[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




 
  EXAMINING H.R. _____, THE TRAFFICKING AWARENESS TRAINING FOR HEALTH 
                            CARE ACT OF 2014

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 11, 2014

                               __________

                           Serial No. 113-173
                           
                           
                           
 
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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

RALPH M. HALL, Texas                 HENRY A. WAXMAN, California
JOE BARTON, Texas                      Ranking Member
  Chairman Emeritus                  JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky               FRANK PALLONE, Jr., New Jersey
JOHN SHIMKUS, Illinois               BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania        ANNA G. ESHOO, California
GREG WALDEN, Oregon                  ELIOT L. ENGEL, New York
LEE TERRY, Nebraska                  GENE GREEN, Texas
MIKE ROGERS, Michigan                DIANA DeGETTE, Colorado
TIM MURPHY, Pennsylvania             LOIS CAPPS, California
MICHAEL C. BURGESS, Texas            MICHAEL F. DOYLE, Pennsylvania
MARSHA BLACKBURN, Tennessee          JANICE D. SCHAKOWSKY, Illinois
  Vice Chairman                      JIM MATHESON, Utah
PHIL GINGREY, Georgia                G.K. BUTTERFIELD, North Carolina
STEVE SCALISE, Louisiana             JOHN BARROW, Georgia
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   DONNA M. CHRISTENSEN, Virgin 
GREGG HARPER, Mississippi            Islands
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BILL CASSIDY, Louisiana              JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky              JERRY McNERNEY, California
PETE OLSON, Texas                    BRUCE L. BRALEY, Iowa
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
CORY GARDNER, Colorado               BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas                  PAUL TONKO, New York
ADAM KINZINGER, Illinois             JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Ohio
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina

                                 _____

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan                LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          JIM MATHESON, Utah
PHIL GINGREY, Georgia                GENE GREEN, Texas
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            JOHN BARROW, Georgia
BILL CASSIDY, Louisiana              DONNA M. CHRISTENSEN, Virgin 
BRETT GUTHRIE, Kentucky                  Islands
H. MORGAN GRIFFITH, Virginia         KATHY CASTOR, Florida
GUS M. BILIRAKIS, Florida            JOHN P. SARBANES, Maryland
RENEE L. ELLMERS, North Carolina     HENRY A. WAXMAN, California (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)

                                  (ii)
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     1
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, prepared statement...................................    68

                               Witnesses

Katherine Chon, Senior Advisor on Trafficking in Persons, 
  Administration for Children and Families, Department of Health 
  and Human Services.............................................    10
    Prepared statement...........................................    12
    Additional information for the record \1\
Vednita Carter, Founder and Executive Director, Breaking Free....    24
    Prepared statement...........................................    27
Laura J. Lederer, Director, Bastian Center for the Study of Human 
  Trafficking, Indiana Wesleyan University.......................    30
    Prepared statement...........................................    33
Hanni Stoklosa, Emergency Physician, Brigham and Women's Hospital    37
    Prepared statement...........................................    39
Kenneth P. Miller, President, American Association of Nurse 
  Practitioners..................................................    43
    Prepared statement...........................................    45

                           Submitted Material

H.R. 5411, the Trafficking Awareness Training for Health Care Act 
  of 2014, submitted by Mr. Pitts................................     3

----------
\1\ The President's Advisory Council on Faith-based and 
  Neighborhood Partnerships report ``Building Partnerships to 
  Eradicate Modern-Day Slavery'' is available at http://
  docs.house.gov/meetings/IF/IF14/20140911/102647/HHRG-113-IF14-
  Wstate-ChonK-20140911-SD005.pdf.


   EXAMINING H.R. ----------, THE TRAFFICKING AWARENESS TRAINING FOR 
                        HEALTH CARE ACT OF 2014

                              ----------                              


                      THURSDAY, SEPTEMBER 11, 2014

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., in 
room 2123, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Burgess, Ellmers, 
Pallone, Green, and Barrow.
    Staff present: Leighton Brown, Press Assistant; Brenda 
Destro, Professional Staff Member, Health; Sydne Harwick, 
Legislative Clerk; Katie Novaria, Professional Staff Member, 
Health; Tim Pataki, Professional Staff Member; Heidi Stirrup, 
Policy Coordinator, Health; Ziky Ababiya, Democratic Staff 
Assistant; and Hannah Green, Democratic Policy Analyst.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order.
    The Chair will recognize himself for an opening statement.
    Today's hearing focuses on H.R. 5411, The Trafficking 
Awareness Training for Health Care Act of 2014. The bill would 
support the development of evidence-based best practices for 
healthcare providers to identify and assist victims of human 
trafficking. Healthcare providers are among the few 
professionals who have the opportunity to interact with 
trafficked women and girls.
    Because of unusual House scheduling conflicts today, we had 
to delay the start of today's hearing. And, therefore, we will 
dispense with members' oral opening statements. However, 
members' full written statements will be included in the 
record.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The subcommittee will come to order.
    The Chair will recognize himself for an opening statement.
    Trafficking is an issue that many people believe only 
happens abroad, in a Third World country, not in America. But 
trafficking is happening in our own backyard and at an alarming 
rate.
    The United States has become one of the largest markets for 
trafficking with profits in the billions of dollars. As a 
father and a grandparent, this is alarming to know that so many 
women and children are at risk. Although it is important for 
Americans to become more aware of this issue, awareness must be 
accompanied by action.
    I would like to commend my colleague from North Carolina, 
Renee Ellmers, for her concern for the women and children 
involved in this illegal and harmful industry and for proposing 
H.R. 5411, the Trafficking Awareness Training for Health Care 
Act of 2014.
    The bill would support the development of evidence-based 
best practices for healthcare providers to identify and assist 
victims of human trafficking. Health care providers are among 
the few professionals who have the opportunity to interact with 
trafficked women and girls. Placed in this unique and critical 
position, health care workers require heightened skills to help 
these women and girls.
    Health care providers can often interact with victims while 
they are still in captivity. One study found that 28 percent of 
trafficked women saw a health care professional while being 
held captive. Data shows that these victims use emergency room 
and health centers for their care. When providers are trained 
about human trafficking, they have the knowledge and skills to 
provide assistance that can lead to improved care and even 
rescue.
    I would like to welcome all of our witnesses here today. We 
look forward to learning from your expertise and experience.

    [H.R. 5411 follows:]
    
    
 
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    Mr. Pitts. On our first panel today, we have Ms. Katherine 
Chon, a senior policy advisor at the Administration for 
Children and Families at the Department of Health and Human 
Services.
    And I understand that Ms. Chon must leave by 10:30 today 
for the airport. So to maximize members' opportunities for 
questions of Ms. Chon, I will ask her to please summarize her 
statement in a few minutes.
    And, with that, Ms. Chon, you are recognized. You may 
begin.

 STATEMENT OF KATHERINE CHON, SENIOR ADVISOR ON TRAFFICKING IN 
 PERSONS, ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT 
                  OF HEALTH AND HUMAN SERVICES

    Ms. Chon. Chairman Pitts, Ranking Member Pallone, and 
members of the subcommittee, thank you for inviting me to share 
with you the Department of Health and Human Services' work to 
prevent and end human trafficking in all of its forms.
    HHS recognizes that human trafficking is not only a violent 
crime, but it is also a global health problem. The goals of The 
Trafficking Awareness Training for Health Care Act of 2014 
would complement HHS's anti-trafficking efforts to build a 
capacity of first responders to identify and serve victims of 
human trafficking.
    In our ongoing engagement with healthcare providers, this 
week HHS started a series of our pilot SOAR to Health and 
Wellness Training for Health Care Professionals, in which SOAR 
stands for Stop, Observe, Ask, and Respond to human 
trafficking.
    This training seeks to increase knowledge on the diversity 
of human trafficking, identify indicators, utilize trauma-
informed care, and connect with local and national service 
referral resources for trafficking victims.
    We are partnering with local hospitals and community 
clinics in Atlanta, Boston, Houston, Oakland, and Williston and 
New Town, North Dakota, for the trainings, which will be 
evaluated later this fall.
    While the SOAR trainings currently target healthcare 
providers through hospitals and community clinics, the bill 
broadens the reach of training efforts to health professions 
schools.
    In addition to accredited schools of medicine and nursing, 
we recommend dental and social work schools as important target 
audiences because research has shown that victims of 
trafficking have encountered dentists and hospital- and clinic-
based social workers are often responsible for managing the 
follow-up services once a victim has been identified.
    The bill also references evidence-based practices. Since 
there is little evidence-based research specifically on the 
intersection of the healthcare system and human trafficking, 
the anti-trafficking fields may be able to adapt lessons 
learned from efforts in related issue areas, including the 
treatment of domestic violence and sexual assault victims in 
healthcare settings.
    Additional opportunities for healthcare engagement include 
building the capacity of public health professionals to help 
prevent human trafficking, including interventions like the 
John schools, which provide information to purchasers of 
commercial sex who have been arrested and then participate in 
educational programs on the health and behavioral health 
consequences of their actions.
    The Administration looks forward to working with each of 
you to build the capacity of healthcare professionals to 
address the needs of victims of human trafficking.
    Again, thank you for the opportunity to testify today. And 
I would be happy to answer any questions.
    [The prepared statement of Ms. Chon follows:]
    
