[Joint House and Senate Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


114th Congress				      Printed for the use of the
1st Session 		Commission on Security and Cooperation in Europe



               BEST PRACTICES FOR RESCUING TRAFFICKING VICTIMS


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                             DECEMBER 2, 2015


                             Briefing of the

               Commission on Security and Cooperation in Europe
___________________________________________________________________________
                              Washington: 2016



Commission on Security and Cooperation in Europe

234 Ford House Office Building

Washington, DC 20515

202-225-1901

[email protected]

http://www.csce.gov

@HelsinkiComm

Legislative Branch Commissioners

              HOUSE
CHRISTOPHER H. SMITH, New Jersey 
Chairman
ALCEE L. HASTINGS, Florida
ROBERT B. ADERHOLT, Alabama
MICHAEL C. BURGESS, Texas
STEVE COHEN, Tennessee
ALAN GRAYSON, Florida
RANDY HULTGREN, Illinois
JOSEPH R. PITTS, Pennsylvania
LOUISE McINTOSH SLAUGHTER, 
New York

              SENATE
ROGER WICKER, Mississippi,
  Co-Chairman
BENJAMIN L. CARDIN. Maryland
JOHN BOOZMAN, Arkansas
RICHARD BURR, North Carolina
JEANNE SHAHEEN, New Hampshire
TOM UDALL, New Mexico
SHELDON WHITEHOUSE, Rhode Island

Executive Branch Commissioners

Department of State
 Department of Defense
 Department of Commerce

(ii)

                                                   

ABOUT THE ORGANIZATION FOR SECURITY AND COOPERATION IN EUROPE

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Cooperation in Europe, traces its origin to the signing of the Helsinki 
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ABOUT THE COMMISSION ON SECURITY AND COOPERATION IN EUROPE

The Commission on Security and Cooperation in Europe, also known as the 
Helsinki Commission, is a U.S. Government agency created in 1976 to monitor 
and encourage compliance by the participating States with their OSCE 
commitments, with a particular emphasis on human rights.

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from participating States. The website of the Commission is: 
.

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BEST PRACTICES FOR RESCUING TRAFFICKING VICTIMS


December 2, 2015

COMMISSIONERS

Page

Hon. Christopher H. Smith, Chairman, Commission on Security and Cooperation 
in Europe

1

Hon. Steve Cohen, Commissioner, Commission on Security and Cooperation in 
Europe

2

Hon. Michael C. Burgess, Commissioner, Commission on Security and 
Cooperation in 
Europe

3

PARTICIPANTS

``Roxana,'' Foreign-born Female Survivor of Sex Trafficking in the United 
States

4

``Celena,'' Foreign-born Female Survivor of Sex Trafficking in the United 
States

6

Dr. Kimberly Chang, Asian Health Services Community Health Clinic

7

Yaroslaba Garcia, Clinical Director, President, ACT; Southwest Florida 
Regional Human Trafficking Coalition

10

Dr. Jordan Greenbaum, Stephanie Blank Center for Safe and Healthy Children, 
Children's Healthcare of Atlanta

12

Laura J. Lederer, Adjunct Professor of Law, Georgetown University Law 
School

23

Allison Hollabaugh, Counsel, Commission on Security and Cooperation in 
Europe

24

APPENDIX

Prepared Statement of ``Celena''

25

Prepared Statement of Dr. Kimberly Chang

27

Prepared Statement of Dr. Jordan Greenbaum

38

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BEST PRACTICES FOR RESCUING TRAFFICKING VICTIMS


DECEMBER 2, 2015

Commission on Security and Cooperation in Europe

Washington, DC

The briefing was held at 2 p.m. in room 2255, Rayburn House Office 
Building, Washington, DC, Hon. Christopher H. Smith, Chairman, Commission 
on Security and Cooperation in Europe, moderating.

Commissioners present: Hon. Steve Cohen, Commissioner, Commission on 
Security and Cooperation in Europe; and Hon. Michael C. Burgess, 
Commissioner, Commission on Security and Cooperation in Europe.

Panelists present: ``Roxana,'' Foreign-born Female Survivor of Sex 
Trafficking in the United States; ``Celena,'' Foreign-born Female Survivor 
of Sex Trafficking in the United States; Dr. Kimberly Chang, Asian Health 
Services Community Health Clinic; Yaroslaba Garcia, Clinical Director, 
President, ACT; Southwest Florida Regional Human Trafficking Coalition; Dr. 
Jordan Greenbaum, Stephanie Blank Center for Safe and Healthy Children, 
Children's Healthcare of Atlanta; Laura J. Lederer, Adjunct Professor of 
Law, Georgetown University Law School; and Allison Hollabaugh, Counsel, 
Commission on Security and Cooperation in Europe.

Mr. Smith. Good afternoon. And, first of all, let me apologize for being 
late. We did have a series of votes on the floor of the House, so when they 
were over I high-tailed it over here. But thank you so very, very much for 
being here to this Helsinki Commission briefing, which will lead to further 
action by our Commission, and I would predict by the Congress. So what you 
convey to us today, and by extension to other members of the Congress, will 
make a huge difference. So thank you for making the trip and being a part 
of this important undertaking.

I also want to thank Laura Lederer, whom I have worked with forever on 
combating human trafficking, going back to the very beginning when we were 
trying to craft a legislative response to the scourge of modern-day 
slavery. The Trafficking Victims Protection Act, while it shouldn't have 
been, was a huge lift. It took three years to get enacted. There was all 
kinds of opposition to core elements of it. But in the end, at the end of 
the day, it was nose up. And thank God that landmark legislation was 
enacted, as well as subsequent reauthorizations that expanded and 
strengthened the effort.

The estimates, as we all know, is that there are some 14,000 to 17,000 
foreign human trafficking victims each year, and yet we found or rescued 
only 750 victims. In 2013, the number was 520. So we are missing by a very, 
very large extent, foreign trafficking victims.

And then when you factor in the hundreds of thousands of young girls and 
women in our own country who have been trafficked interstate or even within 
their own states, it just underscores that need--these are victims that are 
hidden in stealth, if you will. And as Laura Lederer has done so 
extraordinarily well in her reporting, very often these victims are 
actually at health care facilities. Well over 60 percent visit an emergency 
room. That ought to be--a light bulb ought to go off among our LPNs, 
doctors and nurses working in those. And yet somehow, for whatever reason, 
they leave that emergency room in the hands of the pimp or the exploiter, 
only to be further hurt and traumatized.

We've tried--as chairman of the Helsinki Commission, and also of a 
committee that deals with human rights, we have tried to promote the idea--
and again, a lot of it did come from Dr. Lederer--of making people aware, 
situational awareness, wherever they might be.

Some years ago I chaired a number of briefings just like this on the 
airline industry and the hotels. And best practices were forthcoming. 
Homeland Security stepped up to the plate and did a wonderful job, in my 
opinion, with their efforts. We've taken it internationally. We're trying 
to get more countries to recognize this situational-awareness solution. And 
frankly, many have; not enough, but many have. Delta Airlines continues to 
be one of the leaders. But it ought to be every airline across the board, 
and that ought to be global.

When it comes to health care professionals, who better to recognize and 
then take corrective action, quietly and in a way that does not exacerbate 
the situation? We all know that there have been meetings at HHS over the 
years which have produced, I think, a good start. But frankly, the one that 
was held in 2009 laid out all of the issues in very, very good detail, but 
still we're not there in terms of answers.

Congress did pass a bill this year. Cornyn was the prime sponsor of the 
Senate version that was actually signed into law that has an entire section 
dealing with this and a grant and a study that hopefully will lead to best 
practices. So it's a work in progress. And I think the people that are here 
today are really to be commended; first of all, those who have been 
victimized, thank you for your willingness to come out and tell your story 
and share with all of us, what you have been through; and then, of course, 
those who are on the other side, who have been leaders, who will tell us 
what we need to be doing. So everything you say will help us to do a better 
job in the U.S. House and in the U.S. Senate.

So I'd like to yield to my friend and colleague, Mr. Cohen, for any 
comments he might have.

Mr. Cohen. Thank you, Mr. Chairman.

Mr. Smith. Appreciate it.

Mr. Cohen. Thank you, Mr. Chairman. I really just thank you for the lead on 
this. And I join with you in trying to do what we can to help the problem, 
which is great, trafficking, and look forward to the testimony and seeing 
if we can't find any solutions.

Mr. Smith. Thank you very much.

I'd like to now introduce our distinguished witnesses, beginning first with 
Roxana, who is originally from Nicaragua and was lured into sex trafficking 
in the United States at the age of 19. She is currently a T visa holder, a 
student, and an employee at a cleaning service. She's proud to be free and 
have the privilege of loving her children. We have changed her name to 
protect her identity.

We'll then hear from Celena, who is originally from Mexico and was also 
lured into sex trafficking in the United States when she was 19 years old. 
She has a T visa and has worked with law enforcement in the prosecution of 
her trafficker. In her free time she advocates for trafficking victims and 
is devoted to her young daughter. We have again also changed her name to 
protect her identity.

We'll then hear from Dr. Kimberly Chang, who is a physician at Asian Health 
Services, a federally qualified community health center, which provides 
primary health care for over 24,000 primarily low-income, limited-English-
speaking patients annually, including services such as case management, 
behavioral health care services, outreach, community health care workers, 
including a youth program.

Asian Health Services also has a specific program for minor patients who 
have been or are at risk of being sex trafficked called the Banteay Srei, 
or Citadel of the Women. For the past 12 years Dr. Chang has provided 
health care to domestic minor victims of sex trafficking and helped to 
develop protocols to identify affected patients in the primary care in a 
community health care setting.

We'll then hear from Ms. Yaro Garcia, who is the clinical director at Abuse 
Counseling and Treatment, or ACT, and president as well as co-founder of 
the Southwest Florida Regional Human Trafficking Coalition, for which she 
received the 2014 Human Trafficking Awareness Partner award in light of her 
exemplary work in identifying and treating victims of human trafficking. 
She also assisted in founding Points of Contact Rescue, a new program to 
involve health care facilities, businesses, hotlines and law enforcement in 
the identification and rescue of trafficking victims in the southwest 
Florida community.

She has her master's degree in clinical psychology, is a licensed mental 
health counselor, and is currently working on her Ph.D. in cognitive 
psychology. She is also a certified advocate of victims of domestic 
violence with the Florida Coalition Against Domestic Violence and a 
certified advocate of victims of sexual abuse with the Florida Council 
Against Sexual Assault. She was awarded the Purple Heart Advocacy Award in 
2012 by the Florida Network of Victim Services for her work with human 
trafficking victims and for advocating for victims of abuse.

And finally we'll hear from Dr. Jordan Greenbaum, who has been the medical 
director of the Child Protection Center at Children's Health Care of 
Atlanta since February 2006. She previously served as medical director for 
three children's advocacy centers at the Children's Hospital of Wisconsin 
from 2001 to 2006.

Dr. Greenbaum has helped to launch a number of child abuse prevention 
programs, including projects to prevent shaken baby syndrome and to train 
health care workers to recognize and report abuse and neglect. She also has 
presented information at national and regional workshops. She is a pioneer 
in developing medical screening tools for the identification of trafficking 
victims, as well as in developing a multidisciplinary approach to meet 
victims' needs. She is the current president of the American Professional 
Society of the Abuse of Children, and she recently served on the Wisconsin 
attorney general's task force on children in need.

Before going first to Roxana, I'd like to yield to Dr. Burgess, a member of 
the Energy and Commerce Committee, a medical doctor, and a member of our 
Commission.

Mr. Burgess. Thank you, Chairman.

I really don't have any prepared remarks, but I was excited to see you have 
this hearing today. I think it is important. I had a great deal of 
frustration last year. About a year and a half ago we had all the problems 
with unaccompanied minors who were streaming into the State of Texas. Much 
to my dismay, the question was never even asked to these youngsters when 
they arrived in our country for screening if they had been the victim of 
sexual assault. It was only if the child offered the information.

And the frustrating thing for me, as a physician, I know that when I was in 
practice, if I suspected child abuse, if I suspected that type of child 
abuse, I was required to notify authorities. No one in our federal agency, 
the Office of Refugee Resettlement, was notifying the state authorities 
that there was suspicion that these activities could have occurred. And 
moreover, they weren't even asking the question.

So I don't even know how to tell you how many people may have gone through 
that center in McAllen, Texas, and Mission, Texas, been the victims of 
abuse or traffic on the way through Central America and Mexico. We didn't 
know because we never asked. And to me that was wrong. And to the extent 
that I can, I intend to continue to pursue that and do something about it.

But I thank you for holding this hearing today. And again, I apologize. I 
won't be able to stay with you the whole time. I've got a conflict with the 
Rules Committee, and you know how that is. But thank you for holding the 
hearing.

Mr. Smith. Thank you, Dr. Burgess. Roxana.

Roxana. [Through interpreter.] [Off mic]--God, who also allowed me to be 
here as well. I want all of you to understand that I am going to tell you 
my story, or a little bit of my story, and mainly because I'm hoping that 
all of you will get a little bit more of awareness and understanding that 
I'm not just a number, that I'm a real person.

I am the victim of a web of traffickers in the state where I was 
trafficked. I was initially recruited and brought to the U.S. for this by a 
family member. And I am going to specifically focus on the neglect, on the 
health care industry, where I ended up many times as a result of what was 
being done to me.

Shortly after I got here, after being sold repeatedly, like you sell 
merchandise on a street, I started having health issues. I was taken to a 
clinic where the people who were handling me at the time filled out all of 
my paperwork. They answered most of the questions for me. And they gave me 
a rehearsed story that I had to tell the doctor once I went in the room, to 
the result of no one asking a single question about what was happening to 
me.

The doctor noticed that I had lacerations, that I was severely bleeding, 
and that I had a severe urinary tract infection, for which she asked what 
was going on that I had all these symptoms. And because I had been told to 
rehearse the story, I answered what I was told, which was--I was told to 
say that I had a partner, a romantic partner, who was very large and who 
was the cause of all these symptoms that I had. And the doctor believed it.

Looking back now, there were so many abnormalities with what was happening 
to me. These people were answering questions for me. They never left me 
alone. They filled out my paperwork. Still I was discharged back to these 
people. And she says the concerning thing here is the neglect, but also 
that responsibilities were delegated from everyone who came into the room 
and interviewed me and spoke to me. No one made the effort to make a phone 
call to get me help.

Like that occasion, there were many other occasions where I ended up in the 
health care industry. I'm going to tell you about the most powerful one. I 
ended up pregnant by one of the handlers. The second time that I ended up 
at a health care center, by then I was seven months pregnant. And as you 
can imagine, I had no previous care at all because I was being trafficked 
the whole entire time that I was pregnant. With four months of pregnancy, I 
was still being forced to serve between 40, sometimes 50 johns a day. One 
day I saw 59.

I was taken to a family health care center that had access to all of my 
medical records. They could see that I had been experiencing these 
lacerations and these infections. I had infections in my kidneys. I had all 
kinds of symptoms related to the amount of sexual activity that I was being 
exposed to. And once again no one asked a single question. No one asked if 
I needed any help. No one asked if they could do anything to help me in any 
way. They accepted the same stupid, ridiculous answer that I was taught to 
say, that I had had a very large partner.

I ended up at the hospital one more time to give birth, and it ended up 
being a C-section. Once again these people never left me alone. The two 
handlers that I had at the time took turns staying with me in the room at 
all times. Once again no one saw this as a red flag. We talk so much in the 
health care industry about privacy. What happened to my privacy? I had 
none. And all of the people that came into the room could notice that no 
one was leaving me alone at any time.

This to me is still incredible. Every woman spends time choosing a name for 
their child. You start looking for suggestions. You start thinking of this. 
I didn't have that opportunity, and it happened right in front of the 
health care professionals. I did not get to name my child.

The social worker was the only person at the hospital that realized that 
something was wrong; once again, did nothing. She realized that I did not 
choose the name on the birth certificate. And instead of asking for help, 
she simply came up to me and said I know this is not the name that you 
chose, so I'm just going to white out the first three letters, and then you 
can have this name instead. That's how she helped me--did not call anyone 
for anything else. That was all I received.

That social worker asked me why I was afraid of changing the name, and I 
said because they are going to get mad at me. That was my response. She 
still did nothing. Eventually I was discharged with my daughter, who was 
kidnapped from me at nine months old and taken out of the United States.

