# Exhibit 10

# Decisions













Miscellaneous Latest CE Courses

# Human Trafficking: Red Flags for Dental Professionals

Dentists and dental hygienists should look for the subtle signs of victimization so they can offer appropriate treatment, resources and referrals.

By Sheryl L. Syme, PDH, MS, Susan Camardese PDH, MS and Kimberly Mehlman-Orozco, PhD On Aug 4, 201-7

Dentists and dental hygienists should look for the subtle signs of victimization so they can offer appropriate treatment, resources and referrals

This course was published in the August 2077 issue and expires August 2020. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

### OBJECTIVES

After reading this course, the participant should be able to:

- 1. Discuss trends in human trafficking, and oral health professionals' role in identifying, treating and helping victims.
- 2. Explain the types of individuals that human traffickers target, and tactics for manipulating victims.
- 3. Describe common oral injuries that trafficking victims present with, as well as reasons why victims typically underreport abuse.

Human trafficking is a rampant global health problem affecting a growing number of childrePrfteclia3;f0861<farliaselererldwide basis. traffickers use fraud, coercion, threats and deception to manipulate victims into various forms of exploitation, including domestic servitude, sex trafficking, sham marriages, forced labor and criminal activity. Trafficking is identified as a form of slavery and a major, yet often hidden, crime involving the control of victims for the traffickers' economic gain. Targeting potential victims who appear lost, disenfranchised or in desperate situations, traffickers are adept at isolating victims from social support systems and creating dependency, limiting victims' movement to work settings, and hiding the red flags and signs of victimization. Victims are often lured by promises of lucrative employment, stability, ability to obtain an education, a steady income to send home to 2 support their families, or a loving relationship — some or all of which represent opportunities absent in the victim's life.

While the stories of trafficked survivors often include accounts of trying to improve their lives or that of their families, and desires to migrate to areas that promise a better future, these individuals are not always migrants. Although transportation may be a control tactic to keep human trafficking victims in unfamiliar places, the defining characteristic is exploitation for profit, rather than being moved from one region to another.0 Given the extent of the problem and fact that trafficked individuals may seek dental treatment, oral health professionals have a responsibility to recognize the signs that may indicate victimization, and be prepared to provide appropriate treatment, resources and referrals (Table 1).

The United States is a key source, site of transport and destination for trafficked individuals. Reports of trafficking to the National Human Trafficking Hotline and Polaris BeFree Textline have been increasing in all 50 states and Washington, D.C. The National Human Trafficking Hotline is partially funded by the U.S. Department of Health and Human Services and is operated by Polaris, a nonprofit. nongovernmental anti-trafficking organization. While a lack of uniformity in reporting and tracking victims in a universal database, as well as the clandestine nature of this criminal activity, creates challenges in identifying victims. the U.S. Department of State estimates more than 26 million individuals are subjected to human trafficking worldwide. As regional and global markets increase for human trafficking, so, too, does the need to identify trafficked individuals. Considering that health care providers may be among the few professionals to come in contact with these individuals it behooves clinicians to be prepared to identify possible victims.

.1. \ I I .1'. I . Resources for Seeking Help or Reporting Human Trafficking

| Resources | Purpose |
| ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| National Human Trafficking Hotline
888-373-7888 | 24/7 toll-free national anti-trafficking hotline and resource center providing assistance with service providers and placement resources; operated by the nongovernmental Polaris organization that's funded by the federal government |
| Local Police Department
911 or local contact number | Call for immediate safety, advising and protection concerns |
| Department of Homeland Security
Blue Campaign to End Human Trafficking
*dhs.gov/blue-campaign/victim-centered* | Provides legal assistance, special T-Visa authorization for victims of human trafficking and victim support; provides immigration relief to non-U.S. citizens of human trafficking |
| Polaris Project website and Resource Center
*polarisproject.org* | Nonprofit, nongovernmental organization working directly with victims, Polaris hosts the National Human Resource Center crisis hotline and BeFree Textline: text HELP or INFO to BeFree (233733) |
| U.S. Immigration and Customs Enforcement (ICE)
Homeland Security Investigations (HSI)
866-347-2423 (866-DHS-2-ICE) or report online using the HSI Tip Form *ice.gov/webform/his-tip-form* | U.S. Immigration and Customs Enforcement/Homeland Security Investigations investigates human trafficking and arrests traffickers. Call if clinicians notice suspicious activity in the practice or community |

