Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696597191091.pdf (United States)
House Committee on Oversight and Government Reform HHS and the Catholic Church: Examining the Politicization of Grants December 14, 2011 Written Testimony of Florrie Burke, M.Ed., MA, LMFT Comprehensive Services for Survivors of Human Trafficking 1 Distinguished Members of Congress and Staff: Thank you for the invitation to provide testimony regarding the reproductive health needs of survivors of human trafficking.
I have been working with these survivors since 1997 when as Executive Director of a Mental Health agency, I was asked to design and provide social services to a large group of men, women and children from Mexico who had been enslaved in a peddling scheme for up to 10 years.
This case occurred prior to the passage of the TVPA in 2000, but it was one of the early cases that were reflected in the development of the language of the Trafficking victims Protection Act (TVPA) that seeks to prevent, protect and prosecute.

I have worked since that time providing direct services, creating programs, supervising staff and now as an independent consultant to both governmental and non‐governmental entities.
I also serve as an expert witness and am asked to testify on the psychological impact of human trafficking and the climate of fear that surrounds the victims of this horrendous crime.

Additionally, I provide training on victim‐centered care both nationally and internationally.

During the various aspects of my work, I have had the privilege of interviewing hundreds of survivors of human trafficking.

It is this direct experience that informs the remarks I will make today and in my written testimony.
My intent is to convey the accounts provided to me by survivors in their own words and not based on theory, supposition or ideology.

I have not experienced trafficking myself, but these survivors have and their stories have made a lasting impression on me.

I think it is imperative that the distinguished members of this committee understand the import and urgency reflected in the physical and mental health needs of survivors.
I am not a medical expert, but as a licensed mental health clinician with advanced degrees in clinical psychology, I am considered an expert in the mental health needs of victims and the efficacy of victim‐centered care.

Victim centered care has the core principle of keeping the victim at the center of a case by providing all information from each provider to the victim and ensuring the victim makes decisions based upon this 2 information.

The victim’s needs are always paramount.


It is not the provider who determines what a victim needs, but the informed victim him/herself Trauma is an over‐arching theme among survivors, both male and female.

Trauma results from the experience of trafficking, the unpredictability of punishment, assault, deceit and shame.

Each person is affected uniquely, but commonalities are fear, anxiety, depression and multiple physical symptoms.
Those of us in this room cannot know the feelings of those forced into degrading and physically and mentally dangerous situations like those soon to be described.

We cannot imagine the stress of knowing something is wrong, but being powerless to get help, to get information, to get treatment and care.

Is it not enough that shame and stigma follow the survivor of trafficking, but also physical and psychological damage do as well?
These crimes are taking place here in our country to our citizens and to others who have come here in pursuit of a better life.

Our laws are designed to protect and punish.

The TVPA has done much to aid in the care and protection of victims and the prosecution of traffickers.

The law states that victims are entitled to social services.

This must include the full range of services in order to mitigate the harm of what has occurred.
We cannot turn our backs on the indignities and assaults perpetrated on these individuals.

We cannot deny them access to a full range of reproductive health care.

In the spirit of victim‐centered care, we must provide information about all available services.

Survivors will make their own choices about what services to access, what choices to make.

They will engage in these decisions after being informed.
They will regain the ability to make choices based on need, not on the force or decisions of others.

We must protect these survivors of human trafficking under the law, not punish them further by withholding options that might aid in their recovery and health.

These options include the full range of reproductive health care, including family planning, contraception and abortion.
It is extremely difficult to find adequate health care for survivors of trafficking at the time of their rescue or escape and prior to their certification as victims of the crime.

3 Time is of the essence, however, and low cost or free care must be sought.

Case managers find and research backs it up, that victims of trafficking have very little knowledge of their basic rights, including reproductive health rights.
Additionally, they often lack information about family planning, about the reproductive process and about sexual health.

For these reasons case managers seek referrals that will provide comprehensive education and counseling about all aspects of reproductive health.

This may include family planning, contraception, prevention of disease and termination of a pregnancy.

Health care providers deliver this information to survivors.

