trauma.
 
With this as the catalyst for my doctoral work, I implemented a quality improvement project to develop a training curriculum for healthcare providers and nurses employed in correctional settings. This training is aimed at empowering healthcare providers to screen for and identify sex-traffic victims and give evidence-based, trauma-informed care that helps prevent rape attacks in prison and avoid further sexual victimization and exploitation upon release from prison.
 
During the training sessions that are part of this curriculum, my community partner and I asked nurses and other healthcare providers what they considered to be the most challenging aspects of working with victims of sexual trauma and what might prevent them from screening for histories of sexual violence. Our dialogue shed light on the serious and sometimes overlooked impact that working with victims of sexual trauma and trafficking has on healthcare providers.
  
Caregivers at risk of vicarious trauma
While performing the essential role of identifying victims and preventing sexual violence among incarcerated individuals, healthcare providers are often at increased risk of vicarious traumatization. Nurses by nature tend to empathize with traumatized individuals and, as an innate response, may themselves experience psychological distress and trauma.
 
Participants in these training sessions described social and interpersonal indicators of vicarious trauma, including how personal relationships suffered as a result of their work and, because of a strained work environment filled with disillusioned and burned-out co-workers, the difficulty they experienced in finding joy in their work. They spoke about developing depression and anxiety as a result of working in the correctional system with this victimized population and how caring for these patients brought up trauma from their own past. I was particularly struck by how their work had shaped their worldview. Many of them described how they had been lied to or manipulated by incarcerated patients, which caused them to question the truthfulness of patient reports about violence and trauma and, ultimately, experience a decline in empathy for this population.
 
It is unrealistic to think that providers can come away unscathed from encounters where they are exposed to graphic details of sex-victim trauma. I found this particularly true among healthcare providers who, tasked with providing emotionally complex and demanding care to incarcerated individuals, experience repeated, cumulative, and long-term stress.
 
Vicarious trauma that healthcare providers suffer cannot be ignored. It is associated with significant mental health problems that include traumatic stress disorder; depression; anxiety; dangerous coping strategies, including increased use of alcohol and drugs; and burnout, all of which can contribute to high rates of staff turnover. Loss of sympathy and empathy ultimately leads to compromised care for clients, which further fuels the cycle of failing to help victims of sex trafficking who might otherwise be helped when entering the corrections system.
 
Awareness of risk important
Although nurses and other healthcare providers who work in correctional settings may receive training on how to provide trauma-informed care to their patients, they may not have the tools necessary to address and prevent trauma they experience second-hand. In addition to helping providers focus on their own well-being, providing training on the impact of vicarious trauma in therapeutic relationships as well as coping strategies to promote self-care and enhance a sense of control has been shown to prevent and mitigate the negative impact of working with high-risk populations. In my experience, even providers who do not see themselves as suffering from vicarious trauma realize benefit from training that increases awareness of potential risks. As nurses and other healthcare providers are called upon to undertake efforts to make detection of sex trafficking more visible in healthcare settings, awareness of the concept of vicarious trauma is increasingly important, as they are at increased risk of experiencing such trauma.
 
Looking to the future, providers training for delivery of care to victims of sex trafficking will benefit from incorporation of evidence-based information that supports trauma-informed delivery of care to patients while empowering those healthcare workers to protect themselves from vicarious trauma. There are no easy solutions to the complex and pervasive health problems associated with sex trafficking, but, as nurses, we are on the forefront of helping victims. Improving the health and lives of one of our nation’s most vulnerable populations—incarcerated individuals—can be a powerful step in the right direction.
 
Part 1 in this series: Greater awareness of sex trafficking needed
Part 3 in this series: Integrating sex-trafficking awareness into women’s health curricula
 
Megan Fredericksen, DNP, APRN, CNP, WHNP, a women’s health nurse practitioner, is employed at Oakdale ObGyn Clinic in Maple Grove, Minnesota, USA.
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