# TRAFFICKING TARGETS

Labor trafficking victims are most often recruited through a job offer and represent approximately 11% percent of our nation's victims, while sex trafficking accounts for 82% of victims in the U.S.; of the latter, most are trafficked by their intimate partners.5 In 2016, an estimated one out of six of the 18,500 runaway children reported to the National Center for Missing and Exploited Children were likely sex trafficking victims? Children are often targeted through social networking and escort websites. and at bus and truck stops, train stations, youth centers, homeless shelters, schools and malls —often within hours of displacement from their homes.2718 Youth entrapment and enmeshment schemes are frequently used in sex trafficking of minors and resemble power and control techniques observed in other exploitive relationships, such as intimate partner violence (I PV), in . 9 WhiltikthetRiNeliiiaantie00 ittiProrgdifelart\*PQRROSeateethiefUltiOsiou're ok with this, but you can opt-out if you wish. Accept

**TABLE 2. Human Trafficking Assessment Questions\***Clinicians should identify their interest in helping and avoid sounding judgmental when asking the following screening questions:

1. 1. Are you living and working in a safe place? Where and when do you sleep?
2. 2. Have you ever been pressured to do something that you didn't want to do or were uncomfortable doing?
3. 3. Have you ever been threatened or intimated by someone? If so, what did this person say would happen to you?
4. 4. Are you able to come and go freely at home and work?
5. 5. What happens if you leave or talk of leaving home or work?
6. 6. Do you have access to any money or the money you earn? Has anyone taken some or all of your money, or held your money with promises to keep it safe?
7. 7. Do you owe money to someone? Are you in debt to someone and how are you paying off the debt?
8. 8. Does someone control, supervise and/or monitor you and your work?
9. 9. Has your communication with others been restricted or cut off? Have you ever had a phone or computer? What happened to those items?
10. 10. Do you have days off from work and what do you do on your days off? Are you allowed to take breaks at work? If you are not feeling well, are you able to take time off from work?
11. 11. Has someone ever controlled your access to food and drink, health care and/or medications?
12. 12. Has someone ever taken your identification papers, passport or other personal documents?

\* Adapted from The Polaris Project. Human Trafficking. Recognize the Signs. 2017. Available at: [polarisproject.org/recognize-signs](http://polarisproject.org/recognize-signs).{sup}`1,7,14` Branding and tattooing are common, and mark the trafficked person as property, enabling the trafficker to claim ownership of the victim and signal other pimps to stay away.

## CHALLENGES IN IDENTIFYING VICTIMS

Identifying victims poses a significant challenge to researchers and professionals who provide medical or dental care, interventions and refer resources because trafficked children and adults rarely self-identify. Trafficked victims may underreport because they:{sup}`2,3`

- Lack access to legal or support services
- Fear retaliation from their traffickers against them or their family
- Have been conditioned to fear and distrust anyone other than their captors, including law enforcement or other authorities
- Fear the consequences of being identified as illegal immigrants or criminals, instead of victims
- Feel ashamed of their activities and how their families and communities will receive them if they return
- Feel a sense of hopelessness in escaping their captor, and the emotional or financial indebtedness employed by their controlling trafficker
- Do not identify that they are being trafficked

## PSYCHOLOGICAL AND PHYSICAL COSTS

Traffickers use intimidation and emotional entrapment to control victims, including violence against the individual or their family and friends, threats of deportation, confiscation of identification documents, shaming or guilt, and trauma-bonding (in which the trafficked person fears the trafficker, yet feels relieved to be taken care of, offered employment and allowed to live). Trafficked individuals are routinely exposed to "seasoning"{sup}`16` tactics, such as withholding food, water, sleep or social contact, and psychological trauma that enabled the trafficker to achieve submission, increase dependence and reduce resistance.

Psychological entrapment often prevents victims from escaping, even when opportunities arise.{sup}`17` Victims and survivors may experience multiple psychological conditions, including severe post-traumatic stress disorder, rape trauma syndrome (the series of emotional, physical and behavioral reactions experienced by rape victims), and child sexual abuse accommodation syndrome (in which children go through five stages of response to ongoing abuse, including secrecy, helplessness, accommodation, delayed disclosure and retraction). In addition, victims may have anxiety and/or nervous disorders, psychosomatic syndromes, eating disorders, personality disorders, depression, coping substance abuse (and subsequent addiction), and thoughts of self-harm or suicide.{sup}`3,8,11,18`