    
 
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    [Additional information submitted by Ms. Chon is available 
at http://docs.house.gov/meetings/IF/IF14/20140911/102647/HHRG-
113-IF14-Wstate-ChonK-20140911-SD005.pdf.]
    Mr. Pitts. Thank you.
    We will begin the questioning. I will recognize myself 5 
minutes for that purpose.
    Ms. Chon, according to the Compendium of State Statutes and 
Policies on Domestic Violence and Health Care, which was funded 
by HHS, it states that, ``The goals potentially served by 
mandatory reporting include enhancing patient safety, improving 
healthcare providers' response to domestic violence, holding 
batterers accountable, and improving domestic violence data 
collection and documentation. However, upon closer examination, 
it becomes apparent that mandatory reporting does not 
necessarily accomplish these goals.''
    This statement seems to discourage mandatory reporting by 
healthcare workers. Is that the position of HHS? Is there 
research to support this position?
    Ms. Chon. So I am less familiar with the mandatory 
reporting guidelines around domestic violence. But one thing 
that we have heard from healthcare providers specific to human 
trafficking is that there have been concerns--or questions from 
healthcare providers on reporting requirements balanced with 
HIPAA regulations when it comes to identifying victims of human 
trafficking.
    And so what we are encouraging in our SOAR to Health and 
Wellness training is being familiar with HIPAA requirements but 
also familiar with the local and State statutes around 
mandatory reporting and the healthcare institutions' protocols 
around reporting.
    And, universally, though, we do encourage identifying 
referrals for follow-up social services within the context of 
institution and State and local guidelines as well as Federal.
    Mr. Pitts. Well, that statement seems to discourage 
mandatory reporting by healthcare workers.
    Does that or should that position apply to human 
trafficking?
    Ms. Chon. Well, in terms of mandatory reporting for human 
trafficking, part of it depends on the type of human 
trafficking that a healthcare provider may come across.
    So for victims of child sex trafficking, for example, in 
many States, they are also victims of child abuse, according to 
the State laws, and there are very strict mandatory reporting 
guidelines there.
    In our SOAR to Health and Wellness training, we do go over 
the specific situations in which mandatory reporting would be 
required by law.
    Mr. Pitts. Can you explain what the stop, observe, ask, 
respond to human trafficking in the SOAR training program 
entails, how the training was developed and how the cities 
participating in the pilot were chosen.
    Ms. Chon. Sure. This training is part of one of our many 
commitments in the Federal Strategic Action Plan on services to 
victims of human trafficking. It is an interagency plan, which 
HHS co-chaired with the Departments of Justice and Homeland 
Security.
    And during the public comment process, the anti-trafficking 
field called for increased training for healthcare providers. 
So we identified and formed a national technical working group 
of subject matter experts, including many healthcare 
professionals across a wide spectrum of specialties that have 
experience in training healthcare providers.
    We also had service providers and survivors of human 
trafficking inform the training. It went through Federal 
interagency review and was based on a literature review as 
well.
    Because this is a pilot, we selected five sites in areas 
where we could develop strong partnerships with local 
stakeholders and healthcare providers who were already 
experienced in responding to this issue. So Boston, Oakland, 
Atlanta, and Houston were chosen for those reasons.
    And then New Town and Williston, North Dakota, were chosen 
because there were concerns around the increase in various 
forms of violent crimes, including human trafficking, and the 
need for the healthcare system to receive training to identify 
and respond to a relatively new issue that they felt they were 
seeing in that area.
    Mr. Pitts. Can you explain how HHS was involved in the 
development of the Federal Strategic Action Plan on services 
for human trafficking in the United States? And what goals has 
HHS set in the Strategic Action Plan?
    Ms. Chon. The Strategic Action Plan has four primary goals 
set not just by HHS, but through a collection of more than a 
dozen Federal agencies and partners. It is available online. We 
would be happy to also provide a copy of it as well.
    And, as I mentioned, we co-chaired this process with the 
Departments of Justice and Homeland Security. The draft plan 
was based on a number of community listening sessions across 
the country, national calls as listening sessions, as well as 
literature review.
    And the draft was released for public comment last spring. 
And then Federal agencies reviewed the public comments 
throughout the summer and fall, finalized it, and then the 
final version was released this January.
    Mr. Pitts. The Chair thanks the gentlelady.
    Now yields to the ranking member, Mr. Pallone, for 5 
minutes of questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    Last week I had the opportunity to visit the U.S.-Mexican 
border, and the Administration for Children and Families plays 
an important role there, providing critical health and welfare 
services to the unaccompanied children who cross that border 
every day.
    We all know that the unprecedented number of unaccompanied 
minors have arrived in the U.S. and needed ACF's services this 
year. And Congress clearly has the responsibility to ensure 
that this agency has the resources that it needs to do this 
work.
    We don't want the Administration for Children and Families 
to be forced to reallocate funds from other important programs, 
such as the ones we have heard about this morning.
    So can you just discuss the importance of providing 
adequate funding for the Administration for Children and 
Families programs to address the needs of both domestic and 
foreign victims of human trafficking?
    And in its fiscal year 2015 budget, ACF proposed an 
increase of $8.2 million to specifically assist domestic 
victims of human trafficking. Can you comment on the type of 
work the ACF plans to do with that money?
    Ms. Chon. Sure. Well, the good news is we have not had to 
reallocate any of our anti-trafficking funds to address some of 
the unaccompanied minor needs that have risen over the past 
year.
    In terms of the budget requests, the increase in funding 
will allow HHS to serve victims of all forms of trafficking, so 
foreign nationals as well as U.S. citizens and lawful permanent 
residents.
    Pretty much over the last decade or so, the budget on 
addressing human trafficking has been fixed around $10 million, 
primarily going to serve foreign national victims of 
trafficking.
    In this current fiscal year, we received an increase in 
appropriations, which gave us enough to provide demonstration 
grants to start serving domestic victims of trafficking, so 
U.S. citizens and lawful permanent residents.
    And so what we intend to do, if there is a further increase 
in the budget, is to bring parity at least in the budget that 
goes to serve domestic victims to match up the budget that has 
been going to serve foreign national victims.
    Mr. Pallone. Thanks.
    I also wanted to hear more about the SOAR for Health and 
Wellness initiative and the pilot trainings that are beginning 
this week.
    So let me ask what kind of interest you have seen from the 
communities that are conducting pilot training over the next 
few weeks.
    And after participants complete the pilot trainings, what 
kind of evaluations do you have planned? And what do you plan 
to use these evaluations for to think about the future of the 
SOAR program?
    Ms. Chon. Sure. So there has been significant interest in 
the specific pilot locations. Registrations, we have been 
meeting our goals for this pilot program. We were targeting 
about 45 participants per site. And in some sites, like in 
North Dakota and Houston, there are multiple trainings that are 
being held.
    And it is not just the pilot sites, but we are hearing from 
other communities. Healthcare providers are asking for 
additional resources on training and technical assistance, 
which HHS partly provides through our National Human 
Trafficking Resource Center. Healthcare providers can access 
that at any point.
    Then, in terms of the evaluation, there is a pre- and post-
test for this training, a 3-month evaluation survey, and a 
subset of the participants will participate in qualitative 
surveys as well. We will release the findings of the evaluation 
next spring.
    Mr. Pallone. All right. Earlier this year the Departments 
of Justice, Homeland Security, Health and Human Services 
released a Federal Strategic Action Plan on Services to Victims 
of Human Trafficking in the U.S., and it outlines a number of 
specific actions that different Federal agencies are going to 
take.
    I understand you were involved in the development of this 
plan. What types of comments did you receive from healthcare 
professionals during this process regarding the need to improve 
the healthcare system's response to victims of human 
trafficking?
    Ms. Chon. The overwhelming response that we received in the 
public comment process from healthcare providers was a need for 
additional training and resources, especially if it could be in 
some standardized way and, also, tailored to the specific 
healthcare professions. We also heard comments on having 
screening tools, especially if they could be validated and be 
evidence-based.
    And the type of training that we are providing is different 
from a longer-term curriculum that could be available through 
educational institutions, but we also heard the importance of 
developing skills through curriculum-based efforts in 
educational institutions.
    Mr. Pallone. All right. Thanks.
    I just wanted to say, with regard to the SOAR training, I 
