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EXAMINING H.R. —————, THE TRAFFICKING 

AWARENESS TRAINING FOR HEALTH CARE ACT 

OF 2014 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

SEPTEMBER 11, 2014 

Serial No. 113–173 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

RALPH M. HALL, Texas 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

RENEE L. ELLMERS, North Carolina 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

JOHN D. DINGELL, Michigan 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

GENE GREEN, Texas 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

HENRY A. WAXMAN, California (ex officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 1 

Hon. Fred Upton, a Representative in Congress from the State of Michigan, 

prepared statement .............................................................................................. 68 

WITNESSES

Katherine Chon, Senior Advisor on Trafficking in Persons, Administration 

for Children and Families, Department of Health and Human Services ........ 10 

Prepared statement .......................................................................................... 12 

Additional information for the record 1

Vednita Carter, Founder and Executive Director, Breaking Free ....................... 24 

Prepared statement .......................................................................................... 27 

Laura J. Lederer, Director, Bastian Center for the Study of Human Trafficking, Indiana Wesleyan University ................................................................ 30 

Prepared statement .......................................................................................... 33 

Hanni Stoklosa, Emergency Physician, Brigham and Women’s Hospital ........... 37 

Prepared statement .......................................................................................... 39 

Kenneth P. Miller, President, American Association of Nurse Practitioners ..... 43 

Prepared statement .......................................................................................... 45 

SUBMITTED MATERIAL

H.R. 5411, the Trafficking Awareness Training for Health Care Act of 2014, 

submitted by Mr. Pitts ......................................................................................... 3 

1The President’s Advisory Council on Faith-based and Neighborhood Partnerships report ‘‘Building Partnerships to Eradicate Modern-Day Slavery’’ is 

available at http://docs.house.gov/meetings/IF/IF14/20140911/102647/ 

HHRG-113-IF14-Wstate-ChonK-20140911-SD005.pdf. 

(1) 

EXAMINING H.R. —————, THE TRAFFICKING 

AWARENESS TRAINING FOR HEALTH CARE 

ACT OF 2014 

THURSDAY, SEPTEMBER 11, 2014 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2123, Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Burgess, Ellmers, 

Pallone, Green, and Barrow. 

Staff present: Leighton Brown, Press Assistant; Brenda Destro, 

Professional Staff Member, Health; Sydne Harwick, Legislative 

Clerk; Katie Novaria, Professional Staff Member, Health; Tim 

Pataki, Professional Staff Member; Heidi Stirrup, Policy Coordinator, Health; Ziky Ababiya, Democratic Staff Assistant; and Hannah Green, Democratic Policy Analyst. 

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

OF PENNSYLVANIA 

Mr. PITTS. The subcommittee will come to order. 

The Chair will recognize himself for an opening statement. 

Today’s hearing focuses on H.R. 5411, The Trafficking Awareness 

Training for Health Care Act of 2014. The bill would support the 

development of evidence-based best practices for healthcare providers to identify and assist victims of human trafficking. 

Healthcare providers are among the few professionals who have the 

opportunity to interact with trafficked women and girls. 

Because of unusual House scheduling conflicts today, we had to 

delay the start of today’s hearing. And, therefore, we will dispense 

with members’ oral opening statements. However, members’ full 

written statements will be included in the record. 

[The prepared statement of Mr. Pitts follows:] 

PREPARED STATEMENT OF HON. JOSEPH R. PITTS

The subcommittee will come to order. 

The Chair will recognize himself for an opening statement. 

Trafficking is an issue that many people believe only happens abroad, in a Third 

World country, not in America. But trafficking is happening in our own backyard 

and at an alarming rate. 

2 

The United States has become one of the largest markets for trafficking with profits in the billions of dollars. As a father and a grandparent, this is alarming to know 

that so many women and children are at risk. Although it is important for Americans to become more aware of this issue, awareness must be accompanied by action. 

I would like to commend my colleague from North Carolina, Renee Ellmers, for 

her concern for the women and children involved in this illegal and harmful industry and for proposing H.R. 5411, the Trafficking Awareness Training for Health 

Care Act of 2014. 

The bill would support the development of evidence-based best practices for 

healthcare providers to identify and assist victims of human trafficking. Health care 

providers are among the few professionals who have the opportunity to interact with 

trafficked women and girls. Placed in this unique and critical position, health care 

workers require heightened skills to help these women and girls. 

Health care providers can often interact with victims while they are still in captivity. One study found that 28 percent of trafficked women saw a health care professional while being held captive. Data shows that these victims use emergency 

room and health centers for their care. When providers are trained about human 

trafficking, they have the knowledge and skills to provide assistance that can lead 

to improved care and even rescue. 