Mr. Smith. Roxana, thank you. Please.

Interpreter. She says can I have one more minute?

Mr. Smith. [Off mic.]

Interpreter. I hope I can translate everything. She says that during the 
three-year process that I was being trafficked, I saw other girls, of 
course, going through the same thing that I was going through, being 
repeatedly exploited, repeatedly beaten, and sometimes even killed. She 
says it's my understanding that this is a $152 billion industry a year. And 
it is crazy that we like to think that all we need to be is aware. That's 
not all. We need to get involved. We need to take action. Things need to 
keep changing, and we need to keep going. She thanked all of you many 
times. She said God bless you all. And she says during that process what 
kept me going was the thought of my kids.

Mr. Smith. Roxana, thank you so very much for that very moving and very 
disturbing testimony, because it does motivate. And I and others will have 
questions for you later. But the idea that the handlers were with you even 
during your time of birth, just as if you were property and they owned 
you--shame on all of us, and in this case perhaps health care 
professionals, who did not recognize what should have been obvious.

Interpreter. May I translate it to her?

Mr. Smith. Yes. [The interpreter provides translation to Roxana.]

Roxana. [Through interpreter.] Thank you for listening.

Mr. Smith. Thank you. Celena.

Celena. [Through interpreter.] She says my name is Celena. Thank you for 
being here. Thank you for listening. And as well, I'm going to tell you 
just a tiny bit about my story.

At the age of 19 I was brought to the United States by the man who from 
there on trafficked me for years. My initiation into this process was being 
taken to a house, where I was forced to serve initially 30 to 50 men for a 
long process that lasted weeks. And then I ended up in another state, where 
they moved me, and this continued.

Shortly after this started happening to me, as you can imagine, I was 
crying constantly. I was not behaving according to how they wanted me to. I 
was crying. I was sad constantly. I was not performing to how they wanted 
me to. I felt very ashamed. And I felt this little from what was being 
forced onto me.

So here is my first interaction with the health care industry. They wanted 
to stop me from crying so that I could perform better so they could make 
more money. So they took me to a clinic in New York. The doctor walked in, 
asked me what were my symptoms, and I explained that I felt very anxious 
and very sad and I felt like I wanted to cry all the time. She asked no 
more questions and told me that I was depressed and prescribed me 
medication for depression.

The second time I was experiencing a lot of pain from all of the activity 
that I had to perform every single day. The pain was so excessive that the 
trafficker finally decided to take me back to the clinic now to remedy this 
issue. I ended up in the same clinic, with the same nurse, with the same 
doctor--same people. She walked into the room, asked me what was wrong. I 
explained that I was experiencing pain. She didn't examine me, did not ask 
me any more questions, and gave me painkillers to take the pain away.

In 2009 this was the worst episode for me. I began bleeding excessively. 
And by now I had been bleeding for six months straight nonstop while I was 
still being trafficked every single day. The trafficker forced me to wear 
makeup sponges inside my vagina so that this could stop the excessive 
bleeding that was going on every day so that I could keep working for him.

I couldn't take it anymore, and he finally realized that and took me to the 
doctor. And he told me to say this. He told me to say that I had no family 
in the United States, that I didn't know anyone, and that I had a boyfriend 
who was very sexually active. And I had been experiencing these bleedings 
ever since I had started interacting with him.

That occasion I was at the hospital from 11:00 in the morning until 4:00 
a.m. the next day with several people doing exams and tests on me and 
looking at my interiors. And no one asked a single question. I was not even 
prescribed medication. They didn't provide me any treatment because all I 
had was excessive bleeding and lacerations. So they said just go home and 
drink a lot of Gatorade so you can hydrate, and you should not have any 
sexual activity.

I know that I don't have a lot of time, so I want to thank you. And I'm 
thanking you mainly because I'm hoping that somehow this will go somewhere 
else where all of the young girls and the young adults that are going 
through this could be rescued easier or better or that we find other ways 
to do this for them.

I wish that I could be the person in power to be doing this for the girls. 
But I also understand that people who are in power, like doctors and police 
officers and people that may be in this room, are the ones who could 
possibly make this happen.

Thank you.

Mr. Smith. Thank you, Celena, for that equally moving testimony. Both of 
you said no one asked a single question. That is beyond troubling--two 
different situations, similar exploitation, and yet no one asked a single 
question. So that should propel us to further action as well as to why this 
huge gap in interest by health care professionals.

For this second portion, just so we don't want to be videoing you two----

Interpreter. Yes, please.

Mr. Smith. ----victims, survivors----

Interpreter. Yes.

Mr. Smith. ----if they wouldn't mind sitting down at the front. And then 
we'll video the second part.

Interpreter. Yes.

Dr. Chang. Chairman Smith and esteemed commissioners, thank you so much. 
Thank you so much for holding this hearing and inviting me to speak about 
the importance of the health care system and its professionals in rescuing 
victims from human trafficking.

I'm going to start off with a story as well. One night in 2008, 
``Christina,'' a patient of mine, came to the clinic very sick. She was 
young. She was about 15 years old and had been seeing us at the clinic for 
three years. Although she never disclosed any sexual exploitation, we 
suspected that she was being sex-trafficked.

That night she had a high fever, rashes all over her body, swollen joints 
everywhere, painful. She couldn't walk. She had a racing heartbeat and 
weighed less than 90 pounds. She was anxious and depressed. She had delayed 
seeking care despite feeling ill for three months.

She needed to go to the hospital. When I told her this, she absolutely 
refused, saying to me, ``I'd rather die than go back to jail.'' I didn't 
quite understand the connection between her going to the hospital and her 
being sent to jail. Later I learned that on a previous hospitalization 
Christina was discharged to jail because a bench warrant for her arrest was 
issued when she failed to appear in court on solicitation charges.

Christina did not go to the hospital that night. I feared she was going to 
die that night and we had failed our patient. Or had we? Later that night 
our care did not end when Christina left our clinic walls. Our health 
center's youth program outreach workers and the case manager of Banteay 
Srei, our program working with sex-trafficked minors, worked their 
community connections all night, eventually locating her the next morning. 
The Banteay Srei case manager went to her, went to Christina, convinced her 
to go to the hospital, and personally drove her there. She was hospitalized 
for almost two months, treated, and she survived.

For Christina, our team-based approach and assistance enabling her to 
access care, our public health perspective, extending outside of the clinic 
walls, and our community health care model, was a success. This model can 
be a success for many more victims across the country.

My work with human trafficking victims as a frontline physician has focused 
mostly on the role of the community health centers. And so my comments will 
carry that perspective today. I hope to answer the questions, what is the 
responsibility of the health care system in addressing human trafficking? 
What are the unique opportunities and advantages of community health 
centers in preventing, intervening in, and ending human trafficking? And 
third, what can government and Congress do to interrupt and intervene in 
and to enable community health centers to effectively care for trafficked 
patients?

Christina's story highlights the health care system as a critical access 
point for reaching victims because of the very nature of human trafficking. 
You've heard from Celena and Roxana. Victims experience severe physical, 
mental health and social harms in the short and long term.

So Christina suffered from all three types of harms that night--a possible 
sexually transmitted infection, depression, anxiety and criminalization, so 
physical harms, mental health harms and social harms. And here she was in 
my health center, severely ill, a trafficked patient, refusing to go to the 
hospital. Her fear of being jailed for the very victimization causing her 
illness placed her at risk of dying.

Overall, our response as a society to victims is simply inadequate and 
flawed. When I think about those trafficked, I think about how underground 
and hidden victims engage with systems of care and protection in an above-
ground functioning society. The focus of the criminal justice strategies to 
reach victims and to end labor and sex trafficking is limited, reaching 
only a select few.

In 2006, Asian Health Services conducted an internal survey of the Banteay 
Srei youth development program for the sex-trafficked minors. And we 
learned that out of the 40 girls participating in the program that year, 
only three of them had a law enforcement interaction. This means that 93 
percent, almost 93 percent, of the patients who were being sex trafficked 
participating in our program were not being reached within the criminal 
justice sector. Yet they were engaged with the health care system.

So relying on a justice framework to identify and reach victims means that 
we miss many others who don't receive, don't qualify for, don't want to use 
or are excluded from criminal justice services. And like Christina, many of 
the victims are treated like criminals.

So this call for a robust public health and health care system response to 
human trafficking has been echoed by justice and law enforcement 
leadership. The foremost priority of the criminal justice system is to 
uphold the laws of the state. In best cases, the state interests overlap 
with victims' needs. But sometimes those interests are at odds. When 
victims feel too scared or hopeless to participate in the prosecution of 
their traffickers or when they don't have a strong case for prosecution, 
does that mean they won't get the services and the healing care that they 
need?

Separating the priorities of the state in prosecution of traffickers from 
the priorities of the victims in healing may yield better results in ending 
trafficking by allowing victims the time to heal and regain agency over 
their lives, with one possible outcome being that eventually they'll be 
strong enough to participate in the prosecution.

Compared to other sectors in a functional society, the health care system 
provides opportunities for interaction and engagement throughout the entire 
life span, from pregnancy to childhood to adulthood, from acute emergency 
care to long-term chronic care, from public health outreach to 
hospitalizations. So all points of care are opportunities to prevent and 
start the process to end human trafficking. It's like a long-term process 
of rescue.

So when I think about the health care system, I think about the whole team 
of professionals who provide care. Christina's engagement began outside of 
the clinic walls when the youth program told her about our services and 
educated her about the harms of commercial sexual exploitation and sex 
trafficking. That outreach enabled her to access the clinic. And the 
Banteay Srei case manager enabled her to go to the hospital. She actually 
went and provided that transportation, enabling her to access care, to get 
the life-saving treatment that she needed.

So Christina is not alone. Studies showed--and one of them was Dr. 
Lederer's--that between 28 to 87 percent of trafficking victims had seen a 
health provider or clinic.

I think that community health centers are the best health care response to 
human trafficking. Like Christina, untold numbers of trafficked people are 
accessing care at health centers and their many community programs. A study 
I published this year shows that trafficked minors can be identified in the 
community health center setting when they're asked those questions.

Although there's no single profile of the human trafficking victim, people 
vulnerable to trafficking include runaway youth, foreign nationals with a 
different language or culture, poverty, and those with a history of trauma 
or violence. There's significant overlap between the trafficked and at-risk 
trafficking victims with patients who are seen at community health centers. 
At the community health centers we see a disproportionate share of the 
nation's poor and uninsured. Most are members of racial and ethnic 
minorities. And millions of health center patients are served in a language 
other than English.

Asian Health Services is not the only clinic doing this work. There's other 
models that are developing to provide integrative care for trafficking 
victims. There's a partnership in Honolulu between Kokua Kalihi Valley 
Community Health Center and the Pacific Survivors Center. We provide this 
care despite scarce resources.

So health centers are also unique because they provide these enabling 
services. You heard Roxana and Celena talking about how their handlers were 
answering all their questions and they were providing the interpretation 
for them. So in community health centers, we provide special non-clinical 
help, enabling vulnerable patients access to care, including things like 
interpretation. At Asian Health Services, we have interpreters in 12 
different Asian languages.

So, finally, community health centers serve more than 24 million patients 
in over 9,000 sites across the United States. This equals millions of 
clinical and non-clinical opportunities in that system to reach out to, 
identify, and help trafficked patients.

So with all this in mind, I have some recommendations to help shift the 
care for victims from the criminal justice sector to the health care and 
public health system.

One, create wrap-around care teams in community health centers across the 
nation. Focus on reaching out to and providing care to victims of human 
trafficking.

Two, create human trafficking-specific programs, like Banteay Srei, within 
health centers to address the physical, mental health, and social harms 
that result from being trafficked, through all the stages of trafficking, 
from prevention to long-term care.

Three, ensure language accessibility for victims and cultural competence by 
professionals throughout all systems that engage with human trafficking 
victims.

Four, ensure that non-clinical assistance enabling victims to access care 
is provided throughout the health care system.

Five, incorporate trauma-informed care training throughout all systems that 
engage with human trafficking victims.

And finally, please direct the federal agencies to consider health 
impacts--physical, mental, and social--of anti-trafficking policies on 
victims and survivors.

So in conclusion, let's get back to Christina. So our team that night was 
successful in getting her treated at the hospital. After two months, her 
physical health improved. She was ready to be discharged. But guess where 
she was discharged to. She was discharged directly to the county jail. So 
we can and we must do better.

Thank you.

Mr. Smith. Thank you so very much for those not only insights, but the 
recommendations, which I think will help all of us come up with a better 
plan. Thank you, Dr. Chang. Ms. Garcia.

Ms. Garcia. Thank you. First, thank you so much for the opportunity to 
speak in front of everyone here. I really appreciate the opportunity to do 
this. Thank you.

I work with survivor victims of sex trafficking and labor trafficking every 
single day. I'm here to tell you some of the recommendations that I would 
like to see, but also to tell you about some of the issues that we're still 
experiencing.

The average sex-trafficking victim, as you heard from Celena and from 
Roxana, could be serving 30, 40, 50 johns a day. Take, for example, the 
story of who I will call ``Adele,'' who was found on a Sunday. And on 
Saturday, the day before, she reported serving 70 johns in one day. As you 
can imagine, the repeated exploitation that happens to these victims 
creates many, many health issues that, of course, also end up being 
chronic.

I would like to explain some of the physical abuse that these victims 
sustained over time while being handled. These include punching, slapping, 
hair pulling, ear pulling, being beaten up with sticks and belts and shoes, 
choking, smothering, and, of course, also being repeatedly sexually 
assaulted by the handler as well.

I'll give you another example. This person I will call ``A.T.'' She was 
recruited at age 17. And whenever she complained or whined or made remarks 
about stopping, she was locked in a room with no food while the trafficker 
continued to sexually assault her. In her case, she was trafficked for five 
years; also had contact with the health care industry. No one asked a 
single question. Every single time she was discharged back to the 
trafficker.

Here's my second point. Minor and adult victims of sex trafficking may 
appear to be junkies or addicted to illegal or prescription drugs when they 
show up in the health care industry. It is part of the traffickers' control 
method to create even more vulnerability for the victim by keeping them 
addicted to drugs. Because they have been forced to use drugs from the time 
of recruitment, by the time that they show up in a health care facility, 
they're drug users and addicted to something.

For example, in the case of a person who I will call ``B.T.'' She was 14 
when she was recruited and forced to use drugs on the second day with the 
trafficker, and every day after that. In her particular case, the 
trafficker would decide what drug he would force her to use, whether it was 
injected or by mouth. Sometimes she was given drugs that would make her 
hyper and active because she was expected to serve dozens of buyers, 
sometimes in parking lots. Other times she was given drugs that would 
create unconsciousness because she had a certain buyer who wanted to 
perform certain paraphilic behaviors that she was not OK with performing. 
So while she was unconscious, these things were done to her. She was 
recruited at age 14, trafficked for five years.

Because of the repeated sexual exploitation, physical abuse, the drug use, 
the victims end up having at least one or reported encounters with the 
health care providers in our system. Here are my points for the health care 
providers.

First off, we need to understand that more time needs to be spent assessing 
the difference between perceived prostitution and self-voluntary 
prostitution. Victims are still being treated with confusion regarding the 
symptoms they present and the stories that they tell as to whether or not 
it may be prostitution, even when they're minors.

We are not asking intake staff, nurses, doctors and health social workers 
to become investigators or experts. We need them to understand the unique 
aspects of complex trauma, the bonding that happens between the victim and 
the perpetrator as it happens in human trafficking, and that there is a 
process of incremental disclosure where, unless you spend time talking to 
this person, they are not going to disclose what's happening to them.

Second, health care departments everywhere in the United States, in every 
state, need to have appropriate protocols in place that must be strictly 
followed, even when a patient is denying being forced or coerced, but the 
medical personnel is suspicious that something is going on.

Assuming that it's just prostitution increases the risk of a victim not 
being helped and being discharged back to the perpetrator, as we saw in the 
case of Roxana and Celena. Signs, symptoms and self-disclosures of 
prostitution-related activity should be treated all the same by medical 
professionals. Even when someone is saying I'm prostituting and I'm doing 
it on my own, the protocols still need to be followed.

Any of the previously mentioned signs--physical, psychological, the signs 
that Roxana and Celena talked about--all of these need to be considered by 
medical personnel as enough to make an additional phone call to the 
appropriate state, local or federal law enforcement or nongovernmental 
organization in the area the facility is located in.