am glad that HHS has evaluation steps in place to assess the 
effectiveness of the pilot program, and I think this work would 
provide helpful feedback as we think about what role Congress 
and the Federal Government can play in assisting the healthcare 
community to respond to the needs of trafficking victims.
    So thanks again.
    And thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    And I now recognize the gentlelady from North Carolina, 
Mrs. Ellmers, for 5 minutes for questions.
    Mrs. Ellmers. Thank you, Mr. Chairman.
    And thank you, Ms. Chon, for being with us today. I know 
you have limited time, so I will try to get through my time so 
that we can allow anyone else for questions.
    First of all, I want to say thank you for what you are 
doing, and the SOAR program sounds like we are moving forward 
on a really good HHS initiative.
    We feel very strongly that we want to expand that, and we 
want to make sure that we are reaching out and including our 
education for medical students and nurses. And that really has 
to do with what we are trying to achieve here with the bill 
that we have.
    And, of course, as you know, funding is an issue. We want 
to make sure that there is adequate funding for this project.
    I was wondering if you could comment from that perspective 
on some funds that are available through HHS, the Prevention 
and Public Health Fund, or the PPHF, which basically helps to 
fund innovative projects and outreach.
    I believe that this is one of those areas that--especially 
when we are moving forward with health care--could be a 
positive funding source through HHS that is already there and 
call on Congress to appropriate funds to it.
    Would you like to comment on that?
    Ms. Chon. Sure. In terms of my knowledge of those 
particular funds, I don't believe they have been used for anti-
trafficking training purposes in the past. But I certainly will 
ask the appropriate divisions within HHS how those funds could 
be used for these purposes and then would be happy to get back 
to you on those possibilities.
    Mrs. Ellmers. Great. That would be great if you could get 
back to the committee on the response to that. Because I think, 
as we are moving forward, we would like for this to move as 
quickly as possible. And, you know, we, too, have suggested a 
pilot program with feedback so that we know what is working and 
what isn't.
    I think the training and the education component of it for 
our medical students and our nurses so that they are being 
exposed to this information--one of the things that I found 
over time that is so vital is that many people do not realize 
this is happening here in the United States and that this is 
something that we have to make sure that our healthcare 
providers are understanding and aware of.
    I will yield back.
    I just, again, want to thank you for being here today and 
thank you for sharing your information, and I am looking 
forward to working together on this.
    Ms. Chon. Thank you.
    Mrs. Ellmers. I yield back.
    Mr. Pitts. The Chair thanks the gentlelady.
    I now recognize the gentleman from Georgia, Mr. Barrow, 5 
minutes of questions.
    Mr. Barrow. No questions.
    Mr. Pitts. The Chair recognizes the vice chairman of the 
subcommittee, Dr. Burgess, for 5 minutes of questions.
    Mr. Burgess. Thank you, Mr. Chairman. I apologize for being 
late. There is a lot going on this morning.
    Ms. Chon, thank you for being here. Your agency is one that 
has perhaps come to the attention of this subcommittee a great 
deal more over the last 6 months for a variety of reasons.
    But as we are here today to discuss the prevention of human 
trafficking, I seem to detect that there is a system of best 
practices with evidence-based research and a system of 
promising practices.
    Could you help me understand a little bit the differences 
between the two and why you favor one over the other?
    Ms. Chon. Well, in the scientific community, there is 
always a prioritization around evidence-based practices--so, 
for example, the reason why we put funding into evaluating our 
trainings was because we wanted to have the evidence that the 
training was impactful and met the goals that we set out for 
it, as opposed to best practices or promising or emerging 
practices are those practices that seem to have impact, but 
there have not yet been rigorous evaluation just because the 
research funding wasn't there.
    Mr. Burgess. Well, what population of providers--or 
professionals are you likely to train in the program?
    Ms. Chon. So it is healthcare providers across the spectrum 
from doctors, nurses, dentists, mental health providers, 
clinical social workers, school-based nurses as well because 
they truly are at the frontlines of early identification and, 
also, prevention of human trafficking so that the problem 
doesn't happen in the first place.
    Mr. Burgess. Might I just gently suggest that perhaps you 
could talk to professionals who are in the Office of Refugee 
Relocation, who are also under the Administration of Children 
and Families?
    Because it seems to be missing from some of the hearings 
and briefings we have had on the issue of the unaccompanied 
minors in the lower Rio Grande Valley in my State of Texas.
    In fact, your physician--and, unfortunately, a physician 
was only hired by ORR in May of this year, even with the 
understanding that the problem was tumultuous and growing for 
several months before that. And your doctor reported to us that 
they only investigated cases of sexual assault if the victims 
so self-identified. Of course, these are children that we are 
talking about who are coming into these centers.
    In the State of Texas, it is a reportable crime. I am a 
physician. I was required by law to report to State authorities 
if I thought a child had been abused, let alone was a victim of 
sexual assault. But I was required by law and, if I didn't 
report it, I was in trouble.
    And, yet, you have these children streaming across the Rio 
Grande River as unaccompanied minors, giving themselves up when 
they get across into Texas, taken into centers, evaluated by 
sometimes DMAT teams. And although they do great work, the 
level of training you have got to wonder about. ORR had just 
hired a doctor right before the summer started and, yet, they 
were only investigating cases where a child said, ``Yes. I was 
a victim.''
    And I was down in those intake centers. You would have 
groups of kids sitting on a cement bench, a group of little 5-
year-old boys--I have got a 5-year-old grandson. I know how 
hard it is to get a 5-year-old to sit still--five 5-year-old 
boys just sitting on this bench stone-still, staring into 
space. That is not normal. That is not normal behavior for a 5-
year-old.
    The cell was holding what looked like a class of third-
grade girls except, yes, you realized they were all brought 
there or had turned themselves in. And these people had gotten 
across the entire country of Mexico through the deserts and the 
jungles and the difficulties by coyotes, who are human 
traffickers.
    Why aren't they further investigated? And when those cases 
are found, why are they not reported to State authorities so 
someone can go after the people who are the perpetrators and 
stop this problem at least--if not once and for all, a least 
have a better handle on starting it?
    We are enablers right now, as far as I can see. We are co-
dependents with the child traffickers. And it is not a pretty 
story and does not reflect well on your agency. It does not 
reflect well on the Office of Refugee Resettlement. And it 
needs to stop.
    Thank you, Mr. Chairman. I will yield back my time.
    You may respond if you wish.
    Mr. Pitts. Yes, please.
    Ms. Chon. I think we have the same goals in mind in terms 
of protection for these unaccompanied minors. And I thank you 
for your passion and your concern for this population.
    The Office of Refugee Resettlement, they are a part of a 
departmental working group on human trafficking, and I will 
learn more about what their practices are on the health piece 
in their screening for trafficking.
    Mr. Burgess. Let me just provide you some information. 
Every young woman or child, girl, who's brought into the center 
over the age of 10 is given a pregnancy test. I presume there 
is a reason for that, because they think something might have 
happened during this long journey up here. But then they are 
not further queried about the possibility of sexual assault.
    It is sort of like we are indifferent to the fact that 
these children may have been assaulted on the way up here. We 
are never going to be able to stop the bad guys if we don't do 
the fundamental police work. And your agency is sort of the tip 
of the spear there. That is where it should be happening, and, 
unfortunately, it is not.
    Again, thank you, Mr. Chairman, for the indulgence.
    Mr. Pitts. The Chair thanks the gentleman and thanks the 
witness for answering all your questions.
    We know that you have to leave to catch a plane. We will 
send follow-up questions. And I know other members will have 
questions in writing to you. We will ask that you please 
respond promptly.
    Ms. Chon. Thank you very much.
    Mr. Pitts. Thank you very much, Ms. Chon, for your time.
    And so we will dismiss our first panel and introduce the 
second panel at this time.
    On our second panel we have--and if the staff can set that 
up and I will introduce them in the order of their 
presentation--first, Ms. Vednita Carter, Founder and Executive 
Director of Breaking Free. Then we have Ms. Laura Lederer, 
Director of the Bastian Center for the Study of Human 
Trafficking, Indiana Wesleyan University. Then we have Dr. 
Hanni Stoklosa, emergency physician, Brigham and Women's 
Hospital, and, finally, Dr. Ken Miller, President, American 
Association of Nurse Practitioners.
    So if you will take your seats. Thank you all for coming. 
Your written testimony will made a part of the record. You will 
each be given 5 minutes to summarize your testimony.
    And, Ms. Carter, we will start with you. You are recognized 
for 5 minutes.

