1
Identification of Human
Trafficking Victims by
Health Professionals
–
•
•
•
Suzanne T Poppema, MD
ARHP Conference
September 21, 2013
21
Looking Beneath the Surface:
Role of Health Care Providers in
Identifying and Helping
Victims of Human Trafficking
NATIONAL SYMPOSIUM ON THE HEALTH NEEDS OF
HUMAN TRAFFICKING VICTIMS
POST-SYMPOSIUM BRIEF
Erin Williamson, M.P.A., M.S.W., Nicole M. Dutch, B.A., and Heather J.
Clawson, Ph.D.
Presentation Overview
•
•
•
•
Understanding human trafficking
Identifying human trafficking victims
Health problems of trafficking victims
Special considerations when working
with trafficking victims
• Support for victims through Trafficking
Victims Protection Act of 2000 (the
TVPA)
Human Trafficking: What Is It?
• Human trafficking is a form of modern-day
slavery
• Victims of trafficking exploited for commercial
sex or labor purposes
• Traffickers use force, fraud or coercion to
achieve exploitation
After drug dealing, human trafficking is tied with the
illegal arms trade as the second largest criminal
industry in the world, and it is the fastest
growing.
Human Trafficking: What Is It?
Sex Trafficking: Commercial sex act induced by force, fraud or
coercion, or in which person performing the act is under age 18.
– Victims can be found working in massage parlors, brothels, strip clubs,
escort services
Labor Trafficking: Using force, fraud or coercion to recruit, harbor,
transport, obtain or employ a person for labor or services in
involuntary servitude, peonage, debt bondage or slavery
– Victims can be found in domestic situations as nannies or maids,
sweatshop factories, janitorial jobs, construction sites, farm work,
restaurants
Crime of trafficking occurs with the exploitation of the victim.
The physical movement of the victim is not a requisite.
The TVPA protects both U.S. citizens and non-citizens.
Human Trafficking:
How Are Victims Trafficked?
• Force, fraud and coercion are methods used by
traffickers to press victims into lives of servitude,
abuse
– Force: Rape, beatings, constraint, confinement
– Fraud: Includes false and deceptive offers of
employment, marriage, better life
– Coercion: Threats of serious harm to, or physical
restraint of, any person; any scheme, plan or
pattern intended to cause victims to believe that
failure to perform an act would result in restraint
against them; or the abuse or threatened abuse of
the legal process.
Human Trafficking:
Who Are Victims?
• Approximately 800,000 to 900,000 victims annually
trafficked across international borders.
• Between 18,000 and 20,000 victims trafficked into
United States annually.
• More than half of victims trafficked into United States
are thought to be children; victims are probably about
equally women and men.
• Victims can be trafficked into the U.S. from anywhere.
Victims have come from, among other places, Africa,
Asia, India, Latin America, Eastern Europe, Russia
and Canada.
Human Trafficking:
Who Are Victims?
• Many victims in the U.S. do not speak English and are unable to
communicate with service providers, police, or others who might
be able to help them.
• Often kept isolated and activities restricted to prevent them from
seeking help.
• May be watched, escorted or guarded by traffickers Traffickers
may “coach” victims to answer questions with cover story about
being wife, student or tourist.
• Victims comply and don’t seek help because of fear
• Within the U.S., both citizens and non-citizens fall prey to
traffickers.
• Purpose for coming to United States and immigration status no
longer issue when determined to be victim of trafficking.
Trafficking Victims: Understanding
Mindset
Frequently victims:
• Do not speak English and are unfamiliar with the U.S. culture
• Confined to room or small space to work, eat, sleep
• Fear, distrust health providers, government, police
– Fear of being deported
• Unaware what is being done to them is a crime
– Do not consider themselves victims
– Blame themselves for their situations
• May develop loyalties, positive feelings toward trafficker as
coping mechanism
– May try to protect trafficker from authorities
• Sometimes victims do not know where they are, because
traffickers frequently move them to escape detection
• Fear for safety of family in home country
Understanding the Health Needs of Trafficking Survivors
Immigrants
Exploited
Workers
Trafficked
Trafficked
women
People
Victims of
Violence,
Torture
Sex
Workers
Zimmerman et al, LSHTM 2003
10
11
Identifying Victims of
Human Trafficking
• Frontline health providers play important role
identifying and helping trafficking victims
• While trafficking is largely hidden social
problem, many victims are in plain sight if you
know what to look for
• Very few places where someone from outside
has opportunity to interact with victim
Identifying Victims of
Human Trafficking
• Is potential victim accompanied by another person who seems
controlling?