In most cases, especially in the case of adults, likely the first person 
that should be called is an NGO rather than law enforcement. That NGO could 
lead to law enforcement. That NGO could be the person that they trust 
first.

Third point: All hospital personnel that come in contact with patients have 
to understand human trafficking. There should be at least one individual in 
each department that has been uniquely trained to be able to interview and 
talk to a potential victim.

Specific ways of interviewing have been found to be more successful than 
others. For example, we have found that utilizing the word ``help'' is a 
trigger to the victims because they have already been forewarned by 
traffickers that they are not to accept any help, that they are not to act 
in any way that's going to cause someone to think that they need help. So 
utilizing the word ``help'' by medical personnel is going to automatically 
trigger them to say, no, I'm fine.

What needs to be said is something like, there is this person that's going 
to come and talk to you; this is part of our protocol. And that person 
needs to be uniquely trained to learn how to gain their trust and to be 
able to maintain that trust with that victim.

Next point: All personnel must have appropriate access to numbers and know 
who to call, whether it's services for minor or adult victims, which many 
times are different from state to state; the services that are provided to 
minors and the ones that are provided to adult victims are different in 
many states, and the medical personnel should know the differences on who 
to call.

It is no longer OK for medical personnel not to respond correctly due to 
lack of knowledge or not being able to understand what's going on. They 
must know who to call and how to respond so that the process of helping the 
victim goes through. It's no longer OK for medical personnel to discharge 
patients without creating some type of connection or providing additional 
assistance outside of the medical facility for the victim.

The victim should at least leave with some form of information on how they 
can get help if they decide to do so eventually. Many times we have seen 
cases where when they make contact initially with a health care provider, 
they may not be ready to talk, but two or three days later, because they're 
upset or they got a beating or they had an opportunity to make a call, they 
will call. But what happens when they're discharged and they have no one to 
call, no information, no number? Now we have nothing.

Interagency--and by this I mean law enforcement cooperation and NGOs--is 
critical. There has to be a relationship. Because of this process of 
incremental disclosure, which may take a long period of time, it is 
essential that health care facilities develop relationships with all of the 
agencies that are going to be involved.

Last--I'm going to leave you with this--I have personally seen this: When 
protection procedures for these victims in the health care facilities are 
consistent, honest, and reliable, the victim can feel supported and 
encouraged throughout the internal disclosure process and maybe will agree 
to receive help at the moment or later on. This can surmount current 
difficulties in supporting survivors over time and through the physical and 
psychological difficulties of stepping out of the trafficking environment 
and the post-
trafficking process of restoration and rehabilitation.

Thank you.

Mr. Smith. Yaro Garcia, thank you as well for, again, your very specific 
recommendations and the insights that you have provided. They will all be 
used, I can assure you, very effectively by this Commission and by other 
members of Congress, so thank you.

I'd like to now--Dr. Greenbaum--yield.

Dr. Greenbaum. Thank you. Good afternoon, Chairman Smith, distinguished 
Commission members and members of the audience. I'm grateful for the 
opportunity to testify before you today.

In addition to my oral testimony, I would like to submit written testimony 
into the record.

My name is Jordan Greenbaum. I'm a child abuse physician at the Children's 
Healthcare of Atlanta Stephanie Blank Center for Safe and Healthy Children. 
I'm also a consultant for the International Center for Missing and 
Exploited Children.

The Blank Center provides medical and behavioral health services to 
suspected victims of abuse and their families. The International Center for 
Missing and Exploited Children is a nongovernmental organization that 
combats child trafficking and child exploitation globally.

I'd like to provide testimony today on sex and labor trafficking, 
especially involving minors.

As you know and has been said a few times, reliable estimates of the 
incidence and prevalence of human trafficking throughout the world are not 
available. But the best estimates indicate that millions of adults and 
children worldwide are involved in trafficking. Victims of human 
trafficking may experience a plethora of physical and emotional adverse 
consequences, including traumatic injury from physical assault and sexual 
assault, work-related injury, sexually transmitted infections, post-
traumatic stress disorder, major depression with suicidality, and anxiety 
disorder.

Despite the criminal nature of human trafficking and the desire of 
traffickers to elude detection, we do know that victims come into contact 
with health care providers. We also know that victims rarely self identify 
and may even deny victimization, as we've seen very eloquently. Therefore, 
it is incumbent on the health care provider to recognize signs of at-risk 
youth and adults, to ask questions appropriately, and to provide trauma-
informed care to identified victims.

The problem is, how does a health care provider recognize a potential 
victim if they don't identify themselves as such? This is a real quandary.

At Children's Healthcare of Atlanta, we recently conducted a pilot study to 
describe characteristics of sex trafficking victims. Based on that data, we 
designed a six-item screening tool, and a cutoff score of two positive 
answers was determined to have a 92 percent sensitivity for identifying 
child trafficking victims. A child with a negative screen had a 97 percent 
likelihood of not being a victim. Now, our study results need to be 
validated with other adolescent populations outside Atlanta, and currently, 
we're conducting a multisite study.

Beyond knowing what questions to ask and when to worry, health care 
providers need to know how to interact with potential victims in a way that 
does not re-traumatize them, that encourages trust and honesty. A trauma-
informed approach is absolutely essential.

This approach to patient care involves the medical provider recognizing the 
real possibility that patients they're interacting with have experienced 
some sort of trauma, and that this trauma may influence how the patient 
responds to questions, how they respond to interactions, their behavior 
with health care providers and others.

Victims of human trafficking have almost certainly experienced complex, 
repeated severe trauma. And this, combined with their additional distrust 
of authorities, their fear, their shame, their humiliation, makes it very 
difficult for health care providers to interact with them in a way that's 
appropriate.

It's quite a challenge. It's not easy for a health care provider to 
consistently respond with support and understanding if a patient appears 
hostile, disinterested in receiving help or protective of the trafficker. 
But these reactions may be all related to trauma. The victim is responding 
to their trauma, and it's imperative that health care providers understand 
that and not respond inappropriately. But again, a calm, nonjudgmental, 
supportive approach may be the only way to convince a victim to disclose 
their victimization. But that's not an easy thing, and health care 
providers are not necessarily trained to do that. In medical school, we are 
not trained to do that. In nursing school, they are not either. So this is 
something that has to be learned, and we have to set about training 
professionals on doing that.

The problem is that many curricula had been designed and implemented 
throughout the United States training health care providers--lots of 
webinars, lots of training scenarios--but almost none of these have been 
formally evaluated to see if they're really effective. And this is 
extremely important: Before we invest thousands, hundreds of thousands of 
dollars trying to teach hundreds of thousands of health care providers how 
to respond, we need to know whether these curricula are effective.

There are some exceptions to this. At Children's Health Care of Atlanta, we 
developed a six-part webinar series on child sex trafficking designed for 
health care professionals. Results from the post-webinar survey documented 
significant changes in beliefs about trafficking. And in a six-month 
follow-up survey, we found a significant increase in the percentage of 
webinar participants who are now asking adolescents questions about risk 
factors related to sex trafficking. And that represents an important 
persistent behavior change.

In general, health care providers are not trained to actively seek 
relationships with non-medical outside organizations. We're just not good 
at that. We don't feel comfortable doing that. And so that's another thing 
that has to be learned. We have to have a paradigm shift. Health care 
providers tend to work within the health care system: We're very good at 
interacting with each other but not so good with interacting with other 
people and other agencies, and that has to change. It's a critical step in 
the process of caring for patients who are trafficked victims because we 
need to be able to bridge the gap between the medical world and the 
community agencies that can provide the services to victims.

The HEAL Trafficking organization is developing a protocol that will 
provide step-by-step assistance to health care providers who want to work 
with their community to develop an anti-trafficking multidisciplinary team. 
Such a tool will help providers bridge that gap between the medical clinic 
and the community services that are so important for survivors.

And finally, I want to discuss the World Health Organization's 
International Classification of Diseases. This is a system used by health 
care providers worldwide to code all symptoms, diagnoses, and procedures 
related to health care. The ICD codes are very important because they're 
used to monitor incidence and prevalence of health problems and provide 
critical data for monitoring world health. Currently, there are no specific 
codes for human trafficking. This makes it extremely difficult to obtain 
epidemiologic data about human trafficking and to study health 
complications related to human trafficking.

In December 2014 the International Center for Missing and Exploited 
Children initiated a proposal to the World Health Organization to adopt 
specific ICD codes for child sexual exploitation and adult sexual 
exploitation. In early 2015 the HEAL Trafficking organization initiated a 
similar proposal to the World Health Organization asking for codes for 
labor trafficking. These codes will support the initiative of the SOAR to 
Health and Wellness Act by providing, quote, a reliable methodology for 
collecting and reporting data on a number of human trafficking victims 
identified and served in health care settings, end quote. The International 
Center and HEAL Trafficking are eager to see the proposals accepted and are 
seeking support from other stakeholders.

In conclusion, human trafficking is a public and private health issue, and 
health care providers play a critical role in identifying victims. They 
need training to know how to recognize victims and how to respond 
appropriately. And specifically, this includes trauma-informed care--how to 
respond, how to ask questions, how to do that in an empathic way that 
doesn't discourage victims from coming forth. They need to be able to work 
with community providers, to reach outside the medical system, to help 
bridge that gap so that survivors have somewhere to go. Then we need to 
train them on how to do that. This training needs to occur in the United 
States but also overseas, because trafficking is a transnational problem 
and requires a transnational solution.

Thank you for the opportunity to speak to you today.

Mr. Smith. Thank you so very much, Dr. Greenbaum.

I'll begin with a few questions and then ask our two ladies if they would 
want to come back up to answer any questions for me, either myself or 
anybody in the audience.

First, Dr. Chang, you mentioned 93 percent of the victims didn't have any 
contact with law enforcement. Did any percentage of those victims, as they 
went through your program, decide at some point--and how long was that lag 
between when they had enough confidence--to bring a case or to identify the 
perpetrator of the crime? And what were the outcomes? And did that give 
them any sense of empowerment, that the person that had done such horrific 
things to them has now been held accountable, or at least is not able to do 
it to others?

Dr. Chang. Well, actually, you bring up a very good point, Chairman. We 
actually have a protocol in place now where we will--if as a health care 
provider we suspect any sex trafficking of minors, we will make a report to 
the child abuse professionals. We also make a same-time report to the 
police department. However, what happens is the systems, these two systems 
were not built necessarily to address this problem. So the child welfare 
department says that it's not abuse committed by a caregiver, so refer to 
the police. The police say, is your victim willing to make a report? And 
no, they're not. So we do make these reports in the hopes that the data is 
being collected so that it can show down the line that this is a very big 
issue in our community, but as of yet, there are no systems responses that 
are coming in to intervene within our clinical setting.

Mr. Smith. Does it at least add to the surveillance of a potential 
trafficking area? We just had a case in my own district where we got some, 
what I think was, actionable information. We got it right to the FBI and to 
local law enforcement in that order. And they are now looking into that 
matter very aggressively. Do they at least follow it up in that way?

Dr. Chang. I think they do follow it up that way. And in fact, in 
California, they did just a couple years ago change the reporting 
requirements for child abuse to include suspected sex trafficking.

Mr. Smith. And in terms of the community health centers, has the national 
association at all looked into this as a protocol to follow?

Dr. Chang. I hope they are. And in fact, they did invite me to speak on a 
human trafficking panel last year. So we're getting on that with the 
Association of Asian-Pacific Community Health Organizations, which is a 
member of NACHC as well.

Mr. Smith. You know, we recently had a huge bust in Lakewood, New Jersey, 
which is in my district, of a number of Mexican traffickers and women who 
were liberated who lived in Lakewood. We do have a community health center. 
And frankly, I've been working on this since 1995, and while I've been to 
the community health center, we are checking now to see what it is that 
they do. I think you inspire all of us to look into our own--I have three 
in my district. They serve a very, very compelling need for health care. 
And they do have trauma because that is, as you've all said, a very 
important component of all of this. So thank you for that insight as to 
part of the remedy to helping.

In terms of faith based, do you find, all of you, that you seek to 
integrate the faith-based community? I've been in shelters all over the 
world, as well as in the United States. I can tell you that at least in my 
view, where there has been some connection to faith, the healing process--
you know, mental health, opens up doors, helps diagnose the problem. 
Psychologists, psychiatrists do wonderful work. But when it's done in 
companion with a faith-based approach, the deeper healing often can occur.

I was recently in two shelters, one in Lima, Peru, the other one in La Paz, 
Bolivia. And both were supported by the governments. And, you know, to have 
the Bolivian Government support something, given Evo Morales' viewpoint 
towards the church, which is not a good one--and yet that government does 
support this faith-based initiative in La Paz. But I met many women, young 
women especially, who were there. And the key was longevity, or a key. 
There weren't there for two weeks. It wasn't a shelter just to get out of 
the--they were there in some cases for two years or longer. But they 
learned life skills. They were learning computer skills as well. But they 
had a joy that was just remarkable.

In like manner, I was in Goma in the Democratic Republic of Congo, where 
several women, many women, had been subjected to sexual abuse and rape 
based on war. And again, in HEAL Africa, another faith-based group, they 
were having incredible results, not only treating the physical side as best 
they can but also the mental health side, but the spiritual side as well. 
And I'm just wondering if you find in your work that that's a component 
that you embrace and feel should be a part of this?

Dr. Greenbaum. We certainly see a strong faith-based interest in our--and 
I'm from Georgia, and a lot of faith-based organizations are very 
interested in anti-human trafficking efforts, so they put a major effort 
into creating homes and safe houses and putting forth a lot of volunteers. 
So it's extremely helpful.

Ms. Garcia. As well here in the same format as well, providing places that 
are safe. One of the things that I have noticed with the Point of Contact/
Point of Rescue program that it's mentioned there, with this program it's 
like a triangle effect where we teach the health care personnel, law 
enforcement, and the hotline all to respond to calls and work together in 
this way. Where the faith based I find has helped is through the process 
once they have established some type of connection or relationship with the 
health care provider. Whether it is the psychologists or a counselor, 
whoever it may be, I find that having a neutral person that they maintain 
contact with really helps through the process of that incremental 
disclosure that eventually may lead to prosecution--or successful 
prosecution, I should say. So having that neutral contact that's consistent 
is essential. And in my case, in most successful cases, it has been a 
neutral party. It's not a law enforcement person, it's not the pastor of 
the church, and it's not the doctor. It's someone else who the child or the 
adult is seeing outside of the system.

Mr. Smith. You did say call the NGO rather than law enforcement or at least 
first--

Ms. Garcia. Especially for adults.

Mr. Smith. Are there enough NGOs in your opinion?

Ms. Garcia. No. And this is one of the suggestions--they're probably both 
shaking their heads no--this is one of the suggestions that needs to be 
made that in every county, in every state, there has to be an identified 
NGO that can respond to these calls, outside of the Department of Children 
and Families.

Mr. Smith. Yes, please.

Dr. Chang. Thanks. I wanted to address the spiritual--the faith-based 
response. I think it is essential. And in fact, sometimes traffickers use a 
deeply held faith by a victim as a form of abuse. For example, I did some 
work in the Western Pacific and in the Pacific jurisdictions, and there was 
a young girl who had been sex trafficked and raped and kidnapped forcibly. 
And the traffickers repeatedly told her that her God no longer loved her 
because she had been defiled. And so I think the healing component for 
spiritual aspects is very important.

Mr. Smith. Ms. Yaro Garcia, you mentioned--upon leaving an emergency room 
or health venue, they need to know who to call. How do you convey that if 
the handler, as was said earlier, even to the point of being with her 
during the birth of her child, how do you get that information? Do you look 
for--does an especially trained person look for some place where they close 
the curtain and say, everybody out, and then they just do it like you're 
doing at a----

Ms. Garcia. Correct. That's exactly what we are training the hospital 
personnel to do through Point of Contact/Point of Rescue is first off, you 
must get everyone to leave the room--and medical personnel, by the way, 
have that authority, in every state; they can ask everyone to leave the 
room--and then conversate with the potential victim about, I'm going to 
give you this information; where can you put it? How could I help you 
memorize it? Take it with you. I know you don't want it right now, but if 
you do later, I want you to have it.