 STATEMENTS OF VEDNITA CARTER, FOUNDER AND EXECUTIVE DIRECTOR, 
 BREAKING FREE; LAURA J. LEDERER, DIRECTOR, BASTIAN CENTER FOR 
 THE STUDY OF HUMAN TRAFFICKING, INDIANA WESLEYAN UNIVERSITY; 
   HANNI STOKLOSA, EMERGENCY PHYSICIAN, BRIGHAM AND WOMEN'S 
HOSPITAL; KENNETH P. MILLER, PRESIDENT, AMERICAN ASSOCIATION OF 
                      NURSE PRACTITIONERS

                  STATEMENT OF VEDNITA CARTER

    Ms. Carter. Chairman Pitts, Representative Ellmers and 
distinguished members of the committee----
    Mr. Pitts. If you can press that button. Pull it up close 
so the light is on. Thank you.
    Ms. Carter. Chairman Pitts, Representative Ellmers, and 
distinguished members of the committee, thank you for inviting 
me to testify today to support this groundbreaking bill for the 
training of healthcare professionals to better work with 
victims of human trafficking.
    My name is Vednita Carter. I am a survivor of sexual 
exploitation. I am also the founder and executive director of 
Breaking Free, a nonprofit agency in St. Paul, Minnesota.
    Breaking Free's mission is to educate and provide services 
to women and girls who have been victims of abuse and sexual 
exploitation and need assistance escaping violence in their 
lives.
    Breaking Free is a survivor-led organization and provides 
services to more than 500 victims each year. In the case of 
virtually every sex-trafficking victim we have worked with, 
they were recruited, coerced, defrauded, or forced into 
prostitution.
    Once girls and women are involved in the life of sex 
trafficking, it is extraordinarily difficult for them to 
escape. We can never forget that sex trafficking is modern-day 
slavery.
    Sex trafficking causes tremendous trauma for victims from 
the physical abuse, emotional abuse, sexual abuse, kidnapping, 
and torture they have experienced. It is a terrifying and 
dangerous life.
    83 percent of our clients at Breaking Free were assaulted 
with a deadly weapon. 57 percent were kidnapped before they 
escaped sex trafficking. 86 percent suffer from some type of 
emotional, physical, or mental disability. 71 percent of the 
victims we serve suffer from post-traumatic stress disorder.
    One survivor's story illustrates some of the health issues 
victims of sex trafficking face. As she told me, ``I was 
trafficked when I was 11 years old by my foster mother, who let 
her boyfriend sell us to other men. By the time I was 12, I had 
a pimp. During this time, I was beaten, burned, raped, and 
assaulted. Sometimes I went to a local neighborhood health 
clinic to be treated, but no one ever asked me what had 
happened to me. And, if they did, I lied because I was afraid 
of my pimp. I had severe depression, anxiety, paranoia, and 
mental health issues, even after I became free. I got pregnant 
six times and had six abortions during this time. I had severe 
scar tissue from these abortions because there was no follow-up 
care. In a couple of cases, I had bad infections, so bad that I 
eventually had to have a hysterectomy. To this day, I have 
physical, mental, and emotional issues as a result of that time 
on the street.''
    Another survivor told me, ``I was beaten, strangled, 
kicked, punched, raped, and hit on the head by my pimp. I 
wasn't able to escape until I was diagnosed with cervical 
cancer and, since then, I have been battling serious physical 
and mental health problems, including headaches, shortness of 
breath, bronchitis, chest pain, chlamydia, vaginal infections, 
and urinary tract infections. I also suffer from depression, 
anxiety, and panic attacks. I attempted suicide several 
times.''
    All too often victims of sex trafficking slip through the 
cracks of our medical system. Without appropriate training, 
health professionals are not able to put the pieces of the 
puzzle together to see that the woman or girl in their 
examination room is a sex-trafficking victim, or if the 
professional is able to see the signs, she or he doesn't know 
how to talk to a victim without shaming or retraumatizing her, 
or the professional may be unaware of community resources to 
help the victim.
    Healthcare professionals are in an excellent position to 
identify and help victims, but they need coordinated, evidence-
based, and trauma-informed training to be able to do so.
    The Trafficking Awareness Training for Health Care Act of 
2014 offers the medical community the opportunity to develop 
best practices for identifying and caring for victims and the 
opportunity to help thousands of victims in our Nation break 
free.
    Thank you.
    [The prepared statement of Ms. Carter follows:]
   
 
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    Mr. Pitts. The Chair thanks the gentlelady.
    Now recognizes Ms. Lederer, 5 minutes for opening 
statement.

                 STATEMENT OF LAURA J. LEDERER

    Ms. Lederer. Thank you, Mr. Chairman, and members of the 
committee. Thank you for the invitation today to testify and 
for calling this hearing to address the health effects of human 
trafficking and the need for training for the healthcare 
provider sector.
    Over the last decade, we have looked at human trafficking 
as a human rights abuse and as a criminal justice problem, but 
in the past 5 years, it has become clear that human trafficking 
also has serious public and private health consequences and 
that we need public policy and programmatic responses to train 
healthcare providers to identify victims and to respond 
appropriately.
    Today I want to share with you the preliminary findings 
from a series of focus groups we conducted with domestic 
survivors of sex trafficking around the country. These focus 
groups provide evidence that women and children who are 
trafficked into prostitution are physically, mentally, 
emotionally devastated by the crime and this devastation is 
lasting with illnesses, injuries, and impairments starting 
during trafficking, but lasting often years longer.
    The full set of findings in charts and tables is available 
in my written testimony. I am only going to outline the basic 
findings in my testimony here today.
    Survivors suffer tremendously, virtually without exception. 
In our study, 99.1 percent reported that they had at least one 
physical health problem during trafficking, and the majority 
reported dozens of health issues ranging from neurological, 
cardiovascular, respiratory, gastrointestinal, gynecological, 
dental, and dermatological problems.
    Survivors were also overwhelmingly traumatized not only 
physically, but mentally. The brutal treatment they endured 
created ongoing psychological and mental conditions in many 
victims and also exploited existing mental instability in 
others.
    98.1 percent reported at least one psychological issue 
during their captivity, with an average of more than a dozen 
psychological health problems indicated, including depression, 
flashbacks, panic attacks, helplessness, hyper-alertness, 
disassociation, depersonalization, suicidal ideation, attempted 
suicide, post-traumatic stress disorder.
    Not surprisingly, survivors also reported significant 
numbers of reproductive health problems. More than two-thirds 
of the survivors we talked to contracted some form of sexually 
transmitted disease or infection, some STD or STI, including 
gonorrhea, syphilis, herpes, or chlamydia.
    Survivors also reported many issues around pregnancy. 71.2 
of the survivors we talked to reported at least one pregnancy 
while being trafficked. 21.2 percent reported five or more 
pregnancies. 57.7 percent said they had at least one 
miscarriage. 29 percent said they had more than one miscarriage 
while being trafficked. 55.2 percent reported at least one 
abortion, with 30 percent reporting multiple abortions during 
the time that they were trafficked.
    The prevalence of forced abortion is an especially 
disturbing trend in sex trafficking. Prior research has noted 
the occurrence of forced abortion in victims of sex trafficking 
outside the United States, but our survivors indicated that 
they often did not elect to have abortions.
    More than half of those who answered the question indicated 
that their abortions were forced upon them. In addition, many 
more said they felt forced to choose abortion by the 
circumstance of being trafficked.
    ``How can I take care of my baby when he''--her pimp--
``forced me out on the street every night to make money?,'' one 
victim noted. Another said, ``In most of my six abortions, I 
was under serious pressure from my pimp to abort the babies.''
    Notably, the phenomenon of forced abortion in sex 
trafficking transcends the political boundaries of the abortion 
debate. It violates both the pro-life belief that abortion 
takes an innocent life and the pro-choice ideal of a woman's 
freedom to make her own reproductive choices.
    Survivors were also the victims of violence and abuse at 
the hands of their traffickers. 95.1 percent in our study 
experienced some kind of violence or abuse, as Vednita said, 
including being shot, strangled, burned, kicked, punched, 
beaten, stabbed, raped, penetrated with a foreign object.
    Survivors also reported threats, intimidation, verbal 
abuse, and humiliation. Violence was the rule rather than the 
exception in trafficking. As one survivor said, ``My pimp had 
his girls out on the street every night. It was either you made 
the quota of money for him or you got beaten.''
    Many survivors reported being dependent upon drugs and 
alcohol while they were being trafficked either because the 
substances were forced on them as a control mechanism by their 
traffickers or because the substance abuse was a means of 
coping with their dire circumstances.
    84.3 percent reported use or abuse of drugs, alcohol, or 
both during the time they were trafficked, and the most common 
substances mentioned were alcohol, marijuana, cocaine, crack 
cocaine, Ecstasy, and heroin.
    Perhaps the most shocking finding of our study was that 
87.8 percent of our survivors had sought medical care during 
the time that they were trafficked. The most frequently 
reported treatment site was the hospital emergency room, with 
63.3 percent saying that they sought health care there.
    Survivors also had significant contact with healthcare 
clinics--that is 57.1 percent--including Planned Parenthood, 
urgent care clinics, women's clinics, and neighborhood clinics, 
in that order.
    So, clearly, health providers are first responders and they 
have a unique opportunity to communicate with and to intervene 
on behalf of victims. And for this reason healthcare providers 
must be aware of the signs of trafficking in order to identify 
victims.
    An important part of this training will be to help health 
providers understand the coercive dynamic of trafficking, 
especially the extreme degree of control exercised by the 
trafficker and the prevalence of criminal exploitation of women 
and children. So we need specialized trainings tailored for the 
healthcare sector. These are a critical part of the solution.
    Setting up internal protocols and procedures and 
regulations may also further assist the healthcare providers in 
identifying, treating and responding to and reporting as well 
as referring, where necessary, trafficking victims.
    Finally, we absolutely need more research to help us 
understand the healthcare problems and the needs of trafficking 
victims as well as to identify best practices and to create 
national, State, and local responses to health consequences of 
trafficking.
    The medical community can play a vital role in the ongoing 
fight to eliminate modern-day slavery, and H.R.--whatever the 
number is going to be--the Trafficking Awareness Training for 
Health Care Act of 2014, is an important step in helping to 
equip them for this fight.
    And I thank you so much for having us here today to begin 
this conversation.
    [The prepared statement of Ms. Lederer follows:]
    
    

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    Mr. Pitts. The Chair thanks the gentlelady.
    Now recognizes Dr. Stoklosa, 5 minutes for opening 
statement.