• Does person accompanying potential victim insist on giving
information to health providers?
• Can you see or detect any physical abuse?
• Does potential victim seem submissive or fearful?
• Does potential victim have difficulty communicating because of
language or cultural barriers?
• Does potential victim have any identification?
• Is potential victim suffering from common health problems
experienced by trafficking victims?
Case Studies
• A woman kept in domestic servitude in the
United States for several years was rescued
when a neighbor, noticing that she had a
large tumor, offered to take the woman to
the emergency room/health clinic. Because
the health providers asked the right
questions they realized the woman was a
victim of human trafficking. As a result,
they helped the woman escape her situation.
14
13
Case Study
http://www.pssg.gov.bc.ca/octiptraining/index.html
• A construction worker named Philip visits a
community health centre seeking treatment for a
chest infection. While treating him, the doctor and
nurse notice serious bruises on his chest and
forearms.
• They ask him if he was in an accident at his work
at a construction site. He says no, he just tripped
and fell. They leave the topic alone for the
moment, but a few details Philip lets slip about his
14
15
life make them begin to wonder.
Case Study 2
• They find out that he has been living where
he works, at the construction site, for more
than two months, and that he does not have
proper equipment: no helmet or steel-toed
boots.
• After the doctor treats his bruises and gives
him a prescription for his chest infection,
Philip says he’s worried he may not be able
to afford the medication because
15
16
Case Study 2
• he hasn’t been paid yet for his work—and
then he tells them the real story about his
“accident”:
• It turns out that his employer beat him the
day before when the coughing caused by his
chest infection forced him to stop work
early.
• Copyright © 2011 Province of British
16
17
Columbia.
Health Issues Associated with
Victims of Human Trafficking
• Victims suffer from host of physical and
psychological problems stemming from:
–
–
–
–
–
–
–
Inhumane living conditions
Poor sanitation
Inadequate nutrition
Poor personal hygiene
Brutal physical and emotional abuse
Dangerous workplace conditions
General lack of quality medical care
Health Issues Associated with
Victims of Human Trafficking
• Preventive health care virtually non-existent
• Health problems typically not treated in early
stages
– Tend to fester until they become critical,
life-endangering situations
Health care frequently administered
at least initially by unqualified “doctor”
hired by trafficker with little regard for
well-being of “patients” – even less regard for
disease, infection or contamination control
Health Issues Associated with
Victims of Human Trafficking
• Sexually transmitted diseases, HIV/AIDS, pelvic pain, rectal
trauma and urinary difficulties
• Unwanted pregnancy, resulting from rape or prostitution
• Infertility from chronic untreated sexually transmitted infections
or botched or unsafe abortions
• Infections or mutilations caused by unsanitary and dangerous
medical procedures performed by unqualified individuals
• Chronic back, hearing, cardiovascular or respiratory problems
from endless days toiling in dangerous agriculture, sweatshop or
construction conditions
• Weak eyes and other eye problems from working in dimly lit
sweatshops
Health Issues Associated with
Victims of Human Trafficking
• Malnourishment and serious dental problems
– These are especially acute with child trafficking victims who
often suffer from retarded growth and poorly formed or rotted
teeth
• Infectious diseases like tuberculosis
• Undetected or untreated diseases, such as diabetes
or cancer
• Bruises, scars and other signs of physical abuse and
torture
– Sex-industry victims often beaten in areas that will not
damage their outward appearance, like lower back
Health Issues Associated with
Victims of Human Trafficking
• Substance abuse problems or addictions
• Psychological trauma from daily mental abuse and
torture, including depression, stress-related
disorders, disorientation, confusion, phobias and
panic attacks
• Feelings of helplessness, shame, humiliation, shock,
denial or disbelief
• Cultural shock from finding themselves in strange
country
Communicating with Victims of
Human Trafficking
• Before questioning potential trafficking victim, isolate
individual from person accompanying her/him without
raising suspicions
– Individual accompanying patient may be trafficker posing as
spouse, other family member or employer
– Say that ER/health clinic policy is to examine patient alone
• Enlist trusted translator/interpreter who also