Mr. Smith. Are there many instances where the trafficker or the pimp found 
a card, business card, something with a phone number on, and then----

Ms. Garcia. Yes, I have had those cases, especially with minor victims. 
However, it's few compared to the cases where it hasn't happened.

Mr. Smith. Right.

Dr. Greenbaum. Can I just add something to that? I do a lot of training of 
health care providers, and two of the questions they almost inevitably have 
are, how do we get the person out of the room so we can talk to the child 
alone? And what do I do if the child refuses to stay and I need to make a 
report and they want to leave?

And the answer to the first one is that we usually say it's our policy here 
at Children's or the clinic or wherever you are, it's our policy here to 
interview all adolescents alone, so I'm going to need to have to ask you to 
step out, and there's a waiting room down the hall; can you just step this 
way? You're not really asking them; you're sort of telling them. But you're 
saying, this is a policy; we do it for all parents. And so the person 
usually goes. If they don't, if they refuse to leave the side of the 
victim, like in your case, what I would suggest is that the health care 
provider come up with a different scenario saying, you know, we need to get 
this child a chest X-ray, and we're going to need to take her to radiology. 
We need to draw some labs. We're going to have to take her to the 
laboratory. And so you escort the child or whoever the patient is, you 
escort them out and leave the trafficker in the room.

The other thing that I think refers to what you were getting at as to how 
do you give information to a patient in a safe way. And that is I think 
very difficult, and we have to be very careful because no one knows more 
than the patient how safe they are and what will put them into danger. And 
so I agree, we have to be very, very discreet about that and say, can I 
give you these resources? And if not, if they say, absolutely not, then we 
don't, but we can leave the door open and say, this is a safe place to 
come; if you decide to come back, come here, we can offer you services. 
That's all we can do, but----

Mr. Smith. Dr. Chang, you talked about the fear of jail. And I'm just 
wondering, you know, when we--and I was the prime author of the Trafficking 
Victims Protection Act. One of the areas that we had a great deal of 
headwind to overcome was the T visa and providing safe haven and really 
doing a sea change in terms of saying, these are not perpetrators of 
crimes; these women are victims--or men, but most, obviously, in sex 
trafficking are women. And, you know, that is the law. Matter of fact, the 
definition to anyone that has not attained the age of 18 by definition is a 
trafficking victim if just one commercial sex act is committed, and then 
forceful coercion for anybody after they have attained the age of 18. So 
the fear of jail--is it that law enforcement is not sufficiently aware? Is 
it the local or state laws that are the problem? I mean, federal law I 
think is clear. But your thoughts on that, Dr. Chang.

Dr. Chang. Thank you for asking. That's a wonderful question. And you're 
right, it's--federal law has clearly defined my patients as victims. I 
think it takes--it's taking time for the state laws to catch up--and also 
the application of state laws by the different counties and the different 
prosecuting attorneys, depending on the states and how they divide up their 
law enforcement and criminal justice system. So in California, there are 
still counties that are able to arrest minors for solicitation.

Dr. Greenbaum. I think it's also that traffickers will threaten the child 
or the patient with saying, you'll get arrested, and I won't. If you go to 
law enforcement, they'll arrest you and throw you in jail or deport you.

Ms. Garcia. In the case of Celena, she was held in state federal prison for 
three months when she was found, for three months. And again, this goes 
back to not utilizing the appropriate services that are available and law 
enforcement not understanding that other services also have to be provided, 
that it's not just you interviewing and prosecuting a case; this individual 
has to be allowed to become a--to have a process where they go through that 
process of incrementally disclosing what they want to disclose. Sometimes 
law enforcement has an idea that because they're victims, they should be 
ready to talk; because they're victims, they should be ready to be rescued 
or be helped. This is not what we see with human trafficking. We're talking 
about very, very complex trauma, bonding that happens between the victim 
and the perpetrator.

Mr. Smith. Roxana earlier had spoken about the handler staying with her 
even as the baby was being born. And my question is, are these handlers, 
these pimps that good of actors that they can deceive a group of very 
highly competent--medically speaking, certainly--people? Emergency rooms 
are tough places to work. Are they that pressed for time? Or is it the 
sense of, don't ask questions, just be indifferent, just handle the patient 
and don't judge, or some nonsense like that where you're not judging, 
you're ascertaining the nature of the situation? But it seems to me that 
there would have to be giveaways at all times.

Dr. Chang. Go ahead.

Dr. Greenbaum. I think there are a number of factors, and it probably 
differs with different physicians. I think certainly time and requirements 
for productivity drive a lot of behavior for medical care. They have to see 
a number of patients, and they have to keep going. There are 16 patients 
waiting to be seen. I think there is also discomfort: I'm not sure how to 
ask these questions, I don't know what to do, I don't know--what if they 
say yes, there are a victim? I don't know who to call, so if I don't ask, I 
won't have to respond.

Mr. Smith. Let me ask you on that, is the American Hospital Association, 
are they promulgating recommendations for their own hospitals? Because they 
are a huge network.

Dr. Greenbaum. I think that's a very good point. I don't know that they 
are. We are working very hard with individual medical organizations to try 
to get policy statements. For example, the AMA has issued a policy 
statement saying physicians need to be trained on how to recognize and 
identify victims. And so a number of these medical organizations are 
working. But I think your suggestion of the American Hospital Association 
is a very good one.

Mr. Smith. I will offer, if you want to work with us, we'll write a letter 
to the AMA----

Dr. Greenbaum. Yes. Sign me up.

Mr. Smith. ----AMA is already doing it--American Hospital Association and 
others asking them specifically as the Helsinki Commission what are they 
doing, will they do it, and help us tell them or convey to them what a best 
practice would be for the hospitals--what you're doing. But, I mean, we'll 
work on that immediately.

Dr. Greenbaum. I think the whole thing having to do with trauma--

Mr. Smith. Maybe we'll invite them to a hearing. Find out what they're 
doing.

Dr. Greenbaum. The whole idea of trauma-informed care is such a sea change 
for the medical world for people to really take the time to ask people 
about possible trauma and to interpret their behaviors as possibly 
reflecting their traumatic experiences. And to take it into account is so 
different than what we've been told and taught in medical school, in 
nursing school. It's a hard thing. But it's absolutely essential that we do 
that.

Ms. Garcia. I think we're also looking at an understanding of an issue of 
loyalty. Many of the victims have a sense of loyalty to the trafficker 
because of that bond that I keep talking about. And if medical personnel 
doesn't understand that there is that loyalty, they get confused by, well, 
they don't want to talk about anything happening to them and they don't 
want to say what's happening to them, so therefore what can I do? What they 
can do is understand that there may be that loyalty and approach the issue 
in a different way. Sometimes it's as simple as saying--in the case of 
Roxana, she has told me before, she says, I wish that they would have just 
said to me, you can come back here the next time that you have a fight with 
your partner. As simple as that. Treat it with some normalcy to her, and it 
would've felt safer.

Mr. Smith. Let me ask you, what time of day and what part of the week is 
there any sense that trafficking victims are brought in? Like late Saturday 
night after they have been abused to the point where they break down and 
are unconscious or--because I remember I traveled with the proactive unit 
of the Trenton Police, second term, so it was, like, 32 years ago. And they 
brought in a woman who had been raped who was unconscious. And she was so 
badly beaten it was--I mean, I was crying, I just had to hold back--I felt 
so bad for her. But there was a matter-of-fact attitude towards her that--
and again, trauma people see it all the time, and for them it must be--you 
know, they just steel their emotions. But I kept looking at this poor woman 
who was just battered and wondered, did they catch the guy? Did they--and 
so do you find there is a certain time of the week, certain hours of the 
day that traffickers bring their victims in?

Dr. Greenbaum. I think that since victims have to work 24 hours a day, 
seven days a week, that they can be beaten at any time and be brought in at 
any time. That's my thought on it. I'm interested to hear what the other--
--

Ms. Garcia. Same here. I have not found a specific pattern on times. I know 
in the state of Florida the busiest days for the brothel activity is 
Mondays and Saturdays. However, in my cases that I have worked, no specific 
pattern on when they're taken in. It just basically happens when it gets to 
that point where it just--there is nothing else the trafficker can be 
pushing for.

Mr. Smith. Could I--I'm sorry--Dr. Chang--the WHO--you know, part of my 
subcommittee, it's called Africa, Global Health, Global Human Rights and 
International Organizations, so the U.N. does come under. And, you know, I 
have followed with great interest. I have been up to the U.N. I'm the 
special representative for the U.N. this term; it's the third time I have 
done it over the years, over 35 years, as a member of Congress. But the WHO 
comes under--we deal with them all the time. I have a big hearing, for 
example, next week on tuberculosis, particularly multidrug resistant TB, 
and the WHO has just sounded the alarm for just how dangerous--and I know 
some of the trafficking victims do suffer from that, as well as HIV/AIDS 
and other diseases.

But I'd like to follow up on the WHO side with the codes that you spoke 
about. So again, anything specific you can provide with the post-2015 
sustainable development goals. We tried very hard to get more explicit 
language on combating human trafficking for the global effort, which will 
be in effect for the next 15 years. So specifically on WHO, I'd love to 
follow up with you on that, all of you, if you'd like, because I think 
that's something that needs to be done.

Dr. Greenbaum. We could really use the help. We have submitted the 
proposals, and the ICD 11 is the new coding edition. And that is in its 
beta phase through 2017, and that means that people can provide proposals 
for change, and people review them during this time. And so if we could 
have your support in saying these are good, this is a good idea, or this is 
a good idea, but I suggest you change the wording--we're open to 
suggestions. But we really need support to make it go through. So I would 
love to be able to talk to you a little bit more about that in specific 
details.

Mr. Smith. Very good. Thank you. We'll do that.

You know, we did check with two community health centers in my district. 
And while they're interested, they don't have something, so I'd like to 
follow up with you on that and try to get that going in our area. Thank 
you.

Just a couple of final questions, and maybe we can turn that off and just 
ask one or two final questions of our two other witnesses. But the Federal 
Strategic Action Plan, your thoughts on that? Obviously, it began in 2013. 
Are you encouraged as it's taking shape?

Dr. Chang. I am actually very encouraged by it. I think there has been a 
great push for victims and its services. Department of Health and Human 
Services is involved now. And I think the health resources and services 
administration side is involved as well.

Ms. Garcia. I'm also very encouraged by it. And the only thing that I would 
suggest at this point that I would like to see with it eventually in the 
future is that more specific on protocols and what to do, especially with 
the health care system, a little bit more of that.

Dr. Greenbaum. I'm very encouraged by it as well in the sense that it very 
strongly advocates for a victim-centered approach and increased victim 
services. I do also appreciate the idea that whatever we do, we need to 
make sure that we look at outcomes measures and test the efficacy of these 
various strategies. It's not enough to come up with great ideas that feel 
good and start implementing all these programs. We need to measure the 
outcomes and make sure that they're actually working and helping victims.

Ms. Garcia. I agree with that.

Mr. Smith. Roxana had talked about the rehearsed story. Is that common as 
well?

Ms. Garcia. Yes, almost every single time.

Mr. Smith. And the pimp or person that is accompanying her knows very well 
what she has to say, and if she doesn't say it, there is retaliation?

Ms. Garcia. Yes. In all the cases that I've worked, there is a rehearsed 
story. It's a little different every time, but it always appears to be a 
very normal story.

Mr. Smith. And finally, the national symposium in 2009 on the health needs 
of human trafficking victims had a number of important points, including 
cultural competency or the lack of it, the illiteracy issue. I mean, how 
often, particularly in an emergency room, does that present itself, where 
the attending or the LPN or nurse just doesn't get it because they don't 
understand the language or the nuances? They did say the consequences of 
human trafficking on mental health cannot be overstated, and I think that 
is a huge issue that's gone unfocused upon. And we know more about PTSD and 
other trauma consequences than we've ever known. Is it being applied 
effectively to these trafficking victims?

I wrote a law called the Torture Victims Relief Act--three of them, as a 
matter of fact--which provides torture centers and best practices for 
dealing with torture victims. And we have about 500,000 in the U.S., mostly 
came here, obtained asylum from a country that was a dictatorship--Africa, 
Latin America, Europe, Russia, China. And what I've learned from all of 
that, because we've had witnesses tell their stories, is that the trauma 
continues for decades--not years but decades, unless dealt with. And I'm 
wondering if we're doing enough on the mental health side to address that, 
because that can be disguised. Antidepressants can cloak it. Maybe they're 
needed. I'm not saying they're not. But getting to core issues is--so maybe 
you might want to speak to that.

And then that leads to the other issue of re-victimization, which they also 
discussed at length at the symposium. You know, they just give up, or 
they're coerced back into it, but sometimes it's a matter of such utter 
brokenness that they give up.

Dr. Greenbaum. I think that you make an excellent point. We can treat the 
gonorrhea. We can treat the closed head injury. We can treat the fractures 
and the burns. But it's extremely hard to treat the post-traumatic stress 
disorder, the suicidality. In one study of child survivors, 47 percent had 
attempted suicide in the past year. That's a very large percentage of 
adolescents.

And I think that there are some promising actions. The trauma-focused 
cognitive behavioral therapy is a very effective evidence-based therapy 
that's very good for sexual assault victims and sexual abuse victims. And 
they're working hard on tweaking it so it is appropriate for human 
trafficking victims. Now, it's in its early stages, but there is some 
promising evidence on that.

But again, everything has to be evidence based. And so I think people are 
really aware of that. They're saying, OK, we're going to tweak this 
strategy, but we've got to see if it really works. But it is promising.

Mr. Smith. Yes. Dr. Chang.

Dr. Chang. So one of the promising things about the community health 
centers is that there is the push for the integration between primary care 
and behavior health services. So we are trying in our human trafficking or 
commercially sexually exploited, my own program at Asian Health Services, 
to include the behavior health side to that.

Ms. Garcia. I think it's essential. I think that we could still make more 
progress with it. As previously mentioned, evidence-based services should 
be the key--and, of course, outcomes; we do need to start obtaining some 
types of outcomes on what best practices are, what works, what doesn't. 
Yes, I think all of this----

Mr. Smith. Is there anything you'd like to add as we near the end?

Dr. Greenbaum. I'd just like to thank you so much for focusing so much 
attention on this issue because it is something that is desperately needed, 
and thank you very much for your efforts.

Ms. Garcia. Same thing. Thank you so much. And on behalf of all of the 
victims that I have personally worked with, thank you.

Mr. Smith. Would you want to come back up, ladies, just for a moment?

[Note: The briefing proceeded to an off-the-record session, then returned 
to on-the-record.]

Mr. Smith. I mentioned that I sponsored the Trafficking Victims Protection 
Act. I always meet with traveling TIP people from different countries. As a 
matter of fact, they often go over to the TIP office. And I encourage 
them--when I know they're coming, and very often they ask, we do have 
meetings in my office with my staff.

Eight years ago I was meeting with the trafficking personnel from 
Thailand-- which is a Tier 3 country today, worst offender, but at the time 
they weren't-- and I asked them, if you knew a convicted pedophile was 
traveling to Thailand, what would you do? And they said, we wouldn't allow 
them in, and if they got in we'd watch them very, very carefully.

That day we began working on a new idea called the International Megan's 
Law. We passed a law--states, that is, although there is a federal overlay, 
but it is primarily state law. A little girl in my hometown, Megan Kanka, 
was brutally raped and then murdered by a convicted pedophile who lived 
across the street and nobody knew it. So information would have helped all 
parents in that area, including the Kankas, to take precautionary efforts 
to make sure that no one goes in that house or even near this individual.

The Megan's Laws work, to some extent. I think they work well. They keep 
these individuals from being coaches on soccer teams, baseball, softball, 
whatever it might be. And there's gradations of threat--one, two and three.

Long story short, the International Megan's Law passed three times in the 
House. NCMEC has been a very good supporter, and I'm eternally grateful for 
that, in supporting it. But it is now over on the Senate side again. The 
Foreign Relations Committee has approved it. They're hotlining it, maybe, 
today. Our hopes and fingers are crossed. But it seems to me that the more 
we break the impunity and the ability to travel in secret, to aid and abet 
people who exploit women and children, boys and girls, the quicker we'll 
get to a society where those people are behind bars, and certainly not 
going on these sex tourism trips in secrecy, because you know when they 
come back they're not just ending that. It continues, and they--as you 
mentioned, Ms. Garcia, they--you know, as they rotate the, quote, 
``merchandise''--the victims--they then abuse the women and young girls in 
their locale.