                  STATEMENT OF HANNI STOKLOSA

    Ms. Stoklosa. Chairman Pitts and Ranking Member Pallone, 
thank you for inviting me to testify today.
    And, Representative Ellmers, thank you so much for putting 
forth this bill.
    And I would also like to express my appreciation to Vednita 
Carter for her courage in sharing the survivor perspective.
    I am an emergency medicine physician at Brigham Women's 
Hospital in Boston as well as faculty at Harvard Medical 
School. In Boston, I convened a citywide task force, looking at 
developing a health protocol for victims of trafficking when 
they come to our healthcare settings.
    In addition, I do international research on human 
trafficking, including the monitoring and evaluation study of 
anti-trafficking programs in India as well as looking at the 
health consequences of human trafficking among construction 
workers in Kazakhstan.
    I co-founded HEAL Trafficking in the fall of 2013. ``HEAL'' 
stands for ``Health professional, Education, Advocacy, and 
Linkages.'' And our vision really is to unite health 
professionals who are working on the issue of human 
trafficking.
    We are divided into working groups that are working on the 
issues that are the crux of health and trafficking, including 
education and training protocols, research, direct service, 
prevention, and advocacy.
    HEAL Trafficking brings together a broad range of health 
providers, including administrators, researchers, dentists, 
social workers, nurse practitioners, and physicians. And we are 
pleased to work very closely, especially our education and 
training group, with the SOAR initiative within the Department 
of Health and Human Services.
    I am going to share with you a story from the emergency 
room. This was early on in my training, and it was a busy 
overnight shift, seeing lots and lots of patients. And I took 
care of this young woman, who was Cantonese-speaking, who came 
into the emergency room, and her chief complaint, the main 
reason that she was there, was she had abdominal pain.
    And from a medical perspective, it was a really 
straightforward case. We diagnosed her with a sexually 
transmitted infection. We treated her appropriately. And then 
we discharged her home.
    I knew that something wasn't right. I couldn't put my 
finger on it. And there was this dynamic in the room with an 
older, also Cantonese-speaking woman, but I didn't have any 
training on human trafficking. And so I missed this case of 
human trafficking.
    Later on, as I learned what trafficking was and that it was 
actually happening in the United States, I realized that I 
missed this opportunity with this young woman, this opportunity 
to intervene at her time of need in her interface with the 
healthcare setting.
    Unfortunately, this happens all too often. Victims of 
trafficking are coming to our hospitals and clinics, and they 
are leaving unrecognized and uncared for.
    There are three crucial considerations when we look at 
developing a healthcare initiative for education of our health 
providers nationally. These considerations are who, what, and 
then, ``Then what?''
    So the ``who.'' And Katherine Chon alluded to this. But we 
really need to train all healthcare providers across 
disciplines as well as across specialties. In terms of the 
disciplines, we need to train social workers, EMTs that are 
responding in ambulances, physicians, nurse practitioners.
    And we need to train across specialties. We need to train 
obstetrics and gynecology specialists, dermatologists, 
emergency room providers, surgeons, family medicine providers. 
We need to train the full spectrum.
    And, in addition, we need to train them across the spectrum 
of their education. So from the physician perspective, from 
medical school all the way on up to my board-certification 
process, this needs to be integrated at every stage.
    The second is the ``what.'' The content of the training--
you know, the Department of Health and Human Services is 
working on developing the evidence-based content, and I think 
crucial in that is having trauma-informed, survivor-led 
expertise.
    When I talk to survivors, their everyday ``live'' 
experience is often a very deep-seated, complex experience of 
PTSD due to the repeated physical and emotional and sexual 
abuse that they experienced during the time that they were 
exploited, and our health settings and our health providers 
need to be sensitive to that.
    They need to provide a welcoming environment where they 
aren't even inadvertently revictimizing victims of trafficking. 
And, if they don't trust the health provider, if they don't 
trust that setting, there is no way that that health provider 
is going to get the information they need to be able to 
identify them as a victim.
    The last piece here is that we need to develop a strong 
referral infrastructure. The current state of resources for 
survivors is inadequate and disorganized. Just imagine, as we 
identify further victims of trafficking, what that is going to 
do to burden our already burdened system.
    Survivor care is a long-term process, and survivors need to 
know that they are better off in our healthcare system than 
they are in the arms of their exploiter.
    So, in summary, who should we train? We should train all 
healthcare providers. In terms of the ``what,'' it needs to be 
trauma-informed and survivor-led, and we need to expand 
resources for referral.
    Thank you so much.
    [The prepared statement of Ms. Stoklosa follows:]
   
   
 
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    Mr. Pitts. The Chair thanks the gentlelady.
    And I now recognize Dr. Miller for 5 minutes for an opening 
statement.

                 STATEMENT OF KENNETH P. MILLER

    Mr. Miller. Thank you, Chairman Pitts, Ranking Member 
Pallone, and members of the subcommittee. I appreciate the 
opportunity to speak with you today on behalf of the American 
Association of Nurse Practitioners, the largest full-service 
professional membership organization for NPs of all 
specialties.
    With nearly 52,000 individual members and over 200 
organization members, we represent the more than 192,000 nurse 
practitioners across the Nation.
    My name is Ken Miller, and I am currently serving as the 
President of the American Association of Nurse Practitioners. I 
have also served in many different academic administrative 
roles across the country. I have also worked as a family nurse 
practitioner in New Mexico, Delaware, and the District of 
Columbia.
    NPs have been providing primary, acute, and specialty care 
for a half a century. We are rapidly becoming the healthcare 
provider of choice for millions of Americans. In fact, we 
conducted over 900 million patient visits throughout the United 
States in 2013.
    NPs practice in every community in this country, both urban 
and rural, and see patients from all economic and social 
backgrounds. We provide care in all types of settings, which 
include clinics, hospitals, emergency rooms, urgent care sites, 
private physician or NP practices, nursing homes, schools, 
colleges, retail clinics, public health departments, and 
homeless clinics.
    It is also important to remember that, in many of these 
settings, NPs are the lead provider on site. In fact, there are 
many NP-owned and -managed clinics across the United States. It 
is in these various settings, particularly public health 
departments and primary care clinics, where NPs play a key role 
in recognizing many of the at-risk, vulnerable populations they 
treat.
    NPs, with their emphasis on primary care, health promotion, 
and education, coupled with their nursing background, approach 
the care of their patients holistically.
    Their expert assessment and interviewing skills, combined 
with their education and preparation, uniquely positions them 
to gather information which not only allows them to treat 
symptoms, but also research causality, crucial to effective 
prevention of emotional, physical or sexual abuse.
    Knowing the correct assessments to perform and the right 
questions to ask when treating patients that are victims of 
other types of violent crime and abuse is a skill set similar 
to what NPs must call upon when recognizing and treating 
victims of human trafficking.
    We know today that practicing NPs are confronted with 
patients whom they suspect are victims of human trafficking and 
that we must lead and work with other provider groups to 
develop best practices and procedures that will allow all 
providers to attain the skills needed to ensure that these 
victims are identified, treated, and assisted.
    It is imperative that providers are given clear instruction 
and guidance on how to identify these victims as well as the 
steps to be taken to ensure that victims receive the proper 
protection and care. These best practices need to be carefully 
developed, given the variety of providers and the different 
care settings in which these victims may surface.
    Victims of human trafficking can be extremely difficult to 
locate after their initial healthcare visit due to the 
transient nature of these criminal acts.
    It is critical that best practices include a program that 
provides guidance and gives providers the tools necessary to 
assist victims as quickly as possible. We must ensure that 
providers and victims, working together, can develop these 
evidence-based best practices and work to implement them across 
the healthcare spectrum.
    In closing, it is important to note that strategies may 
vary from clinic to clinic and from State to State. Developing 
best practices to identify signs and symptoms and best 
screening tools is paramount to identifying those who are 
trafficked.
    Reporting procedures are key to removing the victim from 
their deplorable situation. For any program to be effective, 
all healthcare professionals that come into contact with 
suspected victims of abuse must be educated and clinically 
trained to identify these individuals.
    We are pleased to continue to work with Congresswoman 
Ellmers and other members of the subcommittee to develop 
legislation that addresses this issue in a provider-neutral 
manner.
    This ensures that all practicing providers and healthcare 
personnel who may come in contact with victims of human 
trafficking are able to identify and assist them.
    As the voice of nurse practitioners, AANP can reach the 
rapidly growing NP profession throughout the country with this 
important information.
    We thank you for your time and respectfully request that we 
continue to work together on this important issue.
    [The prepared statement of Mr. Miller follows:]
   