understands victim’s cultural needs
– If patient is child, important to enlist help of social services
specialist skilled in interviewing child trafficking or abuse
victims
Communicating with Victims of
Human Trafficking
• For victim’s safety, strict confidentiality is paramount
– Ask questions in safe, confidential and trusting environment
– Limit number of staff members coming in contact with
suspected trafficking victim
• Importance of indirectly and sensitively probing to
determine if person is trafficking victim
– May deny being trafficking victim, so best not to ask direct
questions
– Phrase “trafficking victim” will have no meaning
Communicating with Victims of
Human Trafficking: Questions
• Can you leave your work or job situation if you want?
• When you are not working, can you come and go as you
please?
• Have you been threatened with harm if you try to quit?
• Has anyone threatened your family?
• What are your working or living conditions like?
• Where do you sleep and eat?
• Do you have to ask permission to eat, sleep or go to the
bathroom?
• Is there a lock on your door or windows so you cannot get
out?
Communicating with Victims of
Human Trafficking: Messages
• Gaining victim’s trust important first step in providing
assistance
• Sample messages to convey:
– We are here to help you.
– Our first priority is your safety.
– If you are a victim of trafficking and you cooperate, you will not
be deported.
– We will give you the medical care that you need.
– We can find you a safe place to stay.
– We can help get you what you need.
– We want to make sure what happened to you doesn’t happen
to anyone else.
– You are entitled to assistance. We can help you get
assistance.
– If you are a victim of trafficking, you can receive help to rebuild
your life safely in this country.
Victims of Trafficking
and Their Needs
There are four general areas of victim needs:
• Immediate assistance
– Housing, food, medical, safety and security,
language interpretation and legal services
• Mental health assistance
– Counseling
• Income assistance
– Cash, living assistance
• Legal status
– T visa, immigration, certification
Getting Victims of Human
Trafficking the Help They Need
• If you think you have come in contact with victim of human trafficking,
call National Human Trafficking Resource Center, 1.888.3737.888.
• This hotline will help you:
•
– Determine if you have encountered victims of human trafficking
– Identify local community resources to help victims
– Coordinate with local social service organizations to help protect and
serve victims so they begin process of restoring their lives
For more information on human trafficking visit www.acf.hhs.gov/trafficking.
• Call local police if victim at risk of imminent harm
1.888.3737.888
www.acf.hhs.gov/trafficking
New Virtual Organization
• www.castla.org/heal-trafficking
29
MULTIPURPOSE PREVENTION TECHNOLOGIES (MPTS)
FOR SEXUAL AND REPRODUCTIVE HEALTH
Bethany Young Holt, PhD MPH
Executive Director, CAMI
Reproductive Health 2013
21 September 2013 – Denver, CO
Session Objectives
This session is designed to help you do the following:
 Define multipurpose prevention technologies (MPTs)
 Describe existing MPTs in use globally
 Describe the range of MPT delivery systems in development
 Describe the challenges and timeline for MPTs development
 Provide your input on MPTs that are in development
Global Need… HIV & STIs
 In 2010, 1.8 million people died
of AIDS… in 2009 an estimated
2.6 million become infected with
HIV.1
 Young, married women are the
fastest growing group of HIV+
people worldwide.2
4
 Worldwide, women are 5 times more likely to
get sexually transmitted infections than men.3
 Each day, about 500,000 young people,
mostly women, contract an STI.3
Global Need… family planning
 Each day, close to 800 women in
developing countries die from
complications related to pregnancy
and childbirth.5
 An additional 15 to 20 million women
suffer debilitating consequences of
pregnancy.6
Maternal Mortality Ratio, 2010
8
 222 million women have an unmet need for
modern contraception.7
 There are approximately 80 million unintended
pregnancies in the developing world7
 Resulting in 40 million abortions, 30 million
unplanned births, 10 million miscarriages.7
In the United States
 Nearly half of all pregnancies among
American women are unintended, and
four in ten of these end in abortion.9
 An estimated 750,000 women aged 1519 in US become pregnant annually, of
which over 80% are unintended.10,11
13
 STIs are the most commonly reported
communicable diseases in the US.12
 Of the 18.9 million new cases of STIs
each year in the US, 9.1 million (48%)
occur among 15-24 year olds.12
14
What are Multipurpose Prevention
Technologies (MPTs)?
