Senior Advisor on Trafficking in Persons
Administration for Children and Families
U.S. Department of Health and Human Services
Subcommittee on Health
Committee on Energy and Commerce
United States House of Representatives
September 11, 2014
Chairman Pitts, Ranking Member Pallone, and members of the Subcommittee, thank you for inviting me to testify. I am pleased to have the opportunity to share with you the Department of Health and Human Services’ (HHS) work to prevent and end human trafficking in all of its forms and the Administration’s views on the proposed “Trafficking Awareness Training for Health Care Act of 2014.”
I am Katherine Chon, Senior Advisor on Trafficking in Persons at the Administration for Children and Families (ACF), which is responsible for implementing the Department’s anti-trafficking authorities under the Trafficking Victims Protection Act, in coordination with other HHS divisions and federal partners. Prior to my federal service, I co-founded an international nonprofit organization focused on combating human trafficking and spent a decade in the field working directly with survivors of trafficking, establishing effective victim service programs, and analyzing data and trends to inform public policy.
HHS seeks to prevent human trafficking, protect victims of its diverse forms of exploitation, and support survivors. As a member of the President’s Interagency Task Force to Monitor and Combat Trafficking in Persons, HHS recognizes that human trafficking is not only a violent crime and grave human rights abuse, but it is also a global health problem. Through ACF, HHS addresses the social determinants of health and responds to human trafficking by integrating anti-trafficking responses across multiple human service systems – including child welfare, runaway and homeless youth, domestic violence, refugee resettlement, and Native American community services – working with populations at high risk to human trafficking.
Research has shown that victims of human trafficking often come into contact with the health care and behavioral health systems. Along with law enforcement personnel, health care providers are among the most likely frontline provider who may interact with victims of human trafficking while they are still under conditions of exploitation. In a 2011 study1, 50 percent of foreign national survivors of sex and labor trafficking interviewed gave a history of encountering a health care professional while they were in a situation of human trafficking, yet none of them were identified as a victim during these encounters. In a 2014 study2, almost 88 percent of interviewed survivors of domestic sex trafficking had encountered one or more health care professionals sometime during the period in which they were being trafficked, yet none were identified as a victim during these encounters. As concerning as these statistics are, the lack of research in the area of human trafficking limits our understanding of the health service needs facing this population, and how those needs would best be met.
Victims of human trafficking encounter a variety of health care professionals while still trafficked – this is an often missed opportunity to intercede. In a separate 2014 briefing3 based on an anonymous nation-wide health care survey of sex and labor trafficking victims, 39 percent of respondents had contact with emergency departments, 29 percent with primary care providers, 17 percent with obstetrician and gynecologists, 17 percent with dentists, and three percent with pediatricians.
SOAR to Health and Wellness Training for Health Care Professionals
HHS has worked to engage health care providers during its history of implementing anti-trafficking programming. In 2008, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) sponsored a National Symposium on the Health Needs of Human Trafficking Victims, bringing more than 150 health care professionals, anti-trafficking experts, and federal partners together to discuss victim identification and services in health care settings.
Major discussion points of the symposium, which are available on the HHS website, included:
The important role of health care providers in screening for human trafficking in high risk populations,
- The need for addressing mental health concerns among survivors of trafficking as well as the vicarious trauma that often occurs among service providers, and
- The recognition that human trafficking is an issue with public health consequences impacting prevalence of tuberculosis, HIV/AIDS, and Hepatitis B.
One of the major outcomes of the symposium was the call for increased training for health care professionals in diverse disciplines, including physicians, nurses, dentists, counselors, hospital-based mental health care providers, school-based health care providers, and first responders.
This week, HHS is beginning a series of our pilot SOAR to Health and Wellness trainings for health care professionals, in which SOAR stands for “Stop, Observe, Ask, and Respond to Human Trafficking.” We are partnering with local hospitals and community clinics in Atlanta, Boston, Houston, Oakland, and Williston and New Town, North Dakota for the trainings, which will be evaluated later this fall. The training will equip health care professionals to:
- Describe the scope, diversity, and types of human trafficking in the United States,
- Recognize the common indicators and high-risk factors for human trafficking,
- State how using trauma-informed techniques will enhance interaction with a potential victim of human trafficking, and
- Identify local, state, and national service referral resources for trafficking victims.
The training seeks to decrease known provider-related barriers to identifying victims of human trafficking, which include lack of knowledge, misclassification, non-trauma informed care, judgment, and cultural assumptions.
Trafficking Awareness Training for Health Care Act of 2014
The “Trafficking Awareness Training for Health Care Act of 2014” would complement HHS’ anti-trafficking efforts to engage the health care community by increasing information, awareness, and training for health care providers. While the pilot HHS SOAR to Health and Wellness training currently targets health care providers through hospitals and community clinics, HHS recognizes the importance of integrating awareness of and skills to combat human trafficking into health professions schools. In addition to accredited schools of medicine and nursing, we recommend dental and social work schools as important target audiences because research has shown that victims of trafficking have encountered dentists and hospital and clinic-based social workers who are often responsible for managing the follow-up social and behavioral health services referral process once a victim has been identified.
Unfortunately, there is little evidence-based research on the intersection of the healthcare system and human trafficking, especially when it comes to the impact of training efforts. Therefore, it may be difficult to develop best practices according to the timeline noted in the bill. An alternate option is to identify and develop “promising practices.” The anti-trafficking field may be able to adapt lessons learned from efforts in related issue areas, including treatment of domestic violence and sexual assault victims in health care settings. HHS is concerned that the bill requires, rather than allows the Secretary to make best practices grants and specifies that these grants be made within existing resources. Further, in order to ensure that the program is placed in the HHS agency with the available expertise to carry it out, HHS prefers that the Secretary have the authority to delegate the grant program to the appropriate HHS component.