   
 
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    Mr. Pitts. The Chair thanks the gentleman.
    Thanks to all the witnesses for your very important 
testimony, very moving testimony.
    I will begin questioning and recognize myself, 5 minutes 
for that purpose.
    Ms. Carter, let me start with you. While anyone can become 
a victim of trafficking, are there certain populations that are 
especially vulnerable to trafficking?
    Ms. Carter. Yes. There really are. I think the Native 
American community and African-American women are very highly--
they are preyed upon. They are preyed upon.
    And those are the communities that--Breaking Free is in 
Minnesota. And so Minnesota is--less than 10 percent of the 
population are African-American. Less than 2 percent are Native 
American.
    Yet, still the majority of the 500 women and girls we work 
with a year are African-American and Native American. So those 
are the populations that are very highly susceptible to being 
trafficked.
    Mr. Pitts. Thank you.
    Ms. Lederer, because human trafficking is considered to be 
one of the fastest growing criminal industries, the U.S. 
Government and academic researchers are currently working on an 
up-to-date estimate of the total number of trafficked persons 
in the United States annually.
    Do you know how they collect this information?
    Ms. Lederer. In the United States?
    Mr. Pitts. Yes.
    Ms. Lederer. Chairman Pitts, I don't believe that there is 
a solid number yet.
    I would like to add to what Vednita said. I absolutely 
agree that those populations are vulnerable, but there are also 
many other populations that are vulnerable to being trafficked.
    We know that runways and the homeless and what we call the 
throwaway kids, the kids who don't really have homes where they 
have a loving environment, are very vulnerable to trafficking.
    And in all of the survivors that I have interviewed, there 
was something that happened in the home early on, some abuse, 
either physical, sexual, that drove these children out on to 
the streets. And then out on the streets they are much more 
vulnerable.
    We have some estimates of those vulnerable populations. We 
have heard that it is somewhere between a million and 1.5 that 
are these runaway, homeless and throwaway youth, and they are 
all susceptible to trafficking and are preyed upon by 
traffickers who know exactly what to look for and where to find 
them.
    And so I think that part of what we have done is we have 
begun to identify large, vulnerable populations, and what we 
need to do next is take a much more critical laser-like look at 
what is happening in those populations.
    For instance, we know that street gangs are now preying on 
children in middle schools and that they are literally going to 
middle schools and high schools and recruiting from there, but 
we don't know the who, what, when, where, how of that. And we 
will need specific studies to be able to identify that.
    And I am with you. I think we need to be able to figure out 
on the front end who are these vulnerable populations and 
prevent the trafficking so that we are not constantly doing the 
cleanup that we have been doing over the past 10, 15 years.
    Mr. Pitts. Thank you.
    Dr. Stoklosa, you mentioned your specific patient. You said 
you missed the stage of trafficking--I think that is what you 
said--and you must establish trust.
    What are the indicators that you look for to identify 
trafficking victims, in your experience as a physician in 
Boston?
    Ms. Stoklosa. Thank you for the question.
    I would couch this by saying we need more evidence and we 
need more research to show us what those signs and symptoms 
are.
    But in talking to survivors and from the studies that we 
have thus far, some of the signs and symptoms--and I kind of go 
head to toe whenever I train healthcare providers on this--
general malnutrition, a discrepancy between their story and 
what you are seeing.
    So they say--just very similar to intimate partner 
violence, they are saying, ``Oh, I fell down the stairs'' when 
there are bruises that are at multiple stages of healing on 
their body, cuts or lacerations without an explanation, tattoos 
where they are afraid to talk about them.
    Maybe it is a pimp or maybe it is his branding on them. I 
have spoken with survivors that have been literally hogtied and 
branded. So that is on the skin side of things.
    They may have eye damage from either being beaten or being 
kept in dark places. And so their vision may be impaired from 
that. Signs of oral trauma, including sexually transmitted 
infections that may even present in the mouth. Pulmonary 
disease. Lung trauma.
    And then, on the reproductive side of things, scar tissue 
that is unexplained, presentations of sexually transmitted 
infections that have gone farther than one would expect before 
they sought medical care, and retained foreign bodies either in 
the vagina or in the rectum, from a female perspective, being 
forced to have sex during her menses.
    I could go on from there, but those are some of the signs 
and symptoms that would be concerning.
    Mr. Pitts. Thank you.
    Dr. Miller, health clinics, hospitals, social welfare 
offices, police, frequently and unknowingly experience face-to-
face contact with trafficking victims.
    How do you think this bill will help improve identification 
of trafficking victims from among healthcare providers?
    Mr. Miller. I think one of the most important things that 
it will do is it will establish a program to educate all 
healthcare providers.
    I think many of us get pieces of that throughout our 
programs when we are working for our degrees, but I don't think 
there is any real focus that is totally limited to trafficking.
    I think we talk a lot about abuse and we get a lot of 
information about that, but there is nothing specific to 
trafficking. And I think having this program will really aid us 
in being much more astute in identifying patients who are in 
human trafficking.
    Mr. Pitts. Chair thanks the gentlemen, all the witnesses, 
for your answers.
    I have gone over my time. I yield 5 minutes to the ranking 
member, Mr. Pallone, for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    Earlier this morning we heard from Ms. Chon about the SOAR 
to Health and Wellness Training initiative at HHS, a pilot 
program to improve healthcare professionals' response to human 
trafficking.
    I wanted to ask Dr. Stoklosa, since you participated in the 
technical working group for SOAR, I would like to get your 
thoughts on this new initiative. The pilot training for SOAR 
began this week, and it is happening in five States over the 
next month.
    So will you be involved in the training in Boston next 
week? And what did you see for the type of training that SOAR 
offers in your community?
    Ms. Stoklosa. Thank you so much for the question.
    So both on the HEAL national level as well as individually, 
I have been really pleased to be involved in the SOAR 
initiative to health and wellness, and part of it is based on a 
very well-thought-out process in the development of the 
curriculum and really addressing this unmet need in terms of 
educating our health providers.
    The HEAL trafficking group, especially the education and 
training group, has been interfacing both in terms of input on 
the technical advisory group, both in terms of myself as well 
as others, and we are really pleased with the ultimate outcome 
of the pilot training.
    But it is that. It is a pilot training. And we are pleased 
that what this is going to do is add to the evidence base on 
educating and training our health providers.
    Mr. Pallone. Have you seen much interest in the SOAR 
program in Boston? And what types of healthcare providers have 
already signed up for the SOAR pilot training.
    Ms. Stoklosa. So I will be--along with a couple other 
colleagues, will be doing the training in Boston. And there has 
been an overwhelming response within the Boston healthcare 
community, both within my own hospital system as well as across 
the city of Boston.
    And those that have signed up have come from the spectrum 
of healthcare disciplines as well as specialties, including 
social workers, dentists, from obstetrics and gynecology to 
trauma surgeons.
    So we are very thrilled to see that response, and I think 
it is reflective of the hunger for this education and training 
and the realization that we are interfacing with victims of 
trafficking, but we don't have the tools, as health providers, 
to identify them or care for them.
    Mr. Pallone. Well, thanks.
    After the pilot sessions this month, participants in SOAR 
training will complete evaluations of their experience, which 
will help HHS to assess the effectiveness of the program and 
determine how to move forward.
    What are your hopes for the future of the SOAR training 
program?
    Ms. Stoklosa. So this is the pilot round, as you said, and 
my hope is that this will provide an evidence base so that we 
can have fidelity for the education and training of health 
professionals nationally. As Katherine Chon mentioned, this is 
kind of the 101. This is the general awareness piece.
    Certainly every health provider in the United States, once 
we have shown that this is an effective model, should be 
trained, and that should be incorporated at all stages, as I 
mentioned earlier, of our education and training, from the very 
early stages within professional school all the way along 
through our accreditation processes as--in whatever board 
certification or professional accreditation processes are 
specific to those individual disciplines. And I see HHS really 
taking a lead in facilitating this effort.
    Mr. Pallone. Well, thanks.
    And I want to say I look forward to learning more about the 
results of this pilot program so we can determine how the 
Federal Government can best help healthcare professionals along 
with any other individuals likely to interact with the 
trafficking victims.
    I did want to ask you one more thing, though. This would be 
either to you or Dr. Lederer.
    Current statistics on human trafficking in the U.S. are 
limited. And as Ms. Chon noted in her testimony, while 
researchers like Dr. Lederer have begun to look at the health 
effects of trafficking, more research is clearly needed to 
better understand the health needs of victims of human 
trafficking as well as how healthcare professionals can best 
address the needs.
    Could either of you answer: What need do you see for 
further research regarding the interaction of victims of human 
trafficking with the healthcare system? Either Ms. Lederer or 
Dr. Stoklosa or both of you?