A single product or strategy, configured for
at least two SRH prevention indications:
 Unintended pregnancy
 HIV
 Other STIs
WHY MPTs?
 Greater efficiency in terms of cost, access and delivery of SRH
prevention products
 Capitalize on the demand in populations using one product
type to achieve uptake and use of a second “product”
MPTs: Historical Precedents
H2O + flouride
The pill + iron
Grains + folic acid
Why do women need MPTs?



Healthy timing & spacing of intended pregnancies
Protection against HIV
Protection against other STIs
MPT products currently available
= Male and female condoms are the only currently
available methods for prevention of multiple SRH risks
MPTs in the Pipeline
Drug
Combinations
Drug/Device
Combinations
Multipurpose
Vaccines
Bacterial
Therapeutics Nanoparticles
Successful products means listening to
what women want…
Technology Filter
X1
Product Prioritization
and Gap analysis
3
Anti-retrovirals &non
ARVs
Candidate
MPTs
Ideal MPT Products
Supported
Complexity of developing MPTs
Mechanism of
Action
INDICATION
Dosage and
Administration
10 MPT IVR
3 On-Demand MPT
2 Barrier MPT
23 HC products
Formulation
10 Single Indication IVR
12 On-Demand HIV Only
2 Injectable HIV Only
2 Lacto-based Products
31 HIV Entry Inhibitors
11 Enzyme Inhibitors
7 Other HIV Inhibitors
29 non-HC products
MPT Product Profile:
Working Group Recommendations
MPT PRODUCTS
HIV/STI Prevention
Contraception
Priorities for
st
1
Generation MPTs
“On Demand”
 Used
around time of
intercourse
 For women who have
intermittent sex or want more
direct control over their
protection
Sustained release
 User-initiated,
does not
require daily action
 Should increase
adherence and
effectiveness
On-Demand Products: Gels, NFDs
Tenofovir Gel (CONRAD)
 1st
proof-of-concept vaginal
microbicide
 Coitally-dependent
 Confirmation trial underway
for 2014
MZL Combo NFD (Pop Council)
 MIV-150
+ Zinc Acetate +
LNG in NFD
 Prevents pregnancy, HIV, HSV2, HPV
 Up to 24-hrs protection
On-Demand Products: Devices +
Active Agents
+ TFV Gel (CONRAD)
SILCS (PATH, CONRAD, NICHD)
“One size fits most” silicone
diaphragm
 Intended for OTC pregnancy
prevention
 5-yr shelf life, re-use up to 3
yrs

SILCS barrier = delivery
device
 Non-hormonal MPT protection:
pregnancy, HIV, HSV2 up to
24 hrs

Sustained Release Devices:
Combination Intravaginal Rings
30-day MZL Combo
(Population Council)
MIV-150 + Zinc
Acetate + LNG
 Demonstrated singleAPI success
 Pregnancy, HIV, HSV2

60-day Dapivirine + LNG
(IPM)
DPV + LNG
 Testing underway,
clinical studies 2013
 Pregnancy, HIV

90-day TFV + LNG
(CONRAD)
TFV + LNG
 Testing underway,
clinical studies 2013
 HIV, HSV2

MPT Target Product Profiles (TPPs)
MPT Product Priority and Gap Analysis
 Priority Indications (Regional Differences):
• Pregnancy + HIV
• HIV + STI
• Pregnancy + STI
 Dosage Forms: “Suite of Products”
• Sustained release (IVR), LA Injectable, On-Demand
 Drugs:
• ARV for HIV, HC for pregnancy, STI specific drugs (GAP!)
