[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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
93-716 PDF WASHINGTON : 2015
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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
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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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.]
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