I would like to welcome all of our witnesses here today. We look forward to learning from your expertise and experience. 

[H.R. 5411 follows:] 

3 

4 

5 

6 

7 

8 

9 

10 

Mr. PITTS. On our first panel today, we have Ms. Katherine 

Chon, a senior policy advisor at the Administration for Children 

and Families at the Department of Health and Human Services. 

And I understand that Ms. Chon must leave by 10:30 today for 

the airport. So to maximize members’ opportunities for questions of 

Ms. Chon, I will ask her to please summarize her statement in a 

few minutes. 

And, with that, Ms. Chon, you are recognized. You may begin. 

STATEMENT OF KATHERINE CHON, SENIOR ADVISOR ON 

TRAFFICKING IN PERSONS, ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Ms. CHON. Chairman Pitts, Ranking Member Pallone, and members of the subcommittee, thank you for inviting me to share with 

you the Department of Health and Human Services’ work to prevent and end human trafficking in all of its forms. 

HHS recognizes that human trafficking is not only a violent 

crime, but it is also a global health problem. The goals of The Trafficking Awareness Training for Health Care Act of 2014 would complement HHS’s anti-trafficking efforts to build a capacity of first responders to identify and serve victims of human trafficking. 

In our ongoing engagement with healthcare providers, this week 

HHS started a series of our pilot SOAR to Health and Wellness 

Training for Health Care Professionals, in which SOAR stands for 

Stop, Observe, Ask, and Respond to human trafficking. 

This training seeks to increase knowledge on the diversity of 

human trafficking, identify indicators, utilize trauma-informed 

care, and connect with local and national service referral resources 

for trafficking victims. 

We are partnering with local hospitals and community clinics in 

Atlanta, Boston, Houston, Oakland, and Williston and New Town, 

North Dakota, for the trainings, which will be evaluated later this 

fall. 

While the SOAR trainings currently target healthcare providers 

through hospitals and community clinics, the bill broadens the 

reach of training efforts to health professions schools. 

In addition to accredited schools of medicine and nursing, we recommend dental and social work schools as important target audiences because research has shown that victims of trafficking have 

encountered dentists and hospital- and clinic-based social workers 

are often responsible for managing the follow-up services once a 

victim has been identified. 

The bill also references evidence-based practices. Since there is 

little evidence-based research specifically on the intersection of the 

healthcare system and human trafficking, the anti-trafficking fields 

may be able to adapt lessons learned from efforts in related issue 

areas, including the treatment of domestic violence and sexual assault victims in healthcare settings. 

Additional opportunities for healthcare engagement include 

building the capacity of public health professionals to help prevent 

human trafficking, including interventions like the John schools, 

which provide information to purchasers of commercial sex who 

11 

have been arrested and then participate in educational programs 

on the health and behavioral health consequences of their actions. 

The Administration looks forward to working with each of you to 

build the capacity of healthcare professionals to address the needs 

of victims of human trafficking. 

Again, thank you for the opportunity to testify today. And I 

would be happy to answer any questions. 

[The prepared statement of Ms. Chon follows:] 

12 

13 

14 

15 

16 

17 

18 

[Additional information submitted by Ms. Chon is available at 

http://docs.house.gov/meetings/IF/IF14/20140911/102647/HHRG113-IF14-Wstate-ChonK-20140911-SD005.pdf.] 

Mr. PITTS. Thank you. 

We will begin the questioning. I will recognize myself 5 minutes 

for that purpose. 

Ms. Chon, according to the Compendium of State Statutes and 

Policies on Domestic Violence and Health Care, which was funded 

by HHS, it states that, ‘‘The goals potentially served by mandatory 

reporting include enhancing patient safety, improving healthcare 

providers’ response to domestic violence, holding batterers accountable, and improving domestic violence data collection and documentation. However, upon closer examination, it becomes apparent 

that mandatory reporting does not necessarily accomplish these 

goals.’’ 

This statement seems to discourage mandatory reporting by 

healthcare workers. Is that the position of HHS? Is there research 

to support this position? 

Ms. CHON. So I am less familiar with the mandatory reporting 

guidelines around domestic violence. But one thing that we have 

heard from healthcare providers specific to human trafficking is 

that there have been concerns—or questions from healthcare providers on reporting requirements balanced with HIPAA regulations 

when it comes to identifying victims of human trafficking. 

And so what we are encouraging in our SOAR to Health and 

Wellness training is being familiar with HIPAA requirements but 

also familiar with the local and State statutes around mandatory 

reporting and the healthcare institutions’ protocols around reporting. 