In 2010, ASPE released an issue brief, “Medical Treatment of Victims of Sexual Assault and Domestic Violence and Its Applicability to Victims of Human Trafficking,” that outlined a number of recommendations including:
- The need for comprehensive screening practices: Although there are no universal screening practices on domestic violence in healthcare settings, lessons learned include the effectiveness of posting signs and literature to supplement routine screening and to reinforce the health care setting as a safe place to seek assistance; and to conduct screenings in a private setting away from perpetrators who may accompany potential victims.
- The importance of examination protocols: There is a limited number of evidence-based clinical practices for examination and treatment of victims of sexual assault, but there are lessons that can be applied in anti-trafficking responses including the importance of having an advocate trained in crisis intervention present with the potential victim and integrating information on human trafficking into Sexual Assault Nurse Examiner (SANE) trainings.
- The content of effective training: Training on domestic violence and sexual assault is most effective when it provides information on the internal and external resources available to support comprehensive service delivery, teaches practical skills (e.g. interview techniques, safety assessment, documentation), and informs health care practices to detect and reduce barriers to identification.
The ASPE issue brief also describes how the Joint Commission on Accreditation of Healthcare Organizations, a nonprofit organization that evaluates and accredits more than 17,000 hospitals, healthcare networks, and other healthcare organizations in the United States, has adopted guidelines requiring that member hospitals and organizations have objective criteria for identifying victims of physical assault, sexual assault, domestic violence, and abuse of elders and children. Members must train staff on identification and maintain a list of referral organizations that provide assessments and care for victims. Human trafficking responses could also be integrated into such approaches.
Additional Opportunities for Healthcare Engagement
The public health community has been engaged in anti-trafficking efforts, mostly focused on the prevention of HIV/AIDS and other communicable diseases. Public health professionals have also been engaged in “john schools” in some parts of the country, providing information to purchasers of commercial sex who are arrested and participate in educational programs that may be diversions programs, sentencing options, or combined with other penalties for criminal activity. Topics in these educational programs may include information on health and behavioral health consequences; impact of trauma on health and behavioral health, on communities, families, and survivors; male development, decision making, and health relationships; sex addiction; and anger management. John schools are currently located in more than 55 cities in the United States and serve 100 cities and counties.
Additionally, while many victims of human trafficking may come into contact with health care providers, health disparities may prevent others from accessing health care. According to the Department of Justice-funded study4 of confirmed sex trafficking victims whose race was known, 26 percent were white, 40 percent were black, and 24 percent were Hispanic. Of confirmed labor trafficking victims, 56 percent were Hispanic and 15 percent were Asian. Future studies on the intersection of the healthcare system and human trafficking may want to consider further researching how to meet the health needs of trafficked persons representing populations that may not routinely reach out to the health care community.
Finally, the HHS SOAR to Health and Wellness training is one of many health and public health-related items that HHS has committed to in the Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States, which was released earlier this year and was developed collaboratively with the Department of Justice and the Department of Homeland Security. Members of the Subcommittee may be interested in other action items that HHS will be implementing through 2017 and beyond, which include:
- HHS’s ACF and Substance Abuse and Mental Health Services Administration will provide a series of recommendations on meeting the mental health needs of victims. This follows up on ASPE’s 2008 National Symposium on the Health Needs of Human Trafficking Victims.
- HHS will explore new data collection strategies, such as the rigor and feasibility of one-day census counts of persons receiving social services associated with their human trafficking experience and collecting data through public health methodologies, for compiling unduplicated estimates on the prevalence of human trafficking in the United States.
- HHS’s Health Resources and Services Administration (HRSA) and intra-agency partners will consider adopting action from the HHS Action Plan to Reduce Racial and Ethnic Health Disparities to establish data standards for information collected related to victims of human trafficking.
- ACF will explore the development of standardized health care protocols for intake (including increased focus on medical history and past intimate partner violence), evaluation/examination, referrals, evidence collection, and long-term care (physical, oral, and mental) in human trafficking situations.
- HHS will collaborate through intra-agency efforts to develop and disseminate materials for public health organizations and associations.
- The Department of Homeland Security Office of Health Affairs will coordinate with HHS to support outreach and training efforts to engage medical first responder personnel and hospital staff in emergency rooms and clinic environments.
- ACF, in conjunction with other HHS components, will explore possibilities of partnering with social work schools, counseling schools, and related professional associations to increase training for social work and health professionals on meeting the needs of human trafficking victims.
- ACF and HRSA will consider strategies, in coordination with intra- and interagency partners, to raise awareness about human trafficking in community colleges.
- HHS will incorporate the topic of human trafficking in ongoing tribal consultations and identify information distribution channels to relevant programs through HHS’s Indian Health Service.
The Administration looks forward to working with each of you to build the capacity of health care professionals to address the needs of victims and survivors of human trafficking.
Again, thank you for the opportunity to testify today. I would be happy to answer any questions.
1 Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in settings. Health Hum Rights. 2011; 13(1):1-14
2 Lederer L, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in facilities. The Annals of Health Law. 2014; 23(1):61-91.
3 Chisolm-Straker M, Richardson L, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson P. Trafficking Victims & Health Care: A Survey of Survivors. Power Point. 2014.
4 Duren Banks and Tracey Kyckelhahn, Characteristics of Suspected Human Trafficking Incidents, 2008-2010, 1, (Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, 2011).