So just for the record, we are trying very hard to get this passed. Please 
keep it in your prayers, because I think it will have a chilling effect. 
And we also are trying to get the other countries to look at adopting their 
own Megan's Law so that they, too, know where they are, what they're doing, 
and when they do travel to the United States our hope would be that we get 
noticed in a timely fashion, the way we want to be noticed when they make 
their way here, because we will deny visas to those individuals, just like 
they do. In visa-free countries, or Visa Waiver countries, it presents some 
additional problems. But I think knowing where they are can have a chilling 
effect. And so that becomes part of the rubric of law and policy that helps 
victims, or tries to, and does a prevention strategy so it doesn't happen 
at all, or to the greatest extent possible.

Ms. Garcia. Thank you.

Mr. Smith. Laura, would you like to say something?

Ms. Lederer. No.

Mr. Smith. Please. [Laughter.] Laura Lederer has been a----

Ms. Lederer. I just want to thank you very much for your continued 
leadership on this. And one thought I had is, as I've been hearing 
particularly from the survivors that I've been working with Yaro, is that 
we had that hearing in 1998-1999 with the Cadena brothers, and 15 years--17 
years have passed, and the stories we heard when we were in Yaro's clinic 
were just so similar. It's almost as if the progress that needs to be made, 
particularly on these very young victims from Central America and Mexico 
into the United States--we just need to work harder on it. And I appreciate 
the work on the victims, but on the front end we need to continue to do 
that, too. And that's why it's so important for health providers to get 
over their fear of working with law enforcement and figure out how to do 
that. And so thank you all for being here. I really appreciate your 
participation.

Mr. Smith. Thank you very much.

Ms. Lederer. Thanks.

Ms. Garcia. I agree with you fully that the international aspect of this is 
also very important, where not just international awareness but 
international policies also need to keep increasing and changing and 
improving.

Mr. Smith. I do serve as special representative to the Organization for 
Security and Cooperation Parliamentary Assembly. It's 57 countries, 
parliamentarians. We meet three times a year. The big meeting is in--during 
the summer months, usually around July 4th. And I have offered one 
resolution after another for years, going back to when we first did our 
Trafficking Victims Protection Act of 2000, to try to get the other nations 
to share their best practices, everybody get on the same page--at least 
from a European perspective, the OSCE. And we've been bringing many of 
these ideas.

This hearing really does help us, coupled with all of your written 
testimonies--take this to the other countries as well--because we're 
laggards in some things, others are laggards. We want to get ahead of the 
curve rather than at it or behind it.

Again, what you've conveyed to the Helsinki Commission isn't just for the 
United States and follow up here, like with the Hospitals Association and 
all the other things we hope to do, but also, as special representative, I 
get to bring it to the others. And hopefully it's listened to. And we also 
try to work with the OAS, the African Union, because, again, there are 
areas where, if you get critical policymakers to really understand the 
issue and to do something, it has huge consequences in the positive 
direction.

 I thank you so much for your time, for your efforts, for your courage, for 
being here. You're in our prayers, believe me, because we in my office--and 
we're not unique--we do pray through these issues, believing very strongly 
that we are up against an evil that is otherworldly, to exploit people in 
such a horrific fashion. But thank you so much.

We're adjourned.

Ms. Garcia. Thank you. [Applause.]

Mr. Smith. I'd just add, Allison Hollabaugh, I just want to point out, does 
yeoman's work on the issue of human trafficking and has, as you know, 
helped put this all together. And I want to thank her publicly for her 
work. She is a tremendous asset to the Commission.

Ms. Hollabaugh. Thank you.

Mr. Smith. And so thank you, Allison. [Applause.]

[Whereupon, at 4:15 p.m., the briefing ended.]

A P P E N D I X

Prepared Statement of ``Celena''

My name is Celena. Thank you for being here. Thank you for listening. And 
as well, I'm going to tell you just a tiny bit about my story.

At the age of 19 I was brought to the United States by the man who from 
there on trafficked me for years. My initiation into this process was being 
taken to a house, where I was forced to serve initially 30 to 50 men for a 
long process that lasted weeks. And then I ended up in another state, where 
they moved me, and this continued.

Shortly after this started happening to me, as you can imagine, I was 
crying constantly. I was not behaving according to how they wanted me to. I 
was crying. I was sad constantly. I was not performing to how they wanted 
me to. I felt very ashamed. And I felt this little from what was being 
forced onto me.

So here is my first interaction with the health care industry. They wanted 
to stop me from crying so that I could perform better so they could make 
more money. So they took me to a clinic in New York. The doctor walked in, 
asked me what were my symptoms, and I explained that I felt very anxious 
and very sad and I felt like I wanted to cry all the time. She asked no 
more questions and told me that I was depressed and prescribed me 
medication for depression.

The second time I was experiencing a lot of pain from all of the activity 
that I had to perform every single day. The pain was so excessive that the 
trafficker finally decided to take me back to the clinic now to remedy this 
issue. I ended up in the same clinic, with the same nurse, with the same 
doctor--same people. She walked into the room, asked me what was wrong. I 
explained that I was experiencing pain. She didn't examine me, did not ask 
me any more questions, and gave me painkillers to take the pain away.

In 2009, this was the worst episode for me. I began bleeding excessively. 
And by now I had been bleeding for six months straight nonstop while I was 
still being trafficked every single day. The trafficker forced me to wear 
makeup sponges inside my vagina so that this could stop the excessive 
bleeding that was going on every day so that I could keep working for him.

I couldn't take it anymore, and he finally realized that and took me to the 
doctor. He told me to say that I had no family in the United States, that I 
didn't know anyone, and that I had a boyfriend who was very sexually 
active. And I had been experiencing these bleedings ever since I had 
started interacting with him.

That occasion I was at the hospital from 11:00 in the morning until 4:00 
a.m. the next day with several people doing exams and tests on me and 
looking at my interiors. And no one asked a single question. I was not even 
prescribed medication. They didn't provide me any treatment because all I 
had was excessive bleeding and lacerations. So they said just go home and 
drink a lot of Gatorade so you can hydrate, and you should not have any 
sexual activity.

All of the times I was taken to the hospital or a treatment facility by the 
traffickers no one helped me despite of the many signs that something was 
wrong with my body and with the symptoms that I had. I was bleeding 
excessively and there was swelling and lacerations. I was too quiet, afraid 
to make eye contact and barely talked. How could the doctors believe that I 
simply had a partner who was so active that he was hurting me sexually? 
This makes no sense. The medical staff could have asked me about my 
situation or simply just called law enforcement to get me out of it. Inside 
I was screaming for help I had just lost the ability to ask for help, or to 
desire it or even understand that I wanted help. The medical professionals 
had many opportunities to assist me but instead I was just discharged back 
to the people who were exploiting me.

I know that I don't have a lot of time, so I want to thank you. And I'm 
thanking you mainly because I'm hoping that somehow this will go somewhere 
else where all of the young girls and the young adults going through the 
same thing I did could be rescued easier or better or that we would find 
other ways to do this for them.

I wish that I could be the person in power to be doing this for the girls. 
But I also understand that people who are in power, like doctors and police 
officers and people that may be in this room, are the ones who could 
possibly make this happen.

Thank you.

Prepared Statement of Dr. Kimberly Chang

Chairmen Smith and Wicker, and esteemed Commissioners:

Thank you for inviting me to address the important issue of the role of the 
healthcare system and healthcare professionals in rescuing victims from 
human trafficking.

Introduction

One night in 2008, Christina, a patient of mine, came to the clinic very 
sick. She was young, about 15 years old, and had been seeing us at the 
clinic on and off for three years. Although Christina never disclosed any 
sexual exploitation, we suspected that she was being sex trafficked. That 
night, Christina had a high fever, rashes all over her body, swollen 
painful joints, a racing heartbeat, and weighed less than 90 pounds. She 
was anxious and depressed over her condition. She had delayed seeking 
health care despite feeling ill for three months. She needed to go to the 
hospital. When I told her this, she absolutely refused, stating, ``I'd 
rather die than go back to jail!'' I didn't understand the connection 
between her going to the hospital and being sent to jail. Later I learned 
that on a previous hospitalization, Christina was discharged to jail 
because a bench warrant for her arrest was issued when she failed to appear 
in court on solicitation charges. Christina did not go to the hospital that 
night. When I found out she didn't go, I feared she was going to die. We 
had failed our patient. Or, did we?

Our care did not end when Christina left the clinic's four walls. Our 
health center's youth program outreach workers and Banteay Srei case 
manager contacted their community connections all night, eventually 
locating Christina the next morning. The Banteay Srei case manager went to 
Christina, convinced her to go to the hospital, and personally drove her 
there. Christina was hospitalized for almost two months. She was treated, 
and survived. For Christina, our team-based approach, our assistance 
enabling her to access care, our public health perspective, and our 
community health center model was a success.

This model can be a success for many more victims across the country.

My name is Kimberly Chang. I am a physician at Asian Health Services. Asian 
Health Services is a Federally Qualified Health Center, which provides 
primary health care for over 24,000 primarily low-income, limited-English 
speaking patients annually; including such as case management, behavioral 
healthcare, community health outreach including a youth program, and on-
site culturally and linguistically appropriate care, including 
interpretation in twelve Asian languages. \1\ As a result of caring for 
patients like Christina, we also have a specific program for minor patients 
who have been or are at risk of being sex trafficked or commercially 
sexually exploited, called Banteay Srei (``Citadel of the Women''). \2\ For 
the past twelve years, I provided health care to domestic minor victims of 
sex trafficking, and helped develop protocols to identify affected patients 
in the primary care and community health settings. I am a co-founder of 
HEAL Trafficking, \3\ a network of interdisciplinary health professionals 
committed to preventing and ending human trafficking, and healing patients 
who have been trafficked. I consulted and advised anti-human trafficking 
task forces in the Western Pacific Compact of Free Association nations, and 
other Pacific jurisdictions, in building and strengthening the capacity of 
the public health, community health, and medical sector's response to human 
trafficking. Additionally, I have trained thousands of front-line 
multidisciplinary professionals on the healthcare intersect with human 
trafficking. I spent the past year as a Commonwealth Fund Mongan Minority 
Health Policy Fellow at Harvard Medical School \4\ and the Harvard T.H. 
Chan School of Public Health, working with the Association of Asian Pacific 
Community Health Organizations \5\ to address the role of community health 
centers in caring for victims of human trafficking.

\1\  Asian Health Services. Retrieved November 25, 2015, from http://
www.asianhealthservices.org

\2\  Banteay Srei. Retrieved November 25, 2015, from http://
www.banteaysrei.org/

\3\  HEAL Trafficking. Retrieved November 29, 2015, from http://
healtrafficking.org/

\4\  Commonwealth Fund Mongan Fellowship in Minority Health Policy. 
Retrieved November 25, 2015, from https://mfdp.med.harvard.edu/cfmf/

\5\  Association of Asian Pacific Community Health Organization. Retrieved 
November 25, 2015, from http://www.aapcho.org/

My work with human trafficking victims has focused mostly on the function 
of primary care and public health, particularly the role of community 
health centers, and so my comments will carry that perspective today. As a 
front-line physician, I also see these issues through the lens of my 
affected patients. I hope to provide some context for the role of the 
healthcare system and healthcare professionals by answering: What is the 
responsibility of the healthcare system in addressing the issue of human 
trafficking? What are the unique opportunities and advantages of 
government-funded health centers in preventing, intervening in, 
interrupting, and stopping the victimization of patients who have been or 
are at risk of being trafficked? And, what can government and Congress do 
to enable community health centers to help end human trafficking and 
effectively care for trafficked patients?

Human Trafficking is a Healthcare Issue

Christina's story highlights the position of the healthcare system as a 
critical access point for identifying and reaching out to victims. Because 
of the very nature of human trafficking, victims experience severe 
physical, mental health, and social harms, and visits to any health care 
provider are opportunities to intervene in and interrupt the exploitation. 
\6\ Think about the conditions of human trafficking and the way people are 
controlled for labor or sex, and you get an idea of the health harms to 
victims in the short and long-term. In captivity, victims are deprived of 
health care and food, are socially restricted, and are coerced into drug 
and alcohol use and addiction. They are forced into dangerous, dirty and 
degrading living and working conditions; and they are subject to all forms 
of abuse (physical, sexual, psychological, emotional, behavioral, and 
spiritual). \7\ The health harms fall into three categories:

\6\  Institute of Medicine; National Research Council. (2013). Confronting 
Commercial Sexual Exploitation and Sex Trafficking of Minors in the United 
States. Washington, DC: The National Academies Press.

\7\  Baldwin, S., Eisenman, D., Sayles, J., Ryan, G., & Chuang, K. (2011). 
Identification of Human Trafficking Victims in Health Care Settings. Health 
and Human Rights, 13(1), E36-49.

  physical harms such as sexually transmitted infections, injuries, 
malnutrition;

  mental health harms, such as trauma, depression, anxiety; and

  social harms, such as criminalization and 
stigmatization.8,9,10,11,12,13,14,15

\8\  Institute of Medicine; National Research Council. (2013). Confronting 
Commercial Sexual Exploitation and Sex Trafficking of Minors in the United 
States. Washington, DC: The National Academies Press.

\9\  Zimmerman, C., Yun, K., Shvab, I., Watts, C., Trappolin, L., Treppete, 
M., . . . Regan, L. (2003). The Health Risks and Consequences of 
Trafficking in Women and Adolescents. Findings from a European Study. 
London: London School of Hygiene and Tropical Medicine.

\10\  Felitti, V., Anda, R., Nordenberg, D., Williamson, M., Spitz, A., 
Edwards, V., . . . Marks, J. (1998, May). Relationship of Childhood Abuse 
and Household Dysfunction to Many of the Leading Causes of Death in Adults: 
The Adverse Childhood Experiences (ACE) Study. American Journal of 
Preventive Medicine, 14(4), 245-258. Retrieved from Centers for Disease 
Control and Prevention:http://www.cdc.gov/violenceprevention/acestudy/
index.html

\11\  Dovydaitis, T. (2010). Human Trafficking: The Role of the Health Care 
Provider. J Midwifery Womens Health, 55(5), 482-487. doi:10.1016/
j.jmwh.2009.12.017

\12\  Isaac, R., Solak, J., & Giardino, A. (2011). Health Care Providers' 
Training Needs Related to Human Trafficking: Maximizing the Opportunity to 
Effectively Screen and Intervene. Journal of Applied Research on Children, 
2(1), 1-33.

\13\  Baldwin, S., Eisenman, D., Sayles, J., Ryan, G., & Chuang, K. (2011). 
Identification of Human Trafficking Victims in Health Care Settings. Health 
and Human Rights, 13(1), E36-49.

\14\  Crane, P., & Moreno, M. (2011). Human Trafficking: What is the Role 
of the Heatlh Care Provider? Journal of Applied Research on Children, 2(1), 
1-27. Retrieved November 25, 2015, fromhttp://
digitalcommons.library.tmc.edu/childrenatrisk/vol2/iss1/7

\15\  Willis, B., & Levy, B. (2002). Child Prostitution: Global Health 
Burden, Research Needs. and Interventions. The Lancet, 359, 1417-22.

Christina suffered from all three types of harms that night--malnutrition, 
a possible sexually transmitted disease, depression, anxiety, and 
criminalization. And here she was in my health center, severely ill--a 
trafficked patient refusing to go to the hospital. Her fear of being jailed 
for the very victimization causing her illness placed her at risk of death. 
Overall, our response to victims is simply inadequate and flawed.

A Robust Healthcare System Response is Critical to Victim Support

When I think about people who are being trafficked, I think about how 
underground and hidden victims engage with the systems of care and 
protection in an aboveground functioning society. The focus on criminal 
justice strategies to reach trafficking victims, and to end labor and sex 
trafficking is limited, reaching only a select few. In 2006, Asian Health 
Services' Banteay Srei youth development program for commercially sexually 
exploited minors conducted an internal survey of patients--we learned that 
out of the 40 girls participating in the program, only three had an 
interaction with law enforcement. This means almost 93% of these victims 
were not identified within the justice system! Yet, they were engaged with 
the healthcare system. Relying on a justice framework to identify and reach 
victims means that we miss many others who don't receive, don't qualify 
for, don't want to use, or are excluded from criminal justice services. 
\16\ And, like Christina, there are many victims who are treated as 
criminals.