And, universally, though, we do encourage identifying referrals 

for follow-up social services within the context of institution and 

State and local guidelines as well as Federal. 

Mr. PITTS. Well, that statement seems to discourage mandatory 

reporting by healthcare workers. 

Does that or should that position apply to human trafficking? 

Ms. CHON. Well, in terms of mandatory reporting for human trafficking, part of it depends on the type of human trafficking that a 

healthcare provider may come across. 

So for victims of child sex trafficking, for example, in many 

States, they are also victims of child abuse, according to the State 

laws, and there are very strict mandatory reporting guidelines 

there. 

In our SOAR to Health and Wellness training, we do go over the 

specific situations in which mandatory reporting would be required 

by law. 

Mr. PITTS. Can you explain what the stop, observe, ask, respond 

to human trafficking in the SOAR training program entails, how 

the training was developed and how the cities participating in the 

pilot were chosen. 

Ms. CHON. Sure. This training is part of one of our many commitments in the Federal Strategic Action Plan on services to victims 

of human trafficking. It is an interagency plan, which HHS cochaired with the Departments of Justice and Homeland Security. 

19 

And during the public comment process, the anti-trafficking field 

called for increased training for healthcare providers. So we identified and formed a national technical working group of subject matter experts, including many healthcare professionals across a wide 

spectrum of specialties that have experience in training healthcare 

providers. 

We also had service providers and survivors of human trafficking 

inform the training. It went through Federal interagency review 

and was based on a literature review as well. 

Because this is a pilot, we selected five sites in areas where we 

could develop strong partnerships with local stakeholders and 

healthcare providers who were already experienced in responding 

to this issue. So Boston, Oakland, Atlanta, and Houston were chosen for those reasons. 

And then New Town and Williston, North Dakota, were chosen 

because there were concerns around the increase in various forms 

of violent crimes, including human trafficking, and the need for the 

healthcare system to receive training to identify and respond to a 

relatively new issue that they felt they were seeing in that area. 

Mr. PITTS. Can you explain how HHS was involved in the development of the Federal Strategic Action Plan on services for human 

trafficking in the United States? And what goals has HHS set in 

the Strategic Action Plan? 

Ms. CHON. The Strategic Action Plan has four primary goals set 

not just by HHS, but through a collection of more than a dozen 

Federal agencies and partners. It is available online. We would be 

happy to also provide a copy of it as well. 

And, as I mentioned, we co-chaired this process with the Departments of Justice and Homeland Security. The draft plan was based 

on a number of community listening sessions across the country, 

national calls as listening sessions, as well as literature review. 

And the draft was released for public comment last spring. And 

then Federal agencies reviewed the public comments throughout 

the summer and fall, finalized it, and then the final version was 

released this January. 

Mr. PITTS. The Chair thanks the gentlelady. 

Now yields to the ranking member, Mr. Pallone, for 5 minutes 

of questions. 

Mr. PALLONE. Thank you, Mr. Chairman. 

Last week I had the opportunity to visit the U.S.-Mexican border, 

and the Administration for Children and Families plays an important role there, providing critical health and welfare services to the 

unaccompanied children who cross that border every day. 

We all know that the unprecedented number of unaccompanied 

minors have arrived in the U.S. and needed ACF’s services this 

year. And Congress clearly has the responsibility to ensure that 

this agency has the resources that it needs to do this work. 

We don’t want the Administration for Children and Families to 

be forced to reallocate funds from other important programs, such 

as the ones we have heard about this morning. 

So can you just discuss the importance of providing adequate 

funding for the Administration for Children and Families programs 

to address the needs of both domestic and foreign victims of human 

trafficking? 

20 

And in its fiscal year 2015 budget, ACF proposed an increase of 

$8.2 million to specifically assist domestic victims of human trafficking. Can you comment on the type of work the ACF plans to 

do with that money? 

Ms. CHON. Sure. Well, the good news is we have not had to reallocate any of our anti-trafficking funds to address some of the unaccompanied minor needs that have risen over the past year. 

In terms of the budget requests, the increase in funding will 

allow HHS to serve victims of all forms of trafficking, so foreign nationals as well as U.S. citizens and lawful permanent residents. 

Pretty much over the last decade or so, the budget on addressing 

human trafficking has been fixed around $10 million, primarily 

going to serve foreign national victims of trafficking. 

In this current fiscal year, we received an increase in appropriations, which gave us enough to provide demonstration grants to 

start serving domestic victims of trafficking, so U.S. citizens and 

lawful permanent residents. 