    Ms. Lederer. Thank you for the question, which is an 
excellent question.
    I think we are in the foothills of consciousness in terms 
of figuring out what kind of research needs to be done. I 
believe that we need to--like Dr. Stoklosa's head to toe, we 
kind of need to go very beginning and track.
    So I have talked to 150 survivors across the United States 
over the last year, and I have heard recurring themes. And I 
would start with those recurring themes. One of them is abuse 
in the home.
    Once somebody's been abused, they have been sexually 
assaulted, they have been raped, they have been molested by a 
relative, they are pushed out into the streets. And so we need 
to do a lot more research on the link between early abuse in 
the home and trafficking.
    Then foster care systems. Once they are out of their homes, 
they are into our foster care system. And we need more research 
on how foster care system is working. I believe that those 
systems are failing and are facilitating trafficking at this 
point in time. So we need more research in that area.
    Educational systems. We need more research on the link 
between bullying and trafficking, on the link between the ways 
that street gangs and others prey on--what is the role of the 
educational system right now? How do they facilitate or how are 
they failing to counter trafficking?
    And I can go through each of the various sectors. I think 
that is important.
    I agree with Dr. Stoklosa that all of this needs to begin 
from the listening to survivors. If we listen to survivors, 
they can tell us how to proceed. They know the hell of this. 
They know what works and what doesn't work. They can tell us 
better than any textbook what we need to do. And so we need to 
incorporate survivors into all our programs.
    And then the last thing I would say is that the huge, huge 
need, which is the elephant in the room, is the resources and 
referral. Once we have got these trainings in place--and, 
Representative Ellmers, thank you so much for taking the lead 
on this. This has been such a long time coming.
    But once we do have these trainings and we begin to 
identify these victims, we will need thousands of Breaking 
Frees and we will need to have them up and running so that they 
can do their work properly.
    So there is a lot of research. I would be happy to do a 
fledgling list for you, just a beginning, and think about this 
further with my colleagues, but that is a start.
    Mr. Pallone. Thank you.
    Ms. Stoklosa. And, if I may, I would like to add on to that 
and concur with Laura Lederer's comments.
    One of the gaps that I see is the populations that we have 
data on thus far in terms of intersection with health care. So 
there is more information, though it is still not as much as I 
would like, on sort of the pediatric or the child populations 
specific to sex trafficking.
    We don't know a lot about labor trafficking. We don't know 
as much as I would like about the adult populations and 
transgender population and boys.
    There are a lot of men and boys that are involved in 
trafficking, and they are largely in a hidden population hidden 
within that. And they are especially vulnerable, and we don't 
have much data on them.
    The other thing that I would like to add here in terms of 
the need to add to the evidence base is in terms of going back 
to trauma-informed care.
    Trauma-informed care is something that healthcare providers 
really have no training on at all. And I mentioned earlier 
victims of trafficking especially are in this reality that we 
are not trained to deal with and, as a result, we accidentally, 
in most cases, re-victimize them when they enter into our 
health facilities. And, therefore, they are not going to 
disclose what is really going on.
    We need more data around trauma-informed care to show what 
works and what doesn't work, and we need to train our 
healthcare workforce in it. And it is not only applicable to 
victims of trafficking, but we, as healthcare providers, 
interact with patients that have experienced violence along the 
entire span of their life, unfortunately, from child abuse to 
elder abuse, to intimate partner violence. And, yet, we still 
have no training in trauma-informed care.
    So I think, in some ways, this give us an opportunity to 
expand that very much needed tool kit for healthcare providers. 
And I would echo Laura's comments in terms of needing more 
resources dedicated both to the research as well as to the 
aftercare for victims of trauma.
    Doctors--and I am speaking from that perspective just 
personally. You don't want to ask the questions if you don't 
have a plan, if you don't have a solution, to be able to 
provide.
    And so, if you know that the shelters are limited for 
somebody that is being trafficked, in some ways, it is like an 
unconscious decision, but you would rather not even ask and 
explore that. And so we are also missing opportunities because 
of that.
    Mr. Pallone. Thank you.
    Mrs. Ellmers [presiding]. Thank you. The gentleman yields 
back.
    I am now going to finish up. If any of our other colleagues 
come in, we will certainly allow them time for questions.
    I want to start off--and, at first, I just want to say 
thank you to our panel. Thank every one of you. Ms. Carter, 
especially for your bravery for taking your experience and 
turning it into something positive. It is hard for me to talk 
about without getting emotional. So I apologize.
    We should have done this a long time ago. The fact that we 
are here today on September 11th--in recognition on a very 
emotional day for us, as Americans--and talking about this 
issue, I think is significant.
    Ms. Carter. It is.
    Mrs. Ellmers. And, again, I thank all of you. Because it is 
all of us working together on this issue where we are going to 
solve this problem in this country. My goal is to eradicate 
human trafficking.
    And, Dr. Stoklosa, you touched on the labor trafficking 
that occurs. We are also looking at that, as well, because that 
is another area that, although we, as Americans, know that it 
exists, we really don't want to accept that it exists. And we 
need to be able to identify that.
    First, I want to make a comment just about the prevalence 
here in this country and reference an NIH study in regard to 
trafficking.
    NIH estimates that 50,000 people are trafficked each year 
in the United States, with as many as 400,000 of our minor 
children involved in trafficking, resulting in--and this is the 
question.
    The question is: Why is this happening? What is the 
precipitating factor that creates trafficking? And the answer 
is the dollars. The dollars. It is a very profitable criminal 
industry, resulting in billions of dollars being generated from 
it.
    And, Ms. Carter, I want to just go back to your testimony 
and your experience and now what you are learning when you are 
working with victims.
    One of the things that hit me, working as a nurse for so 
many years, Dr. Stoklosa, I know exactly what you say when you 
know something's wrong, but you just can't put your finger on 
it, and then what would you do if you were to get that 
knowledge, that information, from that patient.
    One of the things that I was struck by was the fact that 
many of the pimps or the human traffickers that--it is the 
attraction, the security, and the love that the victim feels 
that they are receiving from that individual.
    Because of their life experience, this may be the most 
secure thing that they have ever, ever encountered, and that is 
why sometimes it is so difficult to identify them.
    Ms. Carter, can you speak a little bit about that? Is that 
something that you have also seen?
    Ms. Carter. Yes. Definitely. I want to say it is a 
brainwashing process because we know that the average age of 
entry in our country is between 12 and 14 years old. So when 
you have a 12-year-old that has run away from home, that is out 
there on the street, it doesn't take a trafficker a lot of 
effort to convince her that he is going to help her and he 
understands what she has been through.
    So it is kind of like a two-phase process. First, he gets 
her to believe that he is going to do all these things for her. 
And, second, he tells her now that she owes him for doing all 
these things for her.
    So at 12 years old, you are full of fear because you have 
been told that, ``If you don't do this, I am going to go and I 
am going to do this to your sister,'' ``I am going to kill your 
brother,'' ``I am going to''--you know, just all kinds of 
threats. So it doesn't take a lot of convincing to get a child 
involved in this life.
    And there are different types of pimps. You have just your 
hard-core pimp. He knows you are on the run. He knows you are 
out there, you have no place to go. He immediately just turns 
you out.
    And then you have the other kind that just convinces you 
that he is everything to you, and she believes it. Why wouldn't 
she? She can't go get a job. She can't rent an apartment. She 
can't do anything. And she can't go back home because that is 
where all the abuse started. So it is a process.
    Mrs. Ellmers. Thank you, Ms. Carter.
    Dr. Lederer, one of the things in going over the focus 
group information that you have provided to us--that was the 
eye-opening experience that I had.
    Again, understanding and knowing the healthcare community 
and how much any healthcare provider would want to be able to 
identify these victims and then to find out from your focus 
groups that 87 percent go to our healthcare providers, to our 
clinics, to our emergency rooms, and receive care, it was 
difficult for me to accept that, because I just assumed that 
these things were happening behind the scenes, they were not 
out in the open, and that we, as healthcare providers, would 
not be able to identify those victims.
    But when you think about it, it makes perfect sense, 
because they are the product, and that product has to continue 
to be sold. So, therefore, they do seek health care. Their 
traffickers do seek health care.
    I realize we are just at the tip of the iceberg here. This 
is going to be an ongoing discussion into the future so that we 
can eradicate this terrible, terrible crime.
    But one of the things--Dr. Miller, I would like for you to 
comment on this as well.
    As far as expanding, we have all discussed areas where we 
need to go with this. I do want to go back to our schools, with 
our school nurses and our social workers.
    Dr. Lederer, do you believe that this is an area that we 
also need to incorporate into these programs?
    And then, Dr. Miller, I would like for you to----
    Ms. Lederer. Absolutely I do. And I am not a healthcare 