Survivors make the choice for themselves about necessary interventions.
Case managers may discuss these issues if the survivor initiates the conversation, but they do not directly advise or provide any treatment.

I have worked with survivors who have been enslaved for days, months or years.

It is rare that traffickers will allow their victims to receive any health care during the period of trafficking.

There are cases where victims are “discarded” if they become so ill that they cannot perform the exploitive work any longer.
There are other cases where victims are forced to continue working despite painful injuries, untreated infections and undiagnosed disease.

It is rare that service providers will encounter victims during their captivity.

A more common occurrence is that after victims are rescued or escape the trafficking situation, they come into contact with service providers.

Case management programs are tasked with assessment and referral as well as providing practical support.
It is their job to help determine what a trafficked person needs in all areas‐housing, clothing, food, financial assistance, practical information regarding transportation, safety protocols etc.

If the screening assessment of case management programs reveals the need for healthcare services, referrals are made.

A victim‐centered approach means that all necessary information and options are provided.

This is a key component in the restoration of the dignity and personal agency of survivors.
It is imperative that we remember that all rights have been taken away when one is trafficked.

Freedom of movement, withholding of identity documents, choice about work, well‐being etc.

have been denied for most victims of human trafficking.

Service providers work diligently to 4 restore these basic human rights and help to return the power to make decisions back to the survivor.
This includes the important ability for the survivor to make choices about reproductive rights including education, contraception and abortion.

It is well known that trafficking for commercial sex involves repeated rape and high‐risk activity.

What is less well known is that many survivors of domestic servitude and a variety of other labor trafficking situations have also been subjected to rape and sexual assault as a means of control and/or punishment.
The age range of trafficked persons is staggering‐from very young children to elderly persons.

All are vulnerable to serious health consequences.

To illustrate I would like to cite a few examples from my experience: Two teenage girls were forced to work in a brothel.

I was introduced to them the day after their escape.

They showed me the one flimsy item of lingerie in their possession and explained that they had been made to take turns wearing it.
They had escaped through the back door of a clinic the trafficker had taken them to when one became seriously ill and couldn’t work.

I questioned the girls about the illness, the visit to the clinic and any follow up care necessary.

They described a painful infection.

They told me they had been subjected to multiple sexual acts without condoms and were fearful of disease.

The young woman with the infection told me she was not given medication.
This seemed odd to me and upon further questioning, she produced a crumpled up prescription‐she hadn’t understood that this was an order for medication.

English was not the primary language of this young girl and that probably accounted for the misunderstanding that occurred in the clinic about the importance of getting a prescription filled.

There are many important aspects of healthcare that are dependent on clear understanding and without which, serious consequences may result.
Case managers can provide assistance in explaining the complex issues of navigating a healthcare system.

Another group of teenage girls was brought into the country and forced to work as “bar girls.” This included commercial sex acts and rape for many of them.

One became 5 pregnant and was given “liquid and pills” by her traffickers to force a miscarriage.
These means were not effective until late in the pregnancy when after repeated forced ingestion of this “medication,” she endured a very painful and dangerous forced abortion at the hands of her traffickers.

The other women were then coerced into observing her and instructed that the same thing could happen to them.

The young woman was then subjected to psychological torture by being forced to keep the result of the late term miscarriage in close physical proximity for several days.
When the young women from this case were finally rescued, this individual was hospitalized for both physical and psychiatric care.

She was suicidal, made several attempts and remained in residential care for several years to deal with the trauma of her treatment at the hands of her trafficker, the effects of all the medication, the forced abortion and the lack of any information provided to her about her body and what was happening to her and to the fetus.
She had no control over anything that happened to her.

Another survivor who was older‐in her thirties‐had been forced to work as a domestic servant for up to six years.

She was repeatedly raped by her employer, her employer’s son and some friends of the employers.

At no time were condoms used.

When she was finally free, she told these experiences to the case manager and was referred to a clinic for a complete gynecological work‐up.
The clinic staff determined that because of long standing untreated STDs, she had sustained permanent damage and a loss of fertility.

The case manager had to provide support and seek counseling for this woman to help her deal with this devastating diagnosis.