And so what we intend to do, if there is a further increase in the 

budget, is to bring parity at least in the budget that goes to serve 

domestic victims to match up the budget that has been going to 

serve foreign national victims. 

Mr. PALLONE. Thanks. 

I also wanted to hear more about the SOAR for Health and 

Wellness initiative and the pilot trainings that are beginning this 

week. 

So let me ask what kind of interest you have seen from the communities that are conducting pilot training over the next few 

weeks. 

And after participants complete the pilot trainings, what kind of 

evaluations do you have planned? And what do you plan to use 

these evaluations for to think about the future of the SOAR program? 

Ms. CHON. Sure. So there has been significant interest in the 

specific pilot locations. Registrations, we have been meeting our 

goals for this pilot program. We were targeting about 45 participants per site. And in some sites, like in North Dakota and Houston, there are multiple trainings that are being held. 

And it is not just the pilot sites, but we are hearing from other 

communities. Healthcare providers are asking for additional resources on training and technical assistance, which HHS partly 

provides through our National Human Trafficking Resource Center. Healthcare providers can access that at any point. 

Then, in terms of the evaluation, there is a pre- and post-test for 

this training, a 3-month evaluation survey, and a subset of the participants will participate in qualitative surveys as well. We will release the findings of the evaluation next spring. 

Mr. PALLONE. All right. Earlier this year the Departments of 

Justice, Homeland Security, Health and Human Services released 

a Federal Strategic Action Plan on Services to Victims of Human 

Trafficking in the U.S., and it outlines a number of specific actions 

that different Federal agencies are going to take. 

I understand you were involved in the development of this plan. 

What types of comments did you receive from healthcare profesVerDate Mar 15 2010 11:10 Mar 19, 2015 Jkt 037690 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 F:\113-173 TRAFFICKING - AWAIT SCANS\113-173 TRAFFICKING PENDING WAYNE
21 

sionals during this process regarding the need to improve the 

healthcare system’s response to victims of human trafficking? 

Ms. CHON. The overwhelming response that we received in the 

public comment process from healthcare providers was a need for 

additional training and resources, especially if it could be in some 

standardized way and, also, tailored to the specific healthcare professions. We also heard comments on having screening tools, especially if they could be validated and be evidence-based. 

And the type of training that we are providing is different from 

a longer-term curriculum that could be available through educational institutions, but we also heard the importance of developing skills through curriculum-based efforts in educational institutions. 

Mr. PALLONE. All right. Thanks. 

I just wanted to say, with regard to the SOAR training, I am 

glad that HHS has evaluation steps in place to assess the effectiveness of the pilot program, and I think this work would provide 

helpful feedback as we think about what role Congress and the 

Federal Government can play in assisting the healthcare community to respond to the needs of trafficking victims. 

So thanks again. 

And thank you, Mr. Chairman. 

Mr. PITTS. The Chair thanks the gentleman. 

And I now recognize the gentlelady from North Carolina, Mrs. 

Ellmers, for 5 minutes for questions. 

Mrs. ELLMERS. Thank you, Mr. Chairman. 

And thank you, Ms. Chon, for being with us today. I know you 

have limited time, so I will try to get through my time so that we 

can allow anyone else for questions. 

First of all, I want to say thank you for what you are doing, and 

the SOAR program sounds like we are moving forward on a really 

good HHS initiative. 

We feel very strongly that we want to expand that, and we want 

to make sure that we are reaching out and including our education 

for medical students and nurses. And that really has to do with 

what we are trying to achieve here with the bill that we have. 

And, of course, as you know, funding is an issue. We want to 

make sure that there is adequate funding for this project. 

I was wondering if you could comment from that perspective on 

some funds that are available through HHS, the Prevention and 

Public Health Fund, or the PPHF, which basically helps to fund innovative projects and outreach. 

I believe that this is one of those areas that—especially when we 

are moving forward with health care—could be a positive funding 

source through HHS that is already there and call on Congress to 

appropriate funds to it. 

Would you like to comment on that? 

Ms. CHON. Sure. In terms of my knowledge of those particular 

funds, I don’t believe they have been used for anti-trafficking training purposes in the past. But I certainly will ask the appropriate 

divisions within HHS how those funds could be used for these purposes and then would be happy to get back to you on those possibilities. 

22 

Mrs. ELLMERS. Great. That would be great if you could get back 

to the committee on the response to that. Because I think, as we 

are moving forward, we would like for this to move as quickly as 

possible. And, you know, we, too, have suggested a pilot program 

with feedback so that we know what is working and what isn’t. 