provider. So I don't know all of the various subsectors of that 
sector.
    But I think the disappointment over the last 15 years is 
that all these trainings have been like a one-off. If there has 
been a training, it has been two things. It is been a hospital 
calling and saying, ``We would like the training to do as part 
of this seminar that we are putting on. Will you come?'' And 
then the anti-trafficking organization comes, gives a Tip 101, 
and goes home. So it is not only one off, it is reactive 
instead of proactive.
    And what we need is both proactive and we need a methodical 
approach. And, again, I like Dr. Stoklosa's approach of, from 
the beginning, in the academies all the way through all of the 
sector and the subsectors, we absolutely need training.
    And I believe we need training tailored to each of those 
subsectors. So school nurses will need a specialized training 
because they are dealing with a specialized community, and they 
will need to know not only what to look for, but how to 
respond, you know, properly without driving the kids back out 
onto the streets, as I think, if you are not equipped, you can 
do if you are a counselor or a nurse and don't know what to do, 
what to say, and who to refer to.
    So that is a perfect place to begin, and it is at the early 
stage where, if we can prevent it from happening, we are way 
ahead of the ballgame. Because once somebody's been trafficked, 
they are, as we have all been saying, physically, mentally, 
emotionally, spiritually devastated, and building that person 
back up again is almost impossible.
    We spend a lot of time and money. No one's done the cost-
benefit analysis. That is the other big study that needs to be 
done. How much is this costing to do these rescues, 
restorations, reintegrations? It is huge. So that is a good 
place to start.
    Mrs. Ellmers. Dr. Miller.
    Mr. Miller. Yes. I believe that the academic institutions, 
whether it is grade school, high school, or collegiate level, 
need to be much more proactive. And the only way they are going 
to be proactive is if they get the education that they need.
    And, again, I can tell you that, in many of the programs 
around the country, what you hear on abuse is--you may have one 
or two classes and that is it. And what they really need is to 
have a workshop, and that workshop needs to be incorporated 
throughout the entire curriculum for the entire length of time 
that the person is in the program.
    But I also concur that one of the things that needs to be 
done is it has to be focused on whatever level. If it is a 
school nurse, if it is a nurse practitioner, if it is a 
physician, if it is a social worker, whatever their program of 
study is, it really has to be focused in that area. So that 
means we are going to have to be developing programs that are 
really attentive to those types of disciplines.
    Mrs. Ellmers. Thank you.
    And my last question--or discussion, really, because I am 
going to direct this to Dr. Stoklosa, but I would like anyone 
else who would like to comment as well.
    Getting back to the objective that we have--or, obviously, 
our goal is to incorporate programs, if you figure out ways, 
protocols, for best practices on all of these issues.
    And to the point of prevention, it is so important. Ms. 
Lederer was talking about the cost or cost-benefit analysis in 
the long run.
    One of the other areas that we are working on here on the 
House subcommittee is need for mental health reform. And when I 
think of the number of victims who now fall into and need 
mental health care, that opens up another door to more cost and 
continued life situations. They will be affected their entire 
lives.
    What I would like to know, Dr. Stoklosa, from your 
perspective right now--I was paying special attention to what 
you were identifying to the chairman about what you see or some 
of the identifying signs and symptoms that you see today in the 
emergency room.
    One of them, of course, you had mentioned was tattooing and 
branding, and a light bulb went off in my head and I thought: 
My goodness, we are talking about modern-day slavery. These 
women, these children, these men, are being branded.
    And we attribute much of that, too, to gang activity, and I 
can see how healthcare professionals would just make the 
assumption that this is a gang member or a prostitute on the 
street and a chosen lifestyle versus someone who would fall 
into that human-trafficking victim category.
    My mind is going crazy with ideas of what we need to do 
into the future. What do you see now--if a patient comes into 
the emergency room and you identify them as a potential sex-
traffic victim, what do you do from that point on? And what 
barriers exist that we need to be identifying today so that we 
know where to go tomorrow?
    Ms. Stoklosa. Thank you for that question.
    And you brought up a lot of points along the way that I 
could spend forever kind of commenting on, but I am going to 
get to the ``what do you do in that moment.'' And this gets to 
that kind of ``then what?'' question.
    I am going to speak as a clinician in Massachusetts at the 
moment. But it depends on age, first of all. So if they are 
under the age of 18, there are mandated reporting requirements.
    And I should say before I even get into the age thing the 
most important consideration is to meet the victim or the 
survivor where they are at in that moment.
    So, for an under-age-18 individual, I am ultimately going 
to need to initiate a mandated reporting pathway. If the 
patient in front of me feels like I am all about rescuing them 
and doing X, Y, and Z, and I am not there in the moment 
assessing their needs for food, maybe for water, for just 
having that human interaction, all is lost, really.
    So, under the age of 18, mandated reporting, and that would 
initiate child protective services. There is also--in 
Massachusetts, we are lucky enough to have the SEEN Coalition, 
which is a wrap-around set of services for those that are 
victims of sexual exploitation under the age of 18, which 
includes legal services, mental health services.
    And we try to limit the number of even health providers 
that are asking them about their traumatic experience to make 
sure that it is not re-traumatizing for them in that situation 
and then referral to services. Obviously, we take care of their 
medical needs as well.
    If they are over the age of 18, it is finding out where 
they are at and what they want. Maybe it really is just a 
sandwich. Maybe they are not ready to get out of that 
situation.
    It is very akin, in many ways, to what we have seen with 
intimate partner violence. They ultimately have agency in that 
situation. As hard as it is to let them go back out, in some 
cases, that is the choice that is made.
    I see it as a spectrum, that their interaction with caring 
individuals, whether it be interaction with the healthcare 
setting or other providers--ultimately, they may get to that 
point where they are able to say that, ``I want to be out of 
this situation.''
    We have to recognize that sometimes it is actually less 
safe for them to disclose that information. They may know that, 
if some information gets back to their pimp, that they are 
going to be beaten that evening if they were to disclose.
    They may have extreme levels of blackmail that are kind of 
wielded over their heads either against their family, told that 
their family's going to be murdered or that pictures are going 
to be shown to those that love them and care for them.
    So we have no idea what is actually going on in their 
minds, and that is a really important thing for providers to 
realize. And it is really about meeting them where they are at.
    And then, just in terms of the barriers, barriers of 
judgment on behalf of healthcare providers, as you are saying, 
they may just be, like, ``Oh, this is a prostitute. She is 
choosing it.'' A lot of these victims present with substance 
abuse issues. And what I tell health providers is that those 
are opportunities for us.
    There was a case in New England last year where a health 
provider asked someone who had come in with a heroine overdose, 
``You know, I see you have been here a number of times with us. 
How did you get hooked on heroin?''
    And then she reported that it was her pimp. And, from 
there, they were able to uncover this entire trafficking ring. 
So it is being aware of the signs and symptoms and really 
coming at it with that trauma-informed approach.
    And then further barriers are on the referral side. So, 
like, ``What then?'' You know?
    Mrs. Ellmers. Right.
    Ms. Stoklosa. Have them call the National Human Trafficking 
Hot Line. They are a great resource for the survivor to talk 
to. Or, if the survivor is not in that position yet, I can 
speak in a way that is HIPAA-compliant with the National Human 
Trafficking Hot Line. So that is also a great resource.
    But there have to be resources under that--there have to be 
roots to that system. If there is no infrastructure for me to 
refer to, maybe he or she is in some ways better off being in 
the hands of their exploiter. I mean, it really is a tough 
state of affairs.
    Mrs. Ellmers. Would anyone else like to comment on this 
situation of even talking about barriers that exist right now 
and what we are doing today that in the future we can improve 
upon?
    OK. Dr. Stoklosa, you covered that very well.
    I think we are at a point where we can close our meeting. 
We will have 10 business days to submit questions for the 
record, and I ask the witnesses to respond to the questions 
promptly.
    I would imagine that many of the members who could not be 
here for the subcommittee because of ongoing things that are 
happening today--that you will probably receive some written 
questions.
    And then members should submit their questions by the close 
of business day on Thursday, September 25th.
    Before I adjourn, I just want to thank you again for coming 
and testifying on this incredibly emotional and vitally 
important issue. This is something that we can all work on. 
This is definitely a bipartisan issue that everyone has input 
on, and we will be able to come together.
    And I just feel so strongly that we need to be doing 
everything we can to make this happen, and I look forward to 
working with all of you.
    Please know that my door is open. The committee is more 
than happy to take more of your input. And let's work together 
on the solutions that we need to find.
    With that, and without objection, the subcommittee is 
adjourned.
    [Whereupon, at 11:25 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
   
   
 
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