• Non-ARV/non-HC options are longer term (GAP!)
 Other Product Attributes:
• Stability, shelf life, safety and efficacy targets, COST, scale-
up, user preferences, adherence potential, market demand…
Single & Multipurpose Vaccines
Today


Single purpose vaccines
(e.g. HPV)
Multipurpose vaccines that
include HBV (e.g. Twinrix)
Future



Multipurpose STI vaccines
(HSV, HIV, Gonorrhea,
Chlamydia, Trichomonos,
other STIs)
Reversible
immunocontraceptives (e.g.
anti-sperm)
What would your patients
want in a multipurpose
vaccine?
MPT Product Development Timeline
PRE-CLINICAL
NWJ Group, LLC
CLINICAL
The Initiative for
Multipurpose Prevention Technologies
Barriers to progress on MPTs
Initiative for Multipurpose
Prevention Technologies (IMPT)
Scientific
Agenda
National & Int’l
Funding Agencies
BMGF, ICMR, IPPF,
USAID, USFDA, US
National Institutes of
Health, WHO, Wellcome
Trust
Acceptability
and Access
Communications
and Advocacy
Secretariat:
part of the Public Health Institute
SRH Policy and
Advocacy Orgs
Biotechnology
Companies & Orgs
AVAC, ARHP,
Guttmacher Institute
Auritec, Mapp
Biopharmaceutical,
Medicines360,
Osel, ReProtect, Teva,
WomanCare Global
Funding
Coordination
Research & Public
Health Orgs
California Family Health
Council, CONRAD, IPM,
Jhpiego, PATH, IPPF,
Population Council,
Public Health Institute,
RTI International
Universities
China, India, Kenya,
Nigeria, South Africa,
UK, USA
MPT: Conclusions and the Future
So Far…
 MPT Products can potentially address major unmet medical
needs for women globally
• Key advantages over current strategies
The IMPT has defined product attributes for an MPT TPP
• Product specific MPT development is ongoing with partners
 The IMPT has defined MPT pipeline priorities and gaps
• Helps set the R&D agenda for the future
Next…
 Informing/interacting with regulatory agencies and local country
stakeholders will be crucial going forward
 Understanding market/commercialization issues for MPT is crucial
to GO/NO GO decision making
 Consensus agreement on product priorities is crucial to achieve
coordinated investment among funding organizations in MPT
Make MPTs a reality!
Multipurpose Vaccines for Sexual and Reproductive Health
Your Insights can help ensure acceptable
and successful MPT development
MULTIPURPOSE
VACCINES FOR
SEXUAL AND
REPRODUCTIVE
HEALTH
Which of the following vaccine combinations do you
Q1
Enterbelieve
Question
would beText
most useful for your clients?
HS
V
(g
en
+H
PV
+H
IV
HS
V
33%
+H
PV
33%
it a
l. .
.
HI
...
s)
+
pe
lh
er
ita
(c)
33%
(g
en
(b)
HSV (genital
herpes) + HIV
(AIDS)
HSV + HIV +
HPV (genital
warts/cervical
cancer)
HSV + HPV
HS
V
(a)
What do you believe is the minimum acceptable
efficacy rate (for all the pathogens targeted) of a
Q2
EnterMPTQuestion
Text
vaccine?
70
+
25%
90
%
–8
9%
25%
9%
–6
50
(d)
25%
9%
(c)
25%
–4
(b)
30 – 49%
50 – 69%
70 – 89%
90% +
30
(a)
Which type of vaccine administration do you
Q3
your clients
Enterbelieve
Question
Textprefer?