I think the training and the education component of it for our 

medical students and our nurses so that they are being exposed to 

this information—one of the things that I found over time that is 

so vital is that many people do not realize this is happening here 

in the United States and that this is something that we have to 

make sure that our healthcare providers are understanding and 

aware of. 

I will yield back. 

I just, again, want to thank you for being here today and thank 

you for sharing your information, and I am looking forward to 

working together on this. 

Ms. CHON. Thank you. 

Mrs. ELLMERS. I yield back. 

Mr. PITTS. The Chair thanks the gentlelady. 

I now recognize the gentleman from Georgia, Mr. Barrow, 5 minutes of questions. 

Mr. BARROW. No questions. 

Mr. PITTS. The Chair recognizes the vice chairman of the subcommittee, Dr. Burgess, for 5 minutes of questions. 

Mr. BURGESS. Thank you, Mr. Chairman. I apologize for being 

late. There is a lot going on this morning. 

Ms. Chon, thank you for being here. Your agency is one that has 

perhaps come to the attention of this subcommittee a great deal 

more over the last 6 months for a variety of reasons. 

But as we are here today to discuss the prevention of human 

trafficking, I seem to detect that there is a system of best practices 

with evidence-based research and a system of promising practices. 

Could you help me understand a little bit the differences between 

the two and why you favor one over the other? 

Ms. CHON. Well, in the scientific community, there is always a 

prioritization around evidence-based practices—so, for example, the 

reason why we put funding into evaluating our trainings was because we wanted to have the evidence that the training was 

impactful and met the goals that we set out for it, as opposed to 

best practices or promising or emerging practices are those practices that seem to have impact, but there have not yet been rigorous evaluation just because the research funding wasn’t there. 

Mr. BURGESS. Well, what population of providers—or professionals are you likely to train in the program? 

Ms. CHON. So it is healthcare providers across the spectrum from 

doctors, nurses, dentists, mental health providers, clinical social 

workers, school-based nurses as well because they truly are at the 

frontlines of early identification and, also, prevention of human 

trafficking so that the problem doesn’t happen in the first place. 

Mr. BURGESS. Might I just gently suggest that perhaps you could 

talk to professionals who are in the Office of Refugee Relocation, 

who are also under the Administration of Children and Families? 

23 

Because it seems to be missing from some of the hearings and 

briefings we have had on the issue of the unaccompanied minors 

in the lower Rio Grande Valley in my State of Texas. 

In fact, your physician—and, unfortunately, a physician was only 

hired by ORR in May of this year, even with the understanding 

that the problem was tumultuous and growing for several months 

before that. And your doctor reported to us that they only investigated cases of sexual assault if the victims so self-identified. Of 

course, these are children that we are talking about who are coming into these centers. 

In the State of Texas, it is a reportable crime. I am a physician. 

I was required by law to report to State authorities if I thought a 

child had been abused, let alone was a victim of sexual assault. But 

I was required by law and, if I didn’t report it, I was in trouble. 

And, yet, you have these children streaming across the Rio 

Grande River as unaccompanied minors, giving themselves up 

when they get across into Texas, taken into centers, evaluated by 

sometimes DMAT teams. And although they do great work, the 

level of training you have got to wonder about. ORR had just hired 

a doctor right before the summer started and, yet, they were only 

investigating cases where a child said, ‘‘Yes. I was a victim.’’ 

And I was down in those intake centers. You would have groups 

of kids sitting on a cement bench, a group of little 5-year-old boys— 

I have got a 5-year-old grandson. I know how hard it is to get a 

5-year-old to sit still—five 5-year-old boys just sitting on this bench 

stone-still, staring into space. That is not normal. That is not normal behavior for a 5-year-old. 

The cell was holding what looked like a class of third-grade girls 

except, yes, you realized they were all brought there or had turned 

themselves in. And these people had gotten across the entire country of Mexico through the deserts and the jungles and the difficulties by coyotes, who are human traffickers. 

Why aren’t they further investigated? And when those cases are 

found, why are they not reported to State authorities so someone 

can go after the people who are the perpetrators and stop this 

problem at least—if not once and for all, a least have a better handle on starting it? 

We are enablers right now, as far as I can see. We are co-dependents with the child traffickers. And it is not a pretty story and does 

not reflect well on your agency. It does not reflect well on the Office 

of Refugee Resettlement. And it needs to stop. 

Thank you, Mr. Chairman. I will yield back my time. 

You may respond if you wish. 

Mr. PITTS. Yes, please. 

Ms. CHON. I think we have the same goals in mind in terms of 

protection for these unaccompanied minors. And I thank you for 

your passion and your concern for this population. 