\16\  Chang, K., & Littenberg, N. (2015, July 29). Veto of SB 265 doesn't 
end need to help victims of sex trafficking. Honolulu Star-Advertiser.

The call for a robust public health and healthcare system response to human 
trafficking has been echoed by justice and law enforcement 
leadership.17,18 It is understood that the foremost priority of 
the criminal justice system is to uphold the laws of the state. In best 
cases, these state interests overlap with victims' needs. Sometimes, 
however, they are at odds. When victims feel too scared or hopeless to 
participate in the prosecution of their traffickers or they don't have a 
strong case for prosecution, does that mean the victim doesn't deserve and 
won't receive the support he or she needs to heal? The call for a robust 
public health and healthcare system response means we can create solutions 
whose foremost priority is that victims will undergo a healing process or 
obtain the educational and economic opportunities they so urgently need. 
Separating the priorities of the state in prosecuting traffickers, from the 
priorities of victim healing can yield better results in ending 
trafficking, by allowing victims the time to heal and regain agency over 
their lives.

\17\  Holder, E. (2012, April 24). Justice News. Retrieved November 29, 
2015, from The United States Department of Justice: http://www.justice.gov/
opa/speech/attorney-general-eric-holder-speakson-human-trafficking-
thefrank-and-kula-kumpuris

\18\  Tiapula, S. (2010, September 15). Hearing on: Domestic Minor Sex 
Trafficking. Retrieved November 29, 2015, from The United States House of 
Representatives Judiciary Committee. http://judiciary.house.gov/-files/
hearings/pdf/Tiapula100915.pdf

The Healthcare System: Multiple Opportunities for Intervention through a 
Team of Professionals

Compared to other sectors in a functional society, the health care system 
provides opportunities for interaction and engagement throughout the entire 
lifespan--from pregnancy, to childhood, through adulthood; from acute 
emergency care, to long-term, chronic care; from public health community 
outreach, to hospitalizations. All of these points of care are 
opportunities to prevent, intervene in and start the process to end the 
exploitation of trafficked patients, a long-term process of rescue. And 
when I think about the health care system, I think not only of doctors or 
nurses, I think of the whole team of professionals who provide care and 
service. Christina's engagement with the healthcare system began outside 
the clinic walls when she learned about the health harms of commercial 
sexual exploitation, and the care our health center could provide. The 
outreach work of Asian Health Services' youth program community health 
workers, who taught health education to various community groups and 
schools, enabled Christina to access the clinic. And the Banteay Srei case 
manager enabled Christina to get life-saving treatment at the hospital. 
Christina is not alone: studies of victims revealed a wide range of 
encounters with health care professionals and clinics while being 
trafficked--between 28-87% had seen any type of health care professional or 
clinic.19,20,21

\19\  Lederer, L., & Wetzel, C. (2014). The Health Consequences of Sex 
Trafficking and Their Implications for Identifying Victims in Healthcare 
Facilities. Annals of Health Law, 23(1), 61-91.

\20\  Family Violence Prevention Fund. (2005). Turning Pain Into Power: 
Trafficking Survivors' Perspectives on Early Intervention Strategies. San 
Francisco: Family Violence Prevention Fund.

\21\  Baldwin, S., Eisenman, D., Sayles, J., Ryan, G., & Chuang, K. (2011). 
Identification of Human Trafficking Victims in Health Care Settings. Health 
and Human Rights, 13(1), E36-49.

Community Health Centers are the Best Healthcare Response to Human 
Trafficking

Like Christina, untold numbers of trafficked people are accessing care at 
community health centers and their many community programs. Community 
health centers are key components of the healthcare system serving people 
at risk for being trafficked. A study that I published with colleagues this 
year shows that trafficked minors can be identified in a community health 
center. \22\ They offer unique opportunities and advantages in preventing, 
intervening in, and stopping the victimization of patients who have been or 
are at risk of being trafficked. Although there is no single profile of a 
human trafficking victim, vulnerabilities that indicate a higher 
susceptibility to being victimized and trafficked include runaway youth, 
foreign nationals with a different language or culture, poverty, and those 
with a history of trauma or violence. These vulnerabilities make them 
targets for predators seeking to exploit them. \23\ There is significant 
overlap between people who are vulnerable to being trafficked, and patients 
of community health centers. Community health centers serve a 
disproportionate share of the nation's poor and uninsured. Most are members 
of racial or ethnic minorities, and millions of health center patients are 
served in a language other than English. \24\ Asian Health Services is not 
the only clinic doing this work--many others are developing models of care, 
like the partnership in Honolulu, Hawaii, between the Kokua Kalihi Valley 
community health center and the Pacific Survivor Center, providing 
integrated care to trafficking victims. Community health centers provide 
this care, despite scarce resources. \25\

\22\  Chang, K., Lee, K., Park, T., Sy, E., & Quach, T. (2015). Using a 
Clinic-based Screening Tool for Primary Care Providers to Identify 
Commercially Sexually Exploited Children. Journal of Applied Research on 
Children, 6(1), Article 6.

\23\  NHTRC: National Human Trafficking Resource Center. (2015, November 
25). Retrieved from The Victims: https://www.traffickingresourcecenter.org/
what-human-trafficking/human-trafficking/victims

\24\  National Association of Community Health Centers. (2014). A Sketch of 
Community Health Centers Chartbook 2014. Washington, DC. Retrieved November 
25, 2015, from http://www.nachc.com/client/Chartbook-2014.pdf

\25\  Association of Asian Pacific Community Health Organizations. (2015, 
October 30). Establishing Policies and Building Capacity of Community 
Health Centers to Address Human Trafficking Education Brief 2015. Retrieved 
November 25, 2015, from AAPCHO: http://www.aapcho.org/wp/wp-content/
uploads/2015/10/AAPCHO-Human-Trafficking-Education-Brief-103015.pdf

Health centers are also unique in that they provide special non-clinical 
help enabling and facilitating vulnerable patients' access to care, such as 
outreach, case management, translation/interpretation, referrals, 
transportation, eligibility assistance, health education, environmental 
health risk reduction, and health literacy. \26\

\26\  US Department of Health and Human Services Health Resources and 
Services Administration. (2015). Health Center Program Terms and 
Definitions. Retrieved November 25, 2015, from HRSA: http://www.hrsa.gov/
grants/apply/assistance/Buckets/definitions.pdf

And finally, community health centers serve more than 24 million patients 
in over 9000 sites located across the United States. \27\ This equals 
millions of clinical and non-clinical opportunities in the community health 
center system to reach out to, identify, and help trafficked patients.

\27\  National Association of Community Health Centers. About Our Health 
Centers. Retrieved November 25, 2015, from National Association of 
Community Health Centers: http://www.nachc.com/about-our-health-centers.cfm

Organizing our Interventions: A Public Health Prevention Model

A useful framework to help organize the healthcare system interface and 
response to human trafficking victims is through a public health prevention 
model. If we think about human trafficking as a disease, and the very real 
health harms as the symptoms of the patient, we can craft specific 
solutions to prevent and intervene during different stages of the 
exploitation. \28\

\28\  Chang, K., Sy, E., Vo, T., Nguyen, S., Thaing, M., Lee, J., & Quach, 
T. (2014, January/February). Reframing our Response: A New Approach to Care 
for Commercially Sexually Exploited Children. San Francisco Medicine, pp. 
21-22.

  Primary prevention aims to reach people who are not being 
trafficked, but are at risk. Interventions include issue awareness in 
communities, such as media campaigns, about human trafficking.

  Secondary prevention tries to reach victims in early stages of 
trafficking, before many health harms may have occurred. Interventions 
include early identification in various settings, like clinics or schools.

  Tertiary prevention occurs when a victim is being trafficked and 
is also experiencing physical, mental health or social harms. This 
prevention level is late stage and patients usually present in crisis--like 
Christina did that night. Interventions include acute medical visits to the 
Emergency Department, and are the most obvious opportunities for an 
immediate physical rescue.

  And finally, healthcare presents a unique opportunity to assist 
and enable long-term recovery for survivors who are no longer being 
trafficked, or sex trafficked minors who reach 18 years of age--but they 
may have serious health consequences from their exploitation. This stage is 
vital to healing, and to preventing revictimization; yet, it is often 
overlooked in policy and program development.

Table 1: Public Health Model--Prevention Levels \29\

\29\  Chang, K. (2015, August 23). Integration of Primary Care and 
Behavioral Health for Human Trafficking Survivors in Patient-Centered 
Medical Homes. Institute of Violence, Abuse & Trauma: 20th International 
Summit & Training on Violence, Abuse & Trauma Across the Lifespan. San 
Diego, CA.
[GRAPHIC] [TIFF OMITTED] T8260.001


Recommendations for Shifting the System of Care for Victims to the 
Healthcare and Public Health System

I have discussed ways in which our current criminal justice based response 
to victims is suboptimal in providing the care they need, shown that the 
healthcare system is a crucial component in promoting the long-term rescue 
process of trafficked people, and highlighted the unique advantages of 
Federally Qualified Health Centers in a robust healthcare response to end 
human trafficking and support victims. As such, I offer several 
recommendations to help shift the system of care for victims from the 
criminal justice sector to the healthcare and public health system.

1. Create wrap-around care teams in community health centers across the 
nation focused on reaching out to and providing care for victims of human 
trafficking.

a. Care teams include outreach workers, peer educators, social workers, 
therapists, case managers, interpreters, and clinical staff like doctors, 
nurses, medical assistants.

b. A point person on the care team can be a victim advocate to law 
enforcement teams.

c. Behavioral health and oral health should be included in care.

2. Create human trafficking specific programs within health centers to 
address the physical, mental health and social harms that result from being 
trafficked.

a. Programs such as Banteay Srei should be created for victims of different 
types of human trafficking, with an emphasis on culturally relevant 
strategies to help those affected heal and fulfill their human potential.

b. Programming should address all stages of human trafficking, from 
primary, secondary, and tertiary prevention, to long-term care.

3. Ensure that there is language accessibility for victims and cultural 
competence by professionals throughout all systems that engage with human 
trafficking victims, including community health centers.

a. Community health centers provide a model for how to care for vulnerable 
populations. Their emphasis and priority on language access and cultural 
competency in care serves as a model that should be emulated across all 
sectors that work with human trafficking victims.

b. Language access is critically important for criminal justice teams in 
communicating with victims.

4. Ensure that non-clinical assistance enabling patients to access care is 
provided throughout community health centers.

a. Enabling services, according to the Health Resources and Service 
Administration's Bureau of Primary Health Care, are defined as non-clinical 
services that do not include direct patient services to increase a 
patient's access to health care, and should be part of a holistic 
healthcare response and model.

b. This type of enabling assistance is central to the community health 
center model and should be included in their reimbursements. Without this 
assistance, trafficked patients may never realize that help may be just 
around the corner at their neighborhood clinic. They may not be able to 
access case management needed to help them navigate reenrolling into 
school, finding safe housing, or making a police report against a 
trafficker.

5. Incorporate trauma-informed care training throughout all systems that 
engage with human trafficking victims, such as justice, law enforcement, 
and immigration. The healthcare system is no exception, and must approach 
patients from a trauma-informed perspective.

a. A robust healthcare response lies not only in the healthcare system--
professionals from other sectors engaging with victims must be 
knowledgeable and aware of the physical, mental, emotional, and 
psychological effects of human trafficking, and how to work with and engage 
with victims. All victims have experienced some type of trauma. 
Understanding this is crucial.

b. When professionals understand how to partner with those affected, by 
approaching victims from a trauma-informed perspective, those victims will 
be better supported, more likely to begin a healing process and ultimately 
transitioned out of the control of the trafficker and dangerous situations.

6. Direct federal agencies to consider the health impacts (physical, 
mental, and social) of anti- trafficking policies on victims and survivors.

a. Develop a framework and methodology to evaluate the health impacts of 
anti-human trafficking policies across different agencies.

b. Create guidelines on minimizing harmful health impacts in federal agency 
policies.

Conclusion

Let's get back to Christina: Our team was successful in getting her treated 
at the hospital. After two months, her physical health in better shape, she 
was ready to be discharged. But guess where she was discharged to? She was 
discharged directly to the county jail.

We can and must do better.

In conclusion, currently labor and sex trafficking victims are accessing 
the healthcare system. There is a great opportunity to provide better care 
for victims. The criminal justice based response to victims in inadequate 
and the healthcare system is better suited to provide the healing care 
needed. Looking at human trafficking through a health lens will allow us to 
better identify, treat, and follow-up with victims. Federally Qualified 
Health Centers are in the best position to deliver this care across the 
U.S. To do so, they need the resources to create prevention, early 
identification, and acute and long-term care models.

Let's not let another Christina suffer at the hands of traffickers, or our 
response.

Prepared Statement of Yaraslaba Garcia

Mr. Chairman and Members of the Commission. Thank you for this opportunity 
to testify at the United States Commission on Security and Cooperation in 
Europe. My name is Yaro Garcia. I am a Clinical Therapist at Abuse 
Counseling and Treatment Center in Fort Myers, Florida. I am also a member 
of the South West Florida (SWFL) Regional Human Trafficking Coalition. In 
my work I treat victims of both labor and sex trafficking who have been 
trafficked from other countries into the United States.

These men, women, and children are victims of serious abuse over a period 
of months, and many times years, during which they are held against their 
will. For example, in our practice we have encountered young women and 
girls who have been sold as many as 20 to 30 times a day to men who buy and 
use them for 15 to 20 minutes before they are sold to someone else. These 
repeated physical and sexual assaults day in and day out are the cause of 
severe physical and psychological health symptoms, many of which become 
chronic health issues.

This physical abuse (with and without objects) includes: punching, 
slapping, pushing, smothering, kicking, hair and ear pulling, biting, 
strangulation, choking, and sexual assault by the trafficker. The victims 
endure this abuse from both the traffickers and the buyers. Take the case 
of A*T, who was recruited at age 17. She was locked in a room without food 
to force her to continue ``working.'' Whenever she complained, she was 
assaulted by the trafficker to get her to understand that this is what 
would happen to her if she complained again. She was trafficked for over 6 
years.

Minor and adult victims of sex trafficking may also appear to be junkies or 
addicted to illegal and/or prescription drugs. This is part of the 
trafficker's method of control, creating even more vulnerability by keeping 
the victims using drugs. Because they have been forced to use from the time 
of recruitment, the victims may present in a health care facility as a drug 
user/abuser/addict and not a victim of sex trafficking. For example, in the 
case of B*T, who was 14 when she was recruited, was forced to use drugs the 
2nd day with the trafficker, and every day after. The trafficker decided 
which drugs to give her and sometimes injected her with drugs at the 
request of the buyers. Sometimes she was given drugs to make her hyper and 
active because she was expected to serve dozens of buyers. Other times, 
when a buyer wanted something out of the ordinary, such as intercourse with 
a beer bottle or other forms of paraphilic behavior, she was given drugs 
that would numb her and make her unconscious while the buyers repeated 
assaulted her. She was trafficked for 5 years.

Because of repeated sexual exploitation, physical abuse and forced drug use 
the victims end up having at least one or repeated encounters with health 
providers while being handled by traffickers.

It is important to know that in these encounters, when seeking health care, 
minors and adult victims of sex trafficking are taught to rehearse a story 
that they present to medical staff. By the time they end up in the health 
care system they might have formed a complex bond with the trafficker. In 
many cases, the victim is afraid of the trafficker and what he will do to 
her if she doesn't follow his instructions to the letter. In other cases, 
this bond leads to the victim wanting to protect, be afraid, and/or be 
obedient enough, to follow the directions given by the trafficker, saying 
that they are prostituting on their own, that they have been careless about 
their sexual activities, or, simply, that they are in a relationship and 
don't understand why they are having these symptoms.

It is essential that healthcare providers are educated to understand that 
trafficking victims may claim voluntary self-prostitution in order to 
explain the symptoms of abuse. Because of the complexity of the trauma, the 
victims may protect the trafficker and rehearse what they have been told to 
say.

We are not asking the intake staff, nurses, doctors, and health social 
workers to become investigators or even experts. We need them to understand 
the unique aspects of complex trauma, bonding between victim and 
perpetrator as it happens in human trafficking, and the incremental 
disclosure process unique to victims of trafficking. This understanding 
MUST lead to the medical personnel seeking appropriate help for the 
victims.