50%
n
(n
ee
dl
(b
e-
fre
yp
ro
ea
vid
nd
. ..
er
)
50%
M
uc
os
al
tio
(b)
Injection (by
provider)
Mucosal
(needle-free
and selfadministered)
In
je
c
(a)
How much do you believe most of your clients would
willing to pay for the entire series of an
Q4
Enterbe
Question
Text
injectable MPT vaccine?
$3
00
–
$2
50
–
$2
00
–
$1
50
20%
$2
49
20%
$1
99
20%
$1
49
20%
–
(e)
$1
00
(d)
$9
9
(c)
20%
–
(b)
$50 – $99
$100 – $149
$150 – $199
$200 – $249
$250 – $300
$5
0
(a)
Would adding a reversible contraceptive vaccine to
a multipurpose STI vaccine lead to an overall
Q5
Enterincrease
Question
Text
in uptake by your clients?
33%
di
ffe
re
n
ce
33%
No
(c)
33%
No
(b)
Yes
No
No difference
Ye
s
(a)
Q5
Would adding a reversible contraceptive
vaccine to a multipurpose STI vaccine lead to
an overall increase in uptake by your clients?
(a)
(b)
(c)
Yes
No
No difference
The time for MPTs is now
Acknowledgements
Thanks to the following individuals for
their contributions to this effort:
… and the following organizations
for their critical support:








 Association for Reproductive Health
Professionals
 Bill & Melinda Gates Foundation
 Mary Wohlford Foundation
 Microbicide Trials Network
 National Institutes of Health
 Public Health Institute
 US Agency for International
Development
 Wellcome Trust
Joseph Romano (NWJ Group)
Judy Manning (USAID)
Wayne Shields (ARHP)
Kathryn Stewart (CAMI)
Susan Rosenthal (Columbia U)
Diane Royal (CAMI)
Kevin Whaley (Mapp Biopharmaceutical)
Greg Zimmet (Indian U)
Learn more! www.mpts101.org
Thank you!
Support for this project is made possible by the generous support of the American people
through the United States Agency for International Development (USAID) under the terms of
the HealthTech Cooperative Agreement #AID-OAA-A-11-00051, managed by PATH. The
contents are the responsibility of CAMI/PHI and its partners and do not necessarily reflect the
views of USAID or the US Government.
References
Global Need: HIV & STIs
1. UNAIDS. Global Report: UNAIDS Summary of the AIDS Epidemic, 2010. http://www.unaids.org/globalreport/global_report.htm
2. PATH, UNFPA. Female Condom: A Powerful Tool for Protection. Seattle: UNFPA, PATH; 2006.
3. UNFPA. Reproductive Health: Breaking the Cycle of Sexually Transmitted Infections, 2009. http://www.unfpa.org/rh/stis.htm
4. UNAIDS. 2010: A Global View of HIV Infection. http://www.unaids.org/documents/20101123_2010_hiv_prevalence_map_em.pdf
Global Need: Family Planning
5. WHO. May 2012. Fact Sheet No. 348: Maternal Mortality. Media Centre. http://www.who.int/mediacentre/factsheets/fs348/en/index.html
6. Ashford L. Hidden Suffering: Disabilities From Pregnancy and Childbirth in Less Developed Countries. Population Reference Bureau, 2002.
http://www.prb.org/pdf/HiddenSufferingEng.pdf
7. Singh S. and Darroch J.E. Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012. New York, NY: Guttmacher Institute and
United Nations Population Fund (UNFPA), 2012. http://www.guttmacher.org/pubs/AIU-2012-estimates.pdf
8. WHO. 2010: Maternal Mortality Ratio. http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html
In the United States
9. Finer L.B. and Zolna M.R. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception, 2011: doi:
10.1016/j.contraception.2011.07.013.
10. Kost K., et al. U.S. Teenage pregnancies, births and abortions: National and state trends and trends by race and ethnicity. Guttmacher Institute, 2010.