The Office of Refugee Resettlement, they are a part of a departmental working group on human trafficking, and I will learn more 

about what their practices are on the health piece in their screening for trafficking. 

Mr. BURGESS. Let me just provide you some information. Every 

young woman or child, girl, who’s brought into the center over the 

age of 10 is given a pregnancy test. I presume there is a reason 

24 

for that, because they think something might have happened during this long journey up here. But then they are not further 

queried about the possibility of sexual assault. 

It is sort of like we are indifferent to the fact that these children 

may have been assaulted on the way up here. We are never going 

to be able to stop the bad guys if we don’t do the fundamental police work. And your agency is sort of the tip of the spear there. 

That is where it should be happening, and, unfortunately, it is not. 

Again, thank you, Mr. Chairman, for the indulgence. 

Mr. PITTS. The Chair thanks the gentleman and thanks the witness for answering all your questions. 

We know that you have to leave to catch a plane. We will send 

follow-up questions. And I know other members will have questions 

in writing to you. We will ask that you please respond promptly. 

Ms. CHON. Thank you very much. 

Mr. PITTS. Thank you very much, Ms. Chon, for your time. 

And so we will dismiss our first panel and introduce the second 

panel at this time. 

On our second panel we have—and if the staff can set that up 

and I will introduce them in the order of their presentation—first, 

Ms. Vednita Carter, Founder and Executive Director of Breaking 

Free. Then we have Ms. Laura Lederer, Director of the Bastian 

Center for the Study of Human Trafficking, Indiana Wesleyan University. Then we have Dr. Hanni Stoklosa, emergency physician, 

Brigham and Women’s Hospital, and, finally, Dr. Ken Miller, President, American Association of Nurse Practitioners. 

So if you will take your seats. Thank you all for coming. Your 

written testimony will made a part of the record. You will each be 

given 5 minutes to summarize your testimony. 

And, Ms. Carter, we will start with you. You are recognized for 

5 minutes. 

STATEMENTS OF VEDNITA CARTER, FOUNDER AND EXECUTIVE DIRECTOR, BREAKING FREE; LAURA J. LEDERER, DIRECTOR, BASTIAN CENTER FOR THE STUDY OF HUMAN 

TRAFFICKING, INDIANA WESLEYAN UNIVERSITY; HANNI 

STOKLOSA, EMERGENCY PHYSICIAN, BRIGHAM AND WOMEN’S HOSPITAL; KENNETH P. MILLER, PRESIDENT, AMERICAN ASSOCIATION OF NURSE PRACTITIONERS 

STATEMENT OF VEDNITA CARTER 

Ms. CARTER. Chairman Pitts, Representative Ellmers and distinguished members of the committee—— 

Mr. PITTS. If you can press that button. Pull it up close so the 

light is on. Thank you. 

Ms. CARTER. Chairman Pitts, Representative Ellmers, and distinguished members of the committee, thank you for inviting me to 

testify today to support this groundbreaking bill for the training of 

healthcare professionals to better work with victims of human trafficking. 

My name is Vednita Carter. I am a survivor of sexual exploitation. I am also the founder and executive director of Breaking 

Free, a nonprofit agency in St. Paul, Minnesota. 

25 

Breaking Free’s mission is to educate and provide services to 

women and girls who have been victims of abuse and sexual exploitation and need assistance escaping violence in their lives. 

Breaking Free is a survivor-led organization and provides services to more than 500 victims each year. In the case of virtually 

every sex-trafficking victim we have worked with, they were recruited, coerced, defrauded, or forced into prostitution. 

Once girls and women are involved in the life of sex trafficking, 

it is extraordinarily difficult for them to escape. We can never forget that sex trafficking is modern-day slavery. 

Sex trafficking causes tremendous trauma for victims from the 

physical abuse, emotional abuse, sexual abuse, kidnapping, and 

torture they have experienced. It is a terrifying and dangerous life. 

83 percent of our clients at Breaking Free were assaulted with 

a deadly weapon. 57 percent were kidnapped before they escaped 

sex trafficking. 86 percent suffer from some type of emotional, 

physical, or mental disability. 71 percent of the victims we serve 

suffer from post-traumatic stress disorder. 