To seek appropriate help, what is needed is protocols in place that must be 
strictly follow even when a patient is denying being forced, or coerced.

Assuming it is just prostitution increases the risk of a victim not being 
helped and being discharged to perpetrator. Signs, symptoms and self-
disclosures of prostitution-related activity should all be treated the same 
by the medial professionals. Any of the previously mentioned signs should 
be considered by medical personnel enough to make an additional phone call 
to the appropriate state, local, and/or federal law enforcement or Non-
Governmental Organization in the nearby area that can respond. In the case 
of adults, the call should most likely be made to an NGO first, as law 
enforcement may be perceived as a physical and mental threat rather than as 
a protective service.

All hospital personnel that come in contact with patients should understand 
human trafficking. There should be at least one individual in each 
department that has been uniquely trained to be able to interview and talk 
to a potential victim.

Specific ways of interviewing have been found to be more successful than 
others when helping trafficking victims disclose. Using the word ``help'' 
may trigger the victim's fear. It has been more effective to say that 
``other medical personnel are coming in to talk'' as part of their 
``regular protocol.'' It is essential that this appointed individual 
understands that human trafficking victims go through an incremental 
disclosure process and asking direct questions about their situation may 
not reveal any information about being trafficked.

Protection services include partnerships with other agencies. Here are some 
examples:

  Human trafficking services need to be survivor-centered in all 
aspects. Survivor security must be safeguarded as the needs they may 
present are addressed.

  All personnel must have access to appropriate national, state, or 
local hotline that can connect hospital personnel to services for minors 
and adult victims. In most states there is a difference in who will respond 
to a minor or adult victim. These differences must be clarified to the 
personnel in every health care facility.

  Medical personnel need to be able to answer victim questions 
about the process. It is no longer ok for medical staff to not respond 
correctly due to ignorance. They must know who to call and how the response 
process goes to be able to explain to victims.

  It is no longer ok for medical staff to discharge without 
creating for the victim some form of connection, and/or providing 
additional assistance outside of medical care. The potential victim must at 
least leave with some form of information regarding services or help 
available.

  Survivors may do better when being visited by an advocate/
counselor/therapist at the emergency room and/or hospital rather than law 
enforcement. Law enforcement should be involved once the victim has 
developed some type of trust or has accepted support and is ready to talk 
about what happened in the trafficking environment. The process of getting 
law enforcement involved may take hours, days, or months.

  Sound protection starts with proper attitude training for first 
responders. Coordinated training sets the basis for how the victim may 
react and feel about future law enforcement and in some instances their 
experience with an NGO, local police, state and federal jurisdiction.

  Also, as previously discussed, protection efforts need to include 
a best practice, survivor-centered interview process which takes complex 
trauma into account.

  Inter-agency and law enforcement cooperation is critical because 
the process of internal disclosure, which includes development of trust 
over a long period of time, conflicts with many law enforcement and agency 
protocols and resources. Each law enforcement entity needs to have someone 
available who is trained to talk to trafficking victims.

  Victim interviewing techniques should be directed towards the 
comfort of the victim and collaterals with which the victim has developed 
some beginning level of trust.

When protection procedures in the health care system are consistent, 
honest, and reliable, the victim can feel supported and encouraged 
throughout the internal disclosure process, and agree to receive help at 
that moment or later on. This can surmount current difficulties in 
supporting survivors over time and through the physical and psychological 
difficulties of stepping out of the trafficking environment, and the post-
trafficking process of getting well.

Prepared Statement of Dr. Jordan Greenbaum

Good afternoon, Chairman Smith, co-chairman Wicker and distinguished 
Commission members. I am grateful for the opportunity to testify before you 
today. In addition to my oral testimony I would like to submit written 
testimony into the record.

My name is Jordan Greenbaum. I am a child abuse physician at the Stephanie 
Blank Center for Safe and Healthy Children at Children's Healthcare of 
Atlanta, and a consultant for the International Center for Missing and 
Exploited Children. The Blank Center is a hospital-based child protection 
program that provides medical and behavioral health services to suspected 
victims of abuse and their families. The International Centre for Missing 
and Exploited Children is a non-governmental organization that works to 
combat child abduction and child sexual exploitation globally. As the 
protection of children from victimization requires a coordinated, 
comprehensive, and global approach, the International Centre assists 
countries in creating national solutions through public-private 
partnerships; establishing a global resource to prevent child-sexual 
exploitation; creating national centers and affiliates worldwide; and 
providing training to professionals working on child sexual exploitation. 
Through its Global Health Initiative, the Centre seeks to apply a public 
health model to child sexual exploitation, to promote changes in medical 
education regarding exploitation, to facilitate research on the health of 
victims and the long term impact of victimization, and to assess current 
treatment modalities for victims. I would like to provide testimony today 
on the health consequences of sex and labor trafficking, especially 
involving minors.

As you know, reliable estimates of the incidence and prevalence of human 
trafficking are lacking, but the best existing estimates suggest that 
millions of adults and children are involved worldwide. \1\ Child 
trafficking is truly a global phenomenon. According to a recent study by 
the United Nations Office on Drugs and Crime,\2\ 33% of the 40,000 cases of 
human trafficking identified in 128 countries involved children. As 
emphasized by the International Centre for Missing and Exploited Children, 
a missing child is a vulnerable child. Consider the massive numbers of 
children who run away from home, who become separated from parents while 
fleeing turbulence in their home country, who leave home to seek a job in 
the United States so they can feed their impoverished family. These 
children are easy prey for traffickers, who offer them a place to stay, a 
free meal, or a ride to the next city. Victims of human trafficking may 
experience a plethora of adverse physical and behavioral health sequelae, 
including traumatic injury from sexual and physical assault, work-related 
injury, sexually transmitted infections, non-sexually transmitted 
infections, chronic untreated medical conditions, pregnancy and related 
complications, chronic pain syndromes, complications of substance abuse, 
and malnutrition and exhaustion. 3,4,5,6 Mental health 
consequences include depression with suicide attempts, flashbacks, 
nightmares, insomnia and other sleep problems, anxiety disorder, 
hypervigilance, self-blame, helplessness, anger and rage control problems, 
dissociative disorders, post-traumatic stress disorder, and other co-morbid 
conditions.7,8

\1\  International Labour Organization (2012). ILO 2012 Global estimate of 
forced labour: Executive summary. Available at: http://www.ilo. org/wcmsp5 
/groups/public/-ed-norm/- declaration/documents/ publication /wcms-181953 
.pdf Accessed Dec 23, 2014.

\2\  UNODC, Global Report on Trafficking in Persons 2012. (United Nations 
publication, Sales No. E.13.IV.1) (2012) Accessed Nov. 22, 2013. Available 
at: http://www.unodc.org/ documents/data-and- analysis/glotip /Trafficking 
-in-Persons-2012-web.pdf.

\3\  Willis BM LB. Child prostitution: Global health burden, research 
needs, and interventions. Lancet. 1996;359:1417-1422.

\4\  Estes RJ, Weiner NA. The commercial sexual exploitation of children in 
the U.S., Canada and Mexico. Center for the Study of Youth Policy, 
University of Pennsylvania, Accessed at http://www.sp2.upenn.edu/restes/
CSEC-Files/Complete-CSEC-020220.pdf on 7/7/122002.

\5\  AAP Clinical Guidelines: Greenbaum J, Crawford-Jakubiak JE, Committee 
on Child Abuse and Neglect. Child sex trafficking and commercial sexual 
exploitation: Health care needs of victims. Pediatrics, 2015;135(3):566-
574.

\6\  Smith L, Vardaman S, Snow M. The national report on domestic minor sex 
trafficking: America's prostituted children. In: International SH, ed. 
Accessed at http://sharedhope.org/ wp- content/uploads /2012/09/
SHI_National _Report _on_DMST _2009 .pdf on 7/7/132009.

\7\  Zimmerman C. Stolen smiles: A summary report on the physical and 
psychological consequences of women and adolescents trafficked in Europe. 
London School of Hygiene and Tropical Medicine; 2006.

\8\  Choi H, Klein C, Shin MS, Lee HJ. Posttraumatic stress disorder (PTSD) 
and disorders of extreme stress (DESNOS) symptoms following prostitution 
and child abuse. Vio Against Women. 2009;15(8):933-951.

Despite the criminal nature of human trafficking and the desire of 
traffickers to elude detection, research consistently shows that victims do 
have contact with medical professionals. In a study of adult and adolescent 
female sex trafficking survivors, 87.8% had seen health care providers 
(HCP) during their period of exploitation.\9\ In another study of runaway 
and homeless youth involved in commercial sexual exploitation, over 75% had 
seen a provider within the past 6 months.\10\ But we also know that victims 
rarely self-identify when seeking medical care and may even deny 
victimization out of fear of the trafficker, lack of perception of their 
victim status, shame, humiliation, and other 
reasons. \11\ Therefore, it is incumbent on the HCP to recognize signs of 
at-risk youth and adults, ask questions appropriately and provide trauma-
sensitive care to identified victims.

\9\  Lederer L, Wetzel C. The health consequences of sex trafficking and 
their implications for identifying victims in healthcare facilities. Annals 
of Health Law. 2014;23:61-91.

\10\  Curtis, R., Terry, K., Dank, M., Dombrowski, K. and Khan, B. (2008) 
The Commercial Sexual Exploitation of Children in New York City, Volume 
One, The CSEC Population in New York City: Size, Characteristics, and Needs 
Final report submitted to the National Institute of Justice. New York, NY: 
Center for Court Innovation and John Jay College of Criminal Justice.

\11\  AAP Clinical Guidelines: Greenbaum J, Crawford-Jakubiak JE, Committee 
on Child Abuse and Neglect. Child sex trafficking and commercial sexual 
exploitation: Health care needs of victims. Pediatrics, 2015;135(3):566-
574.

Arguably, all adolescents are at risk for human trafficking simply by 
virtue of their age and developmental status. This is a period of risk-
taking and impulsive behavior, when the part of the brain responsible for 
thoughtful consideration of risks and benefits, of delaying gratification, 
of comparing current possible outcomes with past consequences is still 
relatively immature. In contrast, that part of the brain that craves 
rewards and immediate satisfaction is quite active. Adolescents want to 
break away from parents, gain peer acceptance, and begin to form sexual 
relationships. All of these factors increase their vulnerability to 
manipulation and exploitation.

While quantitative, peer-reviewed research on child trafficking is 
relatively scant, available evidence tells us that certain youth in the 
U.S. and around the world face additional risk factors. Homelessness, 
physical abuse and family dysfunction, sexual abuse, poverty, child 
neglect, substance abuse, social upheaval, gender bias and minority status 
increase the risk of child exploitation.12,13,14

\12\  Estes RJ, Weiner NA. The commercial sexual exploitation of children 
in the U.S., Canada and Mexico. Center for the Study of Youth Policy, 
University of Pennsylvania, Accessed at http://www.sp2.upenn.edu/restes/
CSEC_Files/Complete_CSEC_020220.pdf on 7/7/122002.

\13\  Walls NE, Bell S. Correlates of engaging in survival sex among 
homeless youth and young adults. J Sex Res,2011;48(5):423-436.

\14\  Konstantopoulos WM AR, Alpert EJ, Cafferty E, McGahan A, et al. An 
international comparative public health analysis of sex trafficking of 
women and girls in eight cities: Achieving a more effective health sector 
response. J Urban Health: Bulletin of the NY Aca Med. 2013;90(6):1194-1204.

Information on risk factors may be very useful in identifying potential 
victims and additional quantitative research may assist in creating brief 
screening tools to be used in the health care setting. At Children's 
Healthcare of Atlanta we recently conducted a study to describe 
characteristics of child sex trafficking victims and to develop a screening 
tool to identify victims among a high risk adolescent population. We 
evaluated female youth aged 12-18 years who presented to one of three 
metropolitan pediatric emergency departments or one child protection 
clinic, and who were identified as victims of sex trafficking. We compared 
them to similar-aged patients with allegations of sexual assault/sexual 
abuse (ASA) without evidence of trafficking. The two groups differed 
significantly on 16 variables involving reproductive history, high-risk 
behavior, sexually transmitted infections, and prior experience with 
violence. A 6-item screen was constructed and a cut-off score of 2 positive 
answers was determined to have a 92% sensitivity for identifying 
trafficking victims. A child with a negative screen had a 97% likelihood of 
NOT being a victim. Thus, a short, 6-item questionnaire effectively 
distinguished victims of alleged sex trafficking from those with reported 
sexual assault/abuse and no evidence of trafficking. Our study results need 
to be validated with other adolescent populations from outside the Atlanta 
metropolitan region, as regional differences may exist. Currently we are 
conducting a multi-site study of youth presenting to a variety of medical 
settings, with and without previous documentation of sex trafficking 
activity.

However, health care providers need more than a screening tool. They need 
to know when to use it, when to consider the possibility of human 
trafficking. Several months ago I was asked to evaluate an infant with a 
leg fracture because there were concerns the child had been physically 
abused. Initially the child was the sole focus of my concern. But as the 
evaluation progressed I realized that the child was not the only potential 
victim. The mother was young, homeless, without job skills, and was almost 
certainly being trafficked by her boyfriend. I only realized this as we 
discussed her living situation and her tumultuous past history. Thus, one 
evaluation for victimization turned into two. It was every bit as important 
to assess the mother's safety as it was to ensure the child's. Human 
trafficking may involve a child, the child's parents, or the entire family. 
The HCP needs to consider these possibilities in all patient interactions.

Beyond knowing when to worry and what questions to ask, HCPs need to know 
how to interact with potential victims in a way that does not re-traumatize 
them, a manner that encourages honesty and trust. Trauma-informed care is 
essential. This approach to patient care involves the medical provider 
recognizing the real possibility that a patient has experienced significant 
trauma, that this trauma may influence how the patient thinks, acts and 
responds to others, and that questioning of the patient needs to be 
culturally appropriate and very sensitive in order to minimize the 
likelihood of triggering additional anxiety and fear. Victims of human 
trafficking have almost certainly experienced repetitive, severe, complex 
trauma and this, combined with their potential distrust of authorities, 
feelings of humiliation and shame, as well as significant cultural and 
language barriers, may make interviews of patients quite challenging. It 
may not be easy for a health care provider to respond consistently with 
support and understanding when a patient appears hostile, disinterested in 
receiving help, protective of the trafficker, or unwilling to engage. A 
medical provider may not understand that these behaviors are related to the 
patient's fear, anxiety and trauma, and may react negatively. Yet, a calm, 
nonjudgmental, supportive approach is critical and may be the only way to 
build the trust needed for patient disclosure and the possibility of 
intervention. But such a trauma-informed approach must be learned and is 
not in the repertoire of many medical providers. This needs to change.

Multiple studies have demonstrated convincingly that many HCPs lack the 
knowledge and skills to identify and assess victims. In one study 63% of 
medical providers reported never having received training on how to 
identify human trafficking victims. Those who had training were 
significantly more likely to have confidence in their ability to do so and 
to have encountered a victim in the past.\15\ Health care providers who 
participated in the study indicated that the greatest barriers to victim 
identification were a lack of training (34%) and lack of awareness of sex 
trafficking (22%). Further, a study of trafficking survivors demonstrated 
that the failure of HCPs to identify victims was often accompanied by 
behavior that hurt and humiliated victims, making it clear that a trauma-
informed approach is not uniformly practiced. \16\

\15\  Beck ME, Lineer MM, Melzer-Lange M, et al. Medical providers' 
understanding of sex trafficking and their experiences with at-risk 
patients. Peds, 2015;135(4):e895.

\16\  Miller C. Child sex trafficking in the health care setting: 
Recommendations for practice. Paper presented at 25th International Nursing 
Research Congress;July 27, 2014;Hong Kong. From, Stoklosa H, Grace aM, 
Littenberg N. Medical education on human trafficking. Am Med Assoc J 
Ethics,2015;17(10):914-921.

