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A Neurology Nurse Practitioner By Day, An Advocate Against Human Trafficking After Hours

Article In Brief

Neurology nurse practitioner Celia McIntosh, DNP, RN, FNP-C, discusses her work as an advocate against human trafficking.

Celia McIntosh, DNP, RN, FNP-C, has always had a passion for advocacy. As a nurse practitioner in the department of neurology at Rochester Regional Health in Rochester, NY, an encounter with a patient who was experiencing suicidal thoughts after a stroke inspired her to develop a protocol for depression screening and treatment in stroke patients—a relatively common occurrence that was under-recognized at the time. She also spent time as a forensic nurse examiner, doing stints in the emergency department working with patients who had experienced rape.

But she realized she had found a calling in advocacy after encountering representatives of the Rochester Regional Coalition Against Human Trafficking (RRCAHT) while walking into work one day. Today, AAN member Dr. McIntosh is the president of RRCAHT.

How did you get involved with RRCAHT?

In 2014, there was a conference at Rochester Regional Health and RRCAHT had a table with educational materials. I stopped and asked, “What is that about?” When I began talking with them, I was dumbfounded. I thought, “That doesn't happen here!” I couldn't wrap my mind around something so horrific. It hit me that I had to learn more about this issue. So I took their flyers home, started attending their meetings and understanding more about human trafficking, and started to do my own research.

That was the same year that the United Nations Office on Drugs and Crime (UNODC) issued its landmark Global Report on Trafficking in Persons. From that report, I found out that 88 percent of victims of human trafficking come in contact with health care providers, but in most cases, the providers never know.

I had been a nurse for 11 years at that point, and I had never received this information in my nursing education or practice. I felt that there must be a lot of other individuals in health care who didn't know what human trafficking was and the intricacies of it. That's what really started me on the journey of wanting to spread more awareness in the community. Then in 2016, I had the opportunity to run for co-chair of RRCAHT, and after a few months, my co-chair stepped down and I became the sole president of the coalition.

What are some of the misconceptions about human trafficking?

It's not like the movie “Taken.” You're not just grabbed off the street. More commonly, it occurs when someone is psychologically manipulating you, developing a relationship with you, grooming you, selling you a dream, and then flipping a switch on you. We have to talk about the social factors that contribute to human trafficking. One of these is homelessness. Traffickers like to target people who are homeless and often approach people at shelters. “Is the shelter closed? I have a place for you to stay,” they may say. People who have experienced abuse as children are also particularly vulnerable to human trafficking, as are people with mental illness or who abuse substances, and members of the LGBTQ+ community who have been stigmatized or ostracized by their families or communities.

And while sexual trafficking makes up the majority of trafficking cases, a significant proportion—40 percent according to the UNODC report—involves labor trafficking. For example, farm workers may come to the US on a work visa, and they can only work for that employer on their visa. If their employer starts mistreating them, not paying them a fair wage, forcing them to sleep in unheated trailers, or put up with other hazardous or unhealthy working conditions, they can have little recourse. The employer can threaten them that if they leave, run away or try to work with someone else, they'll be “out of status” and could be deported.

What are some of the initiatives you've led as president of RRCAHT?

We've put together a PowerPoint training module that has been distributed to physicians, nurses, nurse practitioners, social workers, as well as to faith-based organizations, and the general public. We've also had meetings with the Nurse-Family Partnership (NFP) Program here in Rochester. [NFP is a nationally recognized, evidence-based home visitation program operated by the Monroe County Department of Public Health that improves the health, well-being, and self-sufficiency of low-income, first-time parents and their children.] We talked with their nurses about the risk factors for human trafficking, why certain people are more vulnerable, and its impact as a public health problem. We hold awareness events at health fairs.

For the last four years, we've held an annual proclamation of January 11 as Human Trafficking Awareness Day, meeting with our legislators and elected officials. Last year, we hosted a roundtable discussion on efforts to decriminalize prostitution in New York State, educating participants as to why this would negatively impact victims of trafficking. In 2016, RRCAHT also launched its “Yes, Here” bus campaign in an effort to educate the community about human trafficking in the area.

What have you been able to do to promote public awareness of this issue?

We've done radio shows to talk about this issue, and I've presented at local, regional, and national conferences, such as the University of Toledo's annual Human Trafficking and Social Justice Conference. Last year, I wrote a grant for us to put on our own conference, and we secured almost $15,000 in funding to bring that information to our community on a broader scale, to a bigger audience, and to spread awareness. Rochester is the third poorest city out of 75 of its size, and when you think about the risk factors associated with poverty, traffickers exploit those.