One survivor’s story illustrates some of the health issues victims 

of sex trafficking face. As she told me, ‘‘I was trafficked when I was 

11 years old by my foster mother, who let her boyfriend sell us to 

other men. By the time I was 12, I had a pimp. During this time, 

I was beaten, burned, raped, and assaulted. Sometimes I went to 

a local neighborhood health clinic to be treated, but no one ever 

asked me what had happened to me. And, if they did, I lied because I was afraid of my pimp. I had severe depression, anxiety, 

paranoia, and mental health issues, even after I became free. I got 

pregnant six times and had six abortions during this time. I had 

severe scar tissue from these abortions because there was no follow-up care. In a couple of cases, I had bad infections, so bad that 

I eventually had to have a hysterectomy. To this day, I have physical, mental, and emotional issues as a result of that time on the 

street.’’ 

Another survivor told me, ‘‘I was beaten, strangled, kicked, 

punched, raped, and hit on the head by my pimp. I wasn’t able to 

escape until I was diagnosed with cervical cancer and, since then, 

I have been battling serious physical and mental health problems, 

including headaches, shortness of breath, bronchitis, chest pain, 

chlamydia, vaginal infections, and urinary tract infections. I also 

suffer from depression, anxiety, and panic attacks. I attempted suicide several times.’’ 

All too often victims of sex trafficking slip through the cracks of 

our medical system. Without appropriate training, health professionals are not able to put the pieces of the puzzle together to see 

that the woman or girl in their examination room is a sex-trafficking victim, or if the professional is able to see the signs, she or 

he doesn’t know how to talk to a victim without shaming or retraumatizing her, or the professional may be unaware of community resources to help the victim. 

Healthcare professionals are in an excellent position to identify 

and help victims, but they need coordinated, evidence-based, and 

trauma-informed training to be able to do so. 

The Trafficking Awareness Training for Health Care Act of 2014 

offers the medical community the opportunity to develop best pracVerDate Mar 15 2010 11:10 Mar 19, 2015 Jkt 037690 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 F:\113-173 TRAFFICKING - AWAIT SCANS\113-173 TRAFFICKING PENDING WAYNE
26 

tices for identifying and caring for victims and the opportunity to 

help thousands of victims in our Nation break free. 

Thank you. 

[The prepared statement of Ms. Carter follows:] 

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Mr. PITTS. The Chair thanks the gentlelady. 

Now recognizes Ms. Lederer, 5 minutes for opening statement. 

STATEMENT OF LAURA J. LEDERER 

Ms. LEDERER. Thank you, Mr. Chairman, and members of the 

committee. Thank you for the invitation today to testify and for 

calling this hearing to address the health effects of human trafficking and the need for training for the healthcare provider sector. 

Over the last decade, we have looked at human trafficking as a 

human rights abuse and as a criminal justice problem, but in the 

past 5 years, it has become clear that human trafficking also has 

serious public and private health consequences and that we need 

public policy and programmatic responses to train healthcare providers to identify victims and to respond appropriately. 

Today I want to share with you the preliminary findings from a 

series of focus groups we conducted with domestic survivors of sex 

trafficking around the country. These focus groups provide evidence 

that women and children who are trafficked into prostitution are 

physically, mentally, emotionally devastated by the crime and this 

devastation is lasting with illnesses, injuries, and impairments 

starting during trafficking, but lasting often years longer. 

The full set of findings in charts and tables is available in my 

written testimony. I am only going to outline the basic findings in 

my testimony here today. 

Survivors suffer tremendously, virtually without exception. In 

our study, 99.1 percent reported that they had at least one physical 

health problem during trafficking, and the majority reported dozens of health issues ranging from neurological, cardiovascular, respiratory, gastrointestinal, gynecological, dental, and dermatological 

problems. 

Survivors were also overwhelmingly traumatized not only physically, but mentally. The brutal treatment they endured created ongoing psychological and mental conditions in many victims and also 

exploited existing mental instability in others. 

98.1 percent reported at least one psychological issue during 

their captivity, with an average of more than a dozen psychological 

health problems indicated, including depression, flashbacks, panic 

attacks, helplessness, hyper-alertness, disassociation, depersonalization, suicidal ideation, attempted suicide, post-traumatic 

stress disorder. 

Not surprisingly, survivors also reported significant numbers of 

reproductive health problems. More than two-thirds of the survivors we talked to contracted some form of sexually transmitted 

disease or infection, some STD or STI, including gonorrhea, syphilis, herpes, or chlamydia. 

Survivors also reported many issues around pregnancy. 71.2 of 

the survivors we talked to reported at least one pregnancy while 

being trafficked. 21.2 percent reported five or more pregnancies. 

57.7 percent said they had at least one miscarriage. 29 percent said 

they had more than one miscarriage while being trafficked. 55.2 

percent reported at least one abortion, with 30 percent reporting 

multiple abortions during the time that they were trafficked. 