More and more training modules are being designed and implemented across 
the country. But health professional training must overcome several 
challenges. First, HCPs are constantly faced with the need to learn about 
new conditions, new procedures, and new research, from new drugs to combat 
human immunodeficiency virus, to the epidemiology of domestic violence, to 
the latest developments in medications for diabetes mellitus and heart 
disease. Human trafficking is one of many critical topics that must compete 
for the attention of professionals. Second, the vast majority of training 
curricula on human trafficking have not undergone formal evaluation to show 
that they effectively increase knowledge, influence beliefs and change 
provider behavior. Such evaluation is critical before we invest heavily in 
efforts to train hundreds of thousands of health professionals. Resources 
are too scarce to be used on unproven strategies.

There are some exceptions to this. One group randomized controlled trial of 
emergency department providers involved delivering focused education on 
human trafficking to physicians, nurses, social workers and other emergency 
department personnel. Results demonstrated significant increases in 
knowledge about trafficking, knowledge about who to call for victim 
services and an increase in the proportion of participants suspecting they 
had encountered a victim, relative to the group of providers who had not 
yet received the training.\17\ At Children's Healthcare of Atlanta, we 
developed a 6-part webinar series for health care professionals across the 
country addressing child sex trafficking. The series was delivered 
repeatedly during 2014. Participants attending one or more webinars were 
asked to complete a post-test survey and a 6-month follow up survey, which 
elicited information about knowledge, beliefs and practices related to 
child trafficking. While the webinar series was advertised as targeting 
HCPs, we had many professionals outside the medical field attending the 
sessions, as well. Survey questions comparing pre vs. post-webinar 
conditions documented significant changes in beliefs about child sex 
trafficking, including an increase in the proportion of participants 
strongly agreeing that

\17\  Grace AM, Lippert S, Collins K, et al. Educating health care 
professionals on human trafficking. Pediatr Emerg Care. 2014;30(12):856-
861.

  human trafficking is a significant problem in their community,

  the language used to describe commercial sexual exploitation can 
shape others' beliefs and opinions,

  prostituted children are victims of child abuse and

  sex trafficking is associated with negative health outcomes. 
Further, in the 6 month follow up survey we found

  a significant increase in the percentage of webinar participants 
asking adolescents about risk factors related to sex trafficking, 
representing an important and persistent change in behavior.

  64% of participants had used information from the webinars when 
interacting with youth,

  75% had used it when interacting with the public, and

  79% had used information from the webinars in their work-related 
duties.

Thus, the webinars were associated with a significant increase in overall 
training competencies and the knowledge change was found to be sustainable 
in a 6-month follow up period. There was measurable change around 
screening, referrals and knowledge-sharing after webinar participation.

An important finding in our study highlights yet another challenge to 
educating busy medical professionals. The vast majority of providers we 
reached with our webinars were nurses; very few physicians participated. 
This is almost certainly due to the timing of the webinars: few physicians 
have time during the day to attend a webinar, and targeting a national 
audience means that any webinar may or may not be scheduled at a convenient 
time, given the multiple U.S. time zones. We have addressed this challenge 
by converting 5 of the 6 webinars into online, self-paced modules. These 
are proving much more effective in reaching the physician audience, 
especially as free continuing medical education credits are offered.

An important finding in our study highlights yet another challenge to 
educating busy medical professionals. The vast majority of providers we 
reached with our webinars were nurses; very few physicians participated. 
This is almost certainly due to the timing of the webinars: few physicians 
have time during the day to attend a webinar, and targeting a national 
audience means that any webinar may or may not be scheduled at a convenient 
time, given the multiple U.S. time zones. We have addressed this challenge 
by converting 5 of the 6 webinars into online, self-paced modules. These 
are proving much more effective in reaching the physician audience, 
especially as free continuing medical education credits are offered.

However, webinars and online modules cannot substitute for in-person 
training with role playing and mentoring. Didactic teaching, especially if 
supplemented with toolkits containing lists and algorithms are very helpful 
but HCPs need to feel comfortable with patient interactions if they are to 
fundamentally change their behavior and actively screen for human 
trafficking victims. Reaching large numbers of providers in this manner is 
challenging. Ultimately, it may best be accomplished by integrating a 
trauma-informed care model into medical and nursing student training, to be 
implemented when students are learning basic medical history and physical 
exam skills. Alternatively, residents could receive training during their 
required didactic teaching conferences.\18\ Such training would be 
extremely useful to all practitioners when they interact with patients who 
may have experienced any kind of significant trauma, be it a major medical 
procedure, a motor vehicle crash or any sort of recent violent event. That 
is, the skills needed to interact with a traumatized trafficking victim are 
also useful when interacting with victims of other major trauma, and are an 
essential part of the arsenal of clinical tools used by effective HCPs.

\18\  H-65.966: Physicians response to victims of human trafficking. Policy 
of American Medical Association. No date given. Accessed at https://www. 
ama-assn.org/ssl3/ ecomm/PolicyFinderForm. pl?site=www.ama- assn.org&uri 
=%2Fresources%2Fhtml%2FPolicyFinder %2Fpolicyfiles%2FHnE%2FH- 65.966.HTM on 
July 14, 2015.

The role of any HCP extends beyond recognizing and treating illness and 
injury. We are tasked with working with patients and families to prevent 
illness and injury and to provide anticipatory guidance to those at high 
risk. In the area of human trafficking, health care professionals need to 
be educated about risk factors and early signs, then take that knowledge 
and use it to counsel children, parents and adult patients to avoid 
situations that increase vulnerability. Discussing internet safety may save 
a child from sexual exploitation; discussing common recruitment techniques 
involving false advertising for jobs may save an adult from labor 
trafficking. In addition, medical professionals need to use their knowledge 
to help families obtain resources that address current vulnerabilities such 
as homelessness, substance abuse, domestic violence, and poverty. They need 
to look beyond the confines of their offices and clinics to identify 
community resources that may help patients and families.

In general, HCPs are not trained to actively seek relationships with 
outside, nonmedical organizations and agencies, nor do many providers feel 
comfortable in this role. Yet this is a critical step in the process of 
caring for patients and families involved in human trafficking. We must 
assist HCPs in adopting this change in behavior.

We need to encourage them to identify community agencies and organizations, 
and build relationships with governmental and nongovernmental investigators 
and service providers so that victims may obtain the help they need. The 
HEAL Trafficking organization (Health Professional Education, Advocacy, and 
Linkage) is an international organization of professionals that addresses 
human trafficking through a health care lens, serving as a resource on 
health for the broader anti-trafficking community. Currently HEAL is 
developing a protocol that will provide step-by-step assistance to HCPs who 
want to work with their community to build a multidisciplinary anti-
trafficking team. Such a tool will help HCPs bridge the gap between medical 
clinics/hospitals and critical community services that may provide for the 
long term needs of trafficking survivors.

There are other ways HCPs can, and should, work to prevent human 
trafficking. Once again moving beyond the confines of clinic and hospital, 
HCPs can actively support community efforts to end trafficking. They can 
serve on the advisory boards of trafficking organizations or programs that 
address risk factors for exploitation. They can support faith-based 
organizations in their anti-trafficking initiatives, publicly support 
victim-serving organizations, and refer patients and families to these 
programs. They can work with the media to increase public awareness 
regarding human trafficking and available community and national programs 
to combat exploitation. They can encourage their own professional 
organizations to advocate for anti-trafficking policies and initiatives. 
And of course, they can vote.

Several national medical organizations have recognized the potentially 
powerful role of the medical provider in victim service, advocacy and 
prevention, and have published policy statements and reports calling on 
health care professionals to raise their awareness of human trafficking 
issues, and obtain resources for patients. The American Medical Women's 
Association further advocates for patient access to coordinated medical 
care and other support services, appropriate medical treatment, as well as 
advocating for anti-trafficking measures in the community. \19\ Such policy 
statements and clinical reports by the American Medical Association, 
American Medical Women's Association, American College of Obstetrics and 
Gynecology, the American Academy of Pediatrics20,21,22 and 
others are laudable but efforts should not stop here. These and other 
professional medical organizations need to continue to advocate for 
recognition of international and domestic sex and labor trafficking as 
serious threats to the health and development of adults and children in the 
United States and around the globe. That is, human trafficking is not only 
a criminal issue, not only a social issue, it is a public and private 
health issue. The physical and emotional health consequences experienced by 
victims have far-reaching ramifications for the general population. Medical 
organizations need to advocate for public policy that recognizes human 
trafficking as a gross violation of human rights and a violation of the 
Convention on the Rights of the Child.\23\ They need to encourage 
government efforts to increase availability and use of victim services, 
including T- and U-visas by victims and their families. They need to 
support public policy and legislation that recognizes exploited adults and 
children as victims rather than offenders, as all too often victims are 
charged with prostitution, petty theft, immigration violations and other 
crimes associated with their exploitation. Professional medical 
organizations need to advocate for provider education on adult and child, 
sex and labor trafficking, including both domestic and international 
trafficking. Such advocacy should include recommendations that HCPs working 
in the United States and overseas use a victim-centered, age- and 
culturally appropriate and trauma-informed approach to patient care, and 
that they become actively engaged in supportive referral networks for 
trafficking survivors. Healthcare providers need to be aware of processes 
available for immigration assistance, including T- and U-visas, and other 
federal programs. Finally, medical organizations need to support and 
encourage research on domestic and international human trafficking, so that 
screening methods, assessment tools, treatment protocols (especially 
rigorously tested mental health interventions), and prevention efforts may 
be effective and evidence-based. We do not have the time or the financial 
resources to support myriad ideas and strategies that lack reliable 
evidence of effectiveness.

\19\  Position paper on the sex trafficking of women and girls in the 
United States. American Medical Women's Association, May 2014. Accessed at 
https://www.amwa-doc.org/ wp-content/uploads/2013/12/AMWA- Position-Paper-
on-Human-Sex-Trafficking--May-20141.pdf on July 16, 2015.

\20\  5. AAP Clinical Guidelines: Greenbaum J, Crawford-Jakubiak JE, 
Committee on Child Abuse and Neglect. Child sex trafficking and commercial 
sexual exploitation: Health care needs of victims. Pediatrics, 
2015;135(3):566-574.

\21\  H-65.966: Physicians response to victims of human trafficking. Policy 
of American Medical Association. No date given. Accessed at https://
www.ama-assn.org/ssl3 /ecomm/PolicyFinderForm.pl?site=www.ama- 
assn.org&uri=%2 Fresources%2Fhtml%2FPolicyFinder%2 Fpolicyfiles%2FHnE%2 FH-
65.966.HTM on July 14,2015.

\22\  Human Trafficking. Committee opinion of the Committee on Health Care 
for Underserved Women of the American College of Obstetricians and 
Gynecologists, Sept 2011. Accessed at http://www.acog.org/Resources-And-
Publications/Committee-Opinions/Committee-on-Health-Care-for- Underserved-
Women/Human-Trafficking on July 17, 2015.

\23\  United Nations Human Rights, Office of the High Commissioner for 
Human Rights. Convention on the Rights of the Child. Available at: http://
wwwohchrorg/en/ professionalinterest/pages/crcaspx 1990

ICD Codes for Human Trafficking

The World Health Organization's (WHO) International Classification of 
Diseases (ICD) is a system used by HCPs to code all symptoms, diagnoses and 
procedures related to health care. The ICD codes are important because they 
are used to monitor incidence and prevalence of health problems and provide 
critical data for monitoring world health. Currently, the ICD-10 
(International Classification of Diseases-10th Edition) provides diagnostic 
codes for sexual assault of adults and minors, domestic violence and 
several types of child maltreatment, including neglect, physical abuse, 
psychological abuse and sexual abuse. It lacks codes for human trafficking/
commercial exploitation.

As discussed above, victims of human trafficking may experience myriad 
adverse physical and behavioral health sequelae. These effects have been 
demonstrated in victims from diverse geographic regions, reflecting the 
global nature of exploitation and the similarity of harsh experiences 
jeopardizing the health and well-being of victims everywhere. \24\ \25\At 
present, the incidence of the sequelae for each type of trafficking/
exploitation, the risk factors for the sequelae, and the cost of treatment 
are unknown. There is little more than anecdotal data on the relationships 
between the types of exploitation or how sequelae may vary with the 
relationship of victim with exploiter. With specific ICD codes for sexual 
exploitation/trafficking these important questions and others may be 
answered. Codes will help quantify how many exploited persons are 
identified in healthcare settings and facilitate chart reviews for 
additional research information. New ICD codes would allow access to 
critical knowledge that could drive global health efforts and prevention 
strategies to address these severe human rights violations.

\24\  Konstantopoulos WM AR, Alpert EJ, Cafferty E, McGahan A, et al. An 
international comparative public health analysis of sex trafficking of 
women and girls in eight cities: Achieving a more effective health sector 
response. J Urban Health: Bulletin of the NY Aca Med. 2013;90(6):1194-1204.

\25\  Oram S SH, Busza J, Howard LM, Zimmerman C. Prevalence and risk of 
violence and the physical, mental, and sexual health problems associated 
with human trafficking: A systematic review. PLoS Med. 2012;9(5):e1001224.

Currently, the World Health Organization (WHO) is developing the new ICD-11 
coding system and this effort is in its beta phase until 2017. During this 
period proposals for code revisions and new codes are accepted and reviewed 
by stakeholders. In Dec 2014, the International Centre for Missing and 
Exploited Children initiated a proposal to the WHO to adopt specific ICD-11 
codes for sexual exploitation of adults and minors. A similar proposal was 
submitted to the National Center for Health Statistics to update ICD-10. 
These codes specifically distinguish various types of sexual exploitation 
(e.g. exchanging a sex act for something of value; prostitution controlled 
by a 3rd person; child pornography; cyber enticement for sexual purposes; 
and exploitation through a sex-oriented business, not prostitution), and 
types of perpetrators (spouse/partner, parent, unrelated caregiver, etc.). 
Such detail will allow comparison of the incidence of various types of 
exploitation, the health-related complications associated with the various 
types, and the potential impact of various perpetrator-victim relationships 
on health complications and treatment outcomes. It will also provide data 
on the health-related cost of human trafficking in the United States and 
elsewhere. Specific ICD codes for human trafficking will support the 
initiative of the SOAR to Health and Wellness Act by providing ``a reliable 
methodology for collecting and reporting data on the number of human 
trafficking victims identified and served in health care settings.''

In early 2015, HEAL Trafficking initiated a similar proposal to the WHO to 
adopt specific ICD-11 codes for labor trafficking of adults and minors. 
These codes distinguish among several forms of labor trafficking (e.g. 
agriculture, mining/logging; food processing/packaging industry, etc.) and 
various types of perpetrators (e.g. spouse; parent; unrelated caregiver; 
stranger, etc.). The International Centre and HEAL Trafficking are eager to 
see the two proposals for sex and labor trafficking accepted and are 
seeking support from other stakeholders.

In conclusion, new information makes it clear that human trafficking is a 
public and private health issue, that trafficking victims are at risk for 
multiple physical and mental health problems, and that health providers 
play a critical role in identifying trafficking victims. Health care 
providers need training to understand human trafficking and recognize 
potential victims when they encounter them. They need to know how to 
respond appropriately, including using a trauma-informed approach, and 
making critical reports and referrals to service providers. And they need 
contribute to data collection and research. This training needs to take 
place here in the United States, but also in other countries, for 
trafficking is a transnational problem and will require transnational 
solutions.

Recommendations:

1. Develop curricula on human trafficking to be delivered to practicing 
health care providers in the form of online modules, on-site training and 
webinars. Obtain outcomes studies measuring efficacy of curricula in 
impacting participant beliefs, attitudes, knowledge and behavior related to 
human trafficking. Training should include

  Definitions of human trafficking, risk factors and possible 
indicators of victimizationA trauma-informed approach to interacting with 
potential victims

  Appropriate referrals for victims, including common immediate and 
long term needs of survivors (domestic and transnational victims)

  Appropriate reporting procedures (including discussion of 
mandated vs. voluntary reporting)

  Specific information on federal programs such as T- and U-visas

  A discussion of HIPPA as it applies in the context of suspected 
human trafficking

2. Incorporate education on human trafficking into curricula of health 
professionals-in-training (including but not limited to future physicians, 
nurses, physician assistants, advance practice nurses, medical social 
workers and mental health professionals). Conduct formal outcomes 
evaluations on training curricula.

3. Support research that provides an evidence base for development of 
screening tools, effective interview techniques, and successful treatment 
interventions for victims/survivors, with a special focus on mental health 
treatment.

4. Support acceptance by the World Health Organization of ICD-11 codes for 
sexual exploitation and forced labour exploitation.


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