Victims of human trafficking frequently present to medical and dental facilities with a variety of physical health needs, including injuries from violence, head and neck trauma, sexually transmitted diseases (STDs), dental or orofacial conditions, and

{sup}`19,20` Maintaining that the victim used the emotion presenting factors in which the substance was and the action combination was coined with the captors.

multiple pregnancies and forced abortions. Physical injuries to trafficked individuals are oftercirbilic,e03oclibeslutailhand face, including teeth and jaw fractures and mandibular dislocations; consequently, demand for dental care is one of many 3021 common needs of trafficked victims. 22.23

Neglected health conditions — such as uncontrolled asthma, hypertension, diabetes, Elnourishment, obesity, addiction, untreated skin infections/lesions untreated caries and periodontal disease — and withholding medication or noncompliance with recommended therapies may be signs that trafficked individuals are being prevented from accessing care.

## ORAL HEALTH PROFESSIONALS' ROLE

Victims may present for dental services as a result of restricted access to dental hygiene products or deleterious effects on oral health from sex or labor work, as well as for cosmetic purposes. Additionally, a sex trafficker's interest in seeking cosmetic dental services would most likely stem from a desire to make the victim more attractive to clients. Thus, the responsibility of identification relies on the provider's ability to recognize the sometimes subtle signs of victimization and follow up with focused questions to assess immediate treatment and referral needs. That said. the role of oral health professionals in assisting victims of human trafficking has not been extensively discussed in the literature. "25 In some cases, dentists and dental hygienists may be the first responders in rendering care to trafficked individuals.24 A survey of U.S.-based survivors of human trafficking shows that while being trafficked, 26.5% were seen by a dentist, along with other health care providers, but few victims were identified by these clinicians.26

Signs of abuse or other indicators of human trafficking warrant follow-up and a one-on-one conversation without the presence of the victim's attendant. The online version of this article provides examples of questions that can be used to assess whether a patient has been a victim of human trafficking; while this is neither an exhaustive nor cumulative list, it may prove helpful in the assessment process.

In recognition of the suspected frequency with which (as yet unidentified) trafficking victims are being seen in health care facilities. efforts to educate clinicians about human trafficking have increased in the last 10 years.113,21.27 At the same time, documentation of the health consequences and risks of human trafficking is improving, as is science's understanding of the gaps in health care providers' knowledge about this growing problem 18.192328,29 Dentists,{sup}`2024` mental health workers,{sup}`28` emergency room professionals.rawgynecologists or other specialty physicians. 3.1121 and nurses and midwives16'79 would all benefit from training designed to increase recognition of trafficking victims so an interdisciplinary response can be initiated.

# CLINICAL STRATEGIES

Separating the patient from the third party accompanying the individual to the health visit is a crucial first step in conducting screening questions about human trafficking. A third party's refusal to allow the patient to be alone with the provider may indicate that he or she is not concerned with obtaining the best care for the patient, but instead fears being divulged as a trafficker. The patient can be asked if he or she requires an interpreter or prefers a male or female clinician. It is also up to the clinician's judgment to enlist interpreter services if the PrabittaketatcJaifORAite0a5ORIPP6009atiPeciSelfteRtineldlledtkehlit 50tAreVidfttteglifirriNtly0altfaifafft-64ei008490-iinterilfetiet services by the person accompanying the patient may be arfailagmeckflag indicating victimization.

## HUMAN TRAFFICKING CASE SCENARIOS

The following examples represent scenarios of human trafficking that oral health professionals may encounter. They also reflect individuals and relationships that do not necessarily fit stereotypic profiles of victims and perpetrators, which makes identification difficult.

Scenario 1: "8,- a 15.year.old girl, is brought into a dental office as a new patient; she is accompanied by • woman who says she is her aunt and caring for her because mother and father died recently. Initially, is seen by the dental hygienist to start the medical history and assessments. The aunt reports that she doesn't know details of B's medical history, except that she had an abortion this year, a sexually transmitted disease, and has some broken front teeth from falling down steps. The aunt also reports that B dropped out of school this year and has been difficult to manage. The girl appears thy and afraid of the aunt, and asks to use the restroom. The aunt appears nervous when B leaves with the dental hygienist, who has offered to show her to the restroom. The aunt follows them and yells at 8 to hurry up and repeatedly asks the dental hygienist what can be done to fix Ers teeth so they can get back to work soon. After exiting the restroom, the dental hygienist asks 8 if she is OK or in need of assistance, but B is apprehensive and seems afraid of receiving help.