To this day, she experiences intermittent discomfort and pain, but as a result of her work with the case manager and the healthcare system, she knows how and where to access assistance.
Education about condom use and emergency contraception is a vital part of the early service provision following an escape or rescue.

In the first case example provided above, the prescription that had not yet been filled was for an antibiotic to cure the infection.

Without treatment, this teenaged girl was at risk of permanent physical damage.

6 The first HHS grants for services to victims were awarded in 2001 and were awarded directly to case management programs.
These grants provided for the referrals to necessary services for survivors without restriction on referrals for reproductive health services, including contraception and abortion.

This allowed the young woman in the prior example to receive the education, counseling, gynecological exam, follow up and necessary medication.
When USCCB received the contract in 2006, the restrictions around reproductive health care would not allow the same agencies that received initial funding to continue to provide the same inclusive referrals for care.

The HHS funding was often the only funding a program had.

Case managers work long hours at low pay to provide accompaniment, support and referrals to needed services for their clients.
It is not always possible for them to spend additional, uncompensated time locating reproductive health care referrals that can be delivered free of charge.

Time is of the essence in many of these cases and that time was compromised when USCCB denied the ability of case management programs to refer for these services.

As the former co‐founder and director of a program for survivors of human trafficking, this issue confuses and saddens me.
It appears that we have lost sight of the real goal‐ protective, comprehensive services for survivors of a horrible crime.

I admire the work of USCCB and thought they did an excellent job of mobilizing response throughout the country in order to ensure service provision.

However, the restriction on referrals for reproductive health care was critical.
This restriction stands in the way of the health and healing of countless victims and denies the option of choice‐something that had previously been denied by the traffickers and enforcers.

The inability of subcontractors under the USCCB contract with HHS to be able to refer for all types of reproductive health services goes against the notion of providing the assistance needed for the clients we strive to help and protect.
In recognition of the reproductive and sexual health effects of all human trafficking survivors, the Institute on Migration ‐ UN GIFT‐ London School of Hygiene and Tropical 7 Medicine handbook, issued in 2009, titled “Caring for Trafficked Persons: Guidance for Health Providers,” states: “Many people are trafficked for purposes of sexual exploitation; trafficked persons in other types of exploitation may also be sexually abused as a form of coercion and control.
As a consequence, trafficked persons, regardless of gender or age, are at risk of developing complications relating to sexual and reproductive health.

Addressing sexual and reproductive health issues is therefore an important component of caring for someone who has been trafficked.
It is essential that every trafficked person receive timely, competent and comprehensive sexual and reproductive health services even if they were not trafficked explicitly for sexual exploitation.” The TVPA is up for reauthorization again.

This important law has been a model throughout the world and the provisions of the reauthorization serve to strengthen and provide further protections and prosecutorial assistance.
We must not allow this issue before us today to distract from the reauthorization process.

The framework of the TVPA provides a clear message to the United States and the world that services, investigations and prosecutions are vital to a comprehensive fight against human trafficking.

A few months ago I was invited to be the keynote speaker at a healthcare conference.

This conference was comprised of nurse practitioners specializing in women’s health.
As I spoke to them about human trafficking and how they might recognize its victims and assist the survivors, the audience of 500 showed recognition of the reproductive health services that might need to be provided.

This kind of response is typical of the range of service providers to whom survivors may be referred.

They become partners in our efforts to provide care to survivors and try to stem the tide of human trafficking.
Case 8 managers need to be able to refer to reputable, informed providers of reproductive health services like this so that clients can get the quality, informed services they deserve and that might save their lives and the lives of others.

It is unthinkable that we would be prohibited from referring clients for care upon a diagnosis of cancer, heart disease or diabetes etc.
And yet, it has been the practice of the last five years to prohibit referrals for reproductive health care that also helps to halt disease and prevent long‐term health issues or even death.
In closing, I urge the esteemed members of Congress to recognize the effects of modern day slavery on its victims, to recognize the impact of the removal of rights and freedoms, to think about the effect of brutality and rape and to do everything in your considerable power to ensure that we work to restore rights, dignity and health to those who have suffered.

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