11. Finer L.B. et al. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 2006:
38(2):90–96.
12. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance, 2009. Atlanta, GA: U.S. Department of Health and Human
Services, 2010.
13. Kost K. Unintended Pregnancy Rates at the State Level: Estimates for 2002, 2004, 2006 and 2008, New York: Guttmacher Institute, 2013.
http://www.guttmacher.org/pubs/StateUP08.pdf
14. Craft C. Sacramento County one of state's hotbeds for sexually transmitted diseases. Sacramento Bee, July 9, 2013.
http://www.sacbee.com/2013/07/19/5577880/sacramento-county-one-of-states.html#storylink=cpy
67
THE BC4U SERVICE MODEL: ACHIEVING
ASTRONOMICAL LARC RATES IN
ADOLESCENTS
STEPHANIE TEAL, MD, MPH
S. ELIZABETH ROMER, ND, FNP-BC
DISCLOSURES
 Dr. Teal has served on Scientific Advisory Boards for
Actavis, Inc and Bayer Healthcare
 Ms. Romer has no potential financial conflicts of
interest
LEARNING OBJECTIVES
 Develop strategies to make LARC placement the default
clinic visit outcome
 Identify unique features of adolescents that impact the
contraceptive initiation visit
 Integrate experiences of other session participants to
improve your own service delivery model
WHAT IS BC4U?
 Adolescent-specific
 Title X clinic with:
 Dedicated schedulers/web appts
 Evening and same-day appts
 Offers same-day IUDs, implants
 and all other FDA approved methods
 Free
 Confidential
All IUDs
and
implants:
100% OFF!!!
STARTING UP
 Hiring committed staff who shared the vision
 Training schedulers, MAs, all support staff
 Supply chain
 Supplies and equipment
 Promotion and outreach
WHAT DOES IT MEAN TO MAKE LARC
INITIATION THE “DEFAULT OUTCOME”
 Assume the device goes in TODAY
 Minimize contraindications to ONLY what is solidly
supported by evidence
 No funny feelings in left toe
 Always have provider available to place any device
 May need to change work schedules, change providers, change
templates
 Address biases
 Have devices available
 Just do it!
LARC UPTAKE: BC4U 2012
1,182
N=1182
1,182
INITIAL
IUD ATTEMPTS
Initial
IUD
insertion
attempts
n = 485 parous
Mean ± SD or %
21.3 ± 2.3
4.2%
6.6%
29.7%
96.4%
26.4%
33.6%
7.4 ± 0.8
73.4%
n = 697 nullips
Age (years)
Race/ethnicity
Black
Hispanic
Mean ± SD or %
20.6 ± 2.7
95.8%
White
N.S.
Other/Mixed/
Not reported
Uterine depth (cm)
LNG-IUS
3.6%
5.1%
14.5%
63.4%
17.0%
7.0 ± 0.8
79.9%
1.1% Ancillary measures
Teal SB, et al Contraception. 2012; 86:291.
PROVIDERS OF INITIAL IUD ATTEMPTS
ADOLESCENCE
 The process of cognitive, psychosocial and
moral growth and development that
transforms dependent children into
independent self-sufficient members of
society
 CHANGE
WHAT MAKES PROVIDERS DREAD
INTERACTIONS WITH ADOLESCENTS?
 Narcissistic, self-
absorbed
 Disrespectful
 Giggling
 Bravado
 Personal invulnerability
 Flip-flopping
 TMI
 Impulsive behavior
 Intensity of behavior
 Discomfort with
adolescent sexuality
 Difficult to interview: 20
questions
WHAT MAKES ADOLESCENTS DREAD
INTERACTIONS WITH PROVIDERS?
 Being judged
 Disrespectful of her decisions
 Minimization of seriousness of her life
 Threat to burgeoning autonomy
 Gulf between our worlds
 Natural alignment with parent
PUTTING IT ALL TOGETHER
Let her try what she thinks she wants
Respect her social networks as information
sources
Work within her framework
DISCUSSION
82