Scenario 2: "T," a 25.year-old petite woman, is brought into a dental office by a husband and wife who are among the longest tenured families in the practice. They report that T is an undocumented migrant and does not have any medical records. passport or identification documents. She recently became a nanny for their twin 18-month-old sons. and the family explains they are willing to foot the bill to get her decayed teeth restored because she is such a wonderful help with their sons and 'good child care is hard to find." The couple says that Ts appearance frightens the children and embarrasses them in front of friends and family. She does not make eye contact and appears to have multiple faint bruises on her face, neck and forearms. She appears to be unable to sit with her back against the dental chair. The couple reports the twin boys are quite rambunctious and a little rough on T. The couple states that they can speak for T in decision, made about her teeth.

Increasingly, it is recognized that dental providers may routinely encounter, but inadvertently overlook, individuals who are presently (or previously) victims of human trafficking. With this in mind, it is prudent for clinicians to watch for signs of abuse and/or human trafficking, and offer the appropriate treatment, counseling, resources and referrals.

Clinicians should not inquire about trafficking-specific details, but should know their state-mandated OtrOmeifezlasys for children and adults, as well as vulnerable adults, and when weapons are involved. Oral health professionals are mandated to report their suspicions of abuse and neglect perpetrated against children under 18. regardless of consent. Detailed documentation of craniofacial injuries and other injuries identified during the dental examination should include descriptions, locations, duration and information pertaining to the cause.

If a patient divulges that he or she is a victim, it is imperative to establish rapport, acknowledge the presence of trauma symptoms, respect an adult victim's decision on whether he or she is ready and able to self-report, and attend to the individual's immediate needs and safety. Clinicians should not divulge personal addresses or contact information, or attempt to harbor the trafficked person. Unless legally mandated, providers should not contact authorities without consent of an adult trafficking victim; instead, oral health professionals are advised to encourage self-reporting and refer the patient to the appropriate support services-9

If the victim's personal decision is in contrast with the health care provider's, a trauma-informed approach enables the trafficked 31 individual to feel in control and respected, perhaps for the first time. Establishing this level of trust may provide an opportunity 29 for the victim to potentially return when he or she is ready to escape the trafficking situation.

# REFERRALS AND RESOURCES

Compared to other victimized groups, there are relatively few resources and long-term sustainable services for individuals identified as victims of human trafficking. ' Trauma-informed programming is essential to the recovery and reintegration of survivors. and requires an approach that effectively focuses on the physical and mental health consequences of human 3.17.32 trafficking. As noted. Table 1 provides resources for those who seek help or wish to report suspected cases of human trafficking. It is imperative for dental teams to familiarize themselves with local resources. such as housing, legal assistance and trauma-informed care providers, as well as their intake requirements (e.g., residency, gender or age).