Unfortunately, because of COVID-19, we could not gather, so the conference is on hold. We are connecting with people in different ways, using things like webinars, our social media feeds on Facebook and Twitter, and our website.

What has been the effect of the pandemic on human trafficking?

It's very significant. First of all, there's the wage issue and how individuals are being impacted by changes at the federal level with visas. Because when this hit, a lot of things came to a sudden halt, and contract workers had no alternatives. We are also seeing evictions and increased homelessness, which puts more people at risk for exploitation by traffickers. COVID has led to many more people accessing things like food pantries, so there are fewer resources to spread around. When you have no job and no income and someone is saying that they have food and a place for you to stay, that can look very enticing. Another issue associated with COVID for victims of trafficking is that many community resources were shut down— organizations they could go to be in a safe space, have conversations, and get help. Here in Rochester, we've seen about a 40 percent uptick in calls for victims of domestic violence, which often has a huge overlap with trafficking.

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“I had been a nurse for 11 years at that point, and I had never received this information in my nursing education or practice. I felt that there must be a lot of other individuals in health care who didnt know what human trafficking was and the intricacies of it.”—DR. CELIA MCINTOSH

Some people may assume that clinicians in other specialties, like emergency physicians or family physicians, are more likely than neurologists to see victims of human trafficking in their practices. What is the neurologist's role in helping identify and assist victims of trafficking?

Neurologists very well may see victims of trafficking. A lot of these individuals sustain physical injuries, which include head injuries. Someone may come in with a concussion, for example. People who are trafficked are often strangled or choked, which can put them at increased risk for vertebral dissection. Other common presentations could be migraines and other headaches, or seizures—particularly pseudoseizures. We know that often when you have significant trauma, there are underlying psychiatric symptoms that can manifest in physical ways. And individuals who are victims of trafficking are also not immune to having things like myasthenia gravis or MS or other neurological diseases that anyone can present with. It's a matter of taking a careful history and being observant of things that don't seem right.

What are some of the red flags that neurologists should be looking for that might suggest a patient is a victim of trafficking?

Here are some key factors to look for:

  • Presenting with someone who is talking for them or dominating the conversation. Or if they are not with someone else, they may be constantly on the phone and appearing as if they have to “check in” with someone.
  • Not making eye contact.
  • Appearing anxious or fearful.
  • Not knowing where they are. Traffickers often take victims from state to state to state, so if someone has no sense of what town they are in, that is a potential sign.
  • Evidence of physical abuse.
  • Presenting multiple times with somatic complaints.
  • Talking and responding to questions in a way that seems rehearsed, as if they have a script, and being hesitant about answering certain questions.
  • Being unable to produce identification.
  • Specific tattoos. One of the worst traffickers in New York had required multiple girls to be tattooed with his motto B.A.M.—signifying “by any means”—-on their backs and fingers.
  • If something doesn't make sense and you are concerned, you can call the National Human Trafficking Hotline at 888-373-7888.

What else can neurologists do?

They can work with their hospitals and health systems on institutional responses. Many organizations are developing protocols to help health care providers recognize these and other signs of trafficking. New York State recently passed a law requiring hospitals and health care institutions to do this, and I recently completed the protocols for Rochester Regional Health. HEAL Trafficking, an organization focused on public health response to ending human trafficking and supporting survivors, also has model protocols among their online tools.

Why is this work so important to you?

I've always been passionate about advocacy. Growing up, I figured that would mean going to law school. But working in health care showed me how people can be treated differently sometimes because of their status, whether they're homeless or have a different level of means or look a certain way. The fact that someone will deliberately try to manipulate you into sleeping with multiple men and subject you to physical and psychological abuse, I have a real problem with that and I feel like I have to be a part of doing something about it. I have to bring light to this injustice. I'm not going to be able to save the world overnight, but I can play a role in educating someone who can potentially help an individual who is being trafficked out of this situation.

This work has also inspired me to do more. Prior to getting involved with the coalition, I had done some volunteer nursing work—blood pressure checks and things in different community programs—but not much other than that. But after I began working with RRCAHT, I applied for our police accountability board here in Rochester. I've been on the board for about eight months, and now I am the vice chair.

People saw injustice happening here, and 75 percent of the Rochester community voted to create the board to do something about it. I'm also involved with the Children's Agenda, a group here in Rochester that advocates for evidence-based solutions for the health, education, and success of children, focused on racism and poverty and how they interact with children's issues. I feel drawn to these programs because I feel like I am equipped with the educational and leadership skills to be a small part of making change happen.