**TABLE 3. Red Flags for Identifying Human Trafficking\***

| Indicators for Individual(s) in Question |  |
| -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | -- |
| <b>Work Conditions</b> |  |
| <ul> <li>Is restricted in coming and going places as he/she wishes</li> <li>Is under age 18 and providing commercial sex acts</li> <li>Is in the commercial sex industry and has a handler/manager or pimp</li> <li>Wages are low or non-existent or paid only through tips</li> <li>Works excessively long hours with little or no breaks</li> <li>Experiences strict rules or works under severe restrictions</li> <li>Was recruited with false promises regarding the work he/she would be involved in and promises for a better life, education, higher paying job, or exciting opportunities</li> <li>Works all the time but is unable to pay off debt to trafficker</li> <li>Works or lives in settings marked by high security measures (cameras, boarded or opaque windows, bars on window and doors)</li> </ul> |  |
| <b>Psychological Signs</b> |  |
| <ul> <li>Fearful, anxious, depressed or nervous/paranoid (looking around before talking)</li> <li>Extreme startle response</li> <li>Exhibits combative behaviors as a defense mechanism</li> <li>Become anxious and appears distrustful of law enforcement when brought up in conversation</li> <li>Doesn't make eye contact and appears very submissive or overly emotionally attached to 3rd party</li> <li>Extreme dependence on the 3rd party for living arrangements, drugs, affection</li> <li>Emotionless, withdrawn posture</li> </ul> |  |
| <b>Physical Signs</b> |  |
| <ul> <li>Unmet health and dental care needs</li> <li>Appears malnourished and dehydrated</li> <li>Branding or tattooing in highly visible areas of body to show other pimps that he/she is owned by another pimp</li> <li>Appears to have been physically and/or sexually abused, physically restrained, confined or tortured</li> <li>Reports an unusually high number of sexual partners</li> <li>Self-inflicted injuries</li> <li>Addiction to substances</li> <li>Chronic medical conditions</li> <li>Multiple, new or recurrent sexually transmitted diseases</li> <li>Presents with injuries from inadequate personal protective equipment in the workplace</li> </ul> |  |
| <b>Lack of Autonomy and Self-Determination</b> |  |
| <ul> <li>Has few or no personal belongings</li> <li>Doesn't control own money, finances and doesn't have a financial/bank account</li> <li>Lack of passport, immigration or identification documents; turned them over to his/her handler, trafficker, employer or another person</li> <li>Is not permitted to speak or must seek permission to speak from 3rd party attending appointment who does all the talking, insists on being present or translating, and overrides the conversation with needs for cosmetic treatment and not overall health care needs</li> <li>Has been renamed to show ownership by trafficker or to attract more buyers</li> </ul> |  |
| <b>Lack of Connectedness, Social Outlets and Long-Range Plans</b> |  |
| <ul> <li>Claims to be just visiting and unable to convey where he/she is living</li> <li>States an unverifiable residential address</li> <li>Doesn't know where they are; lack of knowledge of what city, town or even state he/she is in</li> <li>Loss of sense of time</li> <li>Lacking social contacts outside of handler/trafficker; out of touch with family and friends</li> <li>Doesn't express long-range goals or plans for future</li> <li>Difficulty in explaining what he/she does for fun or socially</li> <li>Doesn't discuss inviting friends over to place of residence</li> </ul> |  |
| <b>Other</b> |  |
| <ul> <li>Age appears falsified or discrepancy between reported and suspected age</li> <li>A large discrepancy in age of victim to trafficker</li> <li>Accompanied by controlling and demanding person</li> <li>Accompanied by third party who is interested in obtaining cosmetic dental work to improve victim's appearance(as in sex trafficking) only and not interested in long-term treatment plan or preventive care</li> <li>Accompanied by third party who offers to pay for all dental work in cash</li> </ul> |  |

\* Adapted from *The Polaris Project. Human Trafficking. Recognize the Signs. 2017. Available at: polarisproject.org/recognize-signs*.

## CONCLUSION

Human trafficking is a global public health problem, and dental professionals have the opportunity to play an important role in identifying and lending support to victims. Given the likelihood that dental teams will encounter victims who are seeking treatment under a variety of circumstance, they should be prepared to identify, respond and refer for intervention. Clinicians should utilize the red flag indicators, screening questions, and specific general and oral health presentations commonly associated with trafficking-related injuries as triggers for interventions. Oral health care is an important component of the interdisciplinary care necessary for addressing trafficking victims' psychological and physical needs.

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Featured Image by STEVANOVICGOWISTOCK/GETTY IMAGES PLUS

From Decisions in Dentistry. August 20175(8)30-33.



Sheryl L. Syme, RDH, MS

Sheryl L Syme, RIM. MS, is an associate professor. director of the Bachelor of Science Degree Completion Program, and director of curriculum management in the Division of Dental Hygiene of the Department of Endodontks, Prosthodontics, and Periodontology at the University of Maryland School of Dentistry in Baltimore. She is also the education director for the Mid-Atlantic PANDA (Prevent Abuse and Neglect through Dental Awareness) Coalition and coauthor of the Abuse and Neglect chapter in Darby's and Walsh's Dental Hygiene Theory and Practice. 4th edition. She can be reached at ssymetbumaryland.edu.



Susan Camardese, RDH, MS

Susan Camardese. RDH. MS. is cofounder and president of the Mid-Atlantic PANDA Coalition. She is a public health dental hygienist at Chase Brexton Health Services in Columbia. Maryland. and coauthored the Abuse and Neglect chapter in Darby's and Walsh's Dental Hygiene Theory and Practice. 4th edition.



Kimberly Mehlman-Orozco, PhD

Kimberly Mehlman-Orozco, PhD. is a founding partner and human trafficking expert witness for Mahn. Mehlman and Associates in Alexandria. Virginia. She is also an adjunct professor in the Department of Criminology. Law and Society at Mason University in Fairfax. Virginia. She has trained both federal and local level law enforcement agents on methodology for identifying geographic patterns of human trafficking prevalence.

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