The prevalence of forced abortion is an especially disturbing 

trend in sex trafficking. Prior research has noted the occurrence of 

31 

forced abortion in victims of sex trafficking outside the United 

States, but our survivors indicated that they often did not elect to 

have abortions. 

More than half of those who answered the question indicated 

that their abortions were forced upon them. In addition, many 

more said they felt forced to choose abortion by the circumstance 

of being trafficked. 

‘‘How can I take care of my baby when he’’—her pimp—‘‘forced 

me out on the street every night to make money?,’’ one victim 

noted. Another said, ‘‘In most of my six abortions, I was under serious pressure from my pimp to abort the babies.’’ 

Notably, the phenomenon of forced abortion in sex trafficking 

transcends the political boundaries of the abortion debate. It violates both the pro-life belief that abortion takes an innocent life 

and the pro-choice ideal of a woman’s freedom to make her own reproductive choices. 

Survivors were also the victims of violence and abuse at the 

hands of their traffickers. 95.1 percent in our study experienced 

some kind of violence or abuse, as Vednita said, including being 

shot, strangled, burned, kicked, punched, beaten, stabbed, raped, 

penetrated with a foreign object. 

Survivors also reported threats, intimidation, verbal abuse, and 

humiliation. Violence was the rule rather than the exception in 

trafficking. As one survivor said, ‘‘My pimp had his girls out on the 

street every night. It was either you made the quota of money for 

him or you got beaten.’’ 

Many survivors reported being dependent upon drugs and alcohol 

while they were being trafficked either because the substances 

were forced on them as a control mechanism by their traffickers or 

because the substance abuse was a means of coping with their dire 

circumstances. 

84.3 percent reported use or abuse of drugs, alcohol, or both during the time they were trafficked, and the most common substances 

mentioned were alcohol, marijuana, cocaine, crack cocaine, Ecstasy, 

and heroin. 

Perhaps the most shocking finding of our study was that 87.8 

percent of our survivors had sought medical care during the time 

that they were trafficked. The most frequently reported treatment 

site was the hospital emergency room, with 63.3 percent saying 

that they sought health care there. 

Survivors also had significant contact with healthcare clinics— 

that is 57.1 percent—including Planned Parenthood, urgent care 

clinics, women’s clinics, and neighborhood clinics, in that order. 

So, clearly, health providers are first responders and they have 

a unique opportunity to communicate with and to intervene on behalf of victims. And for this reason healthcare providers must be 

aware of the signs of trafficking in order to identify victims. 

An important part of this training will be to help health providers understand the coercive dynamic of trafficking, especially 

the extreme degree of control exercised by the trafficker and the 

prevalence of criminal exploitation of women and children. So we 

need specialized trainings tailored for the healthcare sector. These 

are a critical part of the solution. 

32 

Setting up internal protocols and procedures and regulations 

may also further assist the healthcare providers in identifying, 

treating and responding to and reporting as well as referring, 

where necessary, trafficking victims. 

Finally, we absolutely need more research to help us understand 

the healthcare problems and the needs of trafficking victims as 

well as to identify best practices and to create national, State, and 

local responses to health consequences of trafficking. 

The medical community can play a vital role in the ongoing fight 

to eliminate modern-day slavery, and H.R.—whatever the number 

is going to be—the Trafficking Awareness Training for Health Care 

Act of 2014, is an important step in helping to equip them for this 

fight. 

And I thank you so much for having us here today to begin this 

conversation. 

[The prepared statement of Ms. Lederer follows:] 

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35 

36 

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Mr. PITTS. The Chair thanks the gentlelady. 

Now recognizes Dr. Stoklosa, 5 minutes for opening statement. 

STATEMENT OF HANNI STOKLOSA 

Ms. STOKLOSA. Chairman Pitts and Ranking Member Pallone, 

thank you for inviting me to testify today. 

And, Representative Ellmers, thank you so much for putting 

forth this bill. 

And I would also like to express my appreciation to Vednita 

Carter for her courage in sharing the survivor perspective. 

I am an emergency medicine physician at Brigham Women’s 

Hospital in Boston as well as faculty at Harvard Medical School. 

In Boston, I convened a citywide task force, looking at developing 

a health protocol for victims of trafficking when they come to our 

healthcare settings. 

In addition, I do international research on human trafficking, including the monitoring and evaluation study of anti-trafficking programs in India as well as looking at the health consequences of 

human trafficking among construction workers in Kazakhstan. 

I co-founded HEAL Trafficking in the fall of 2013. ‘‘HEAL’’ 

stands for ‘‘Health professional, Education, Advocacy, and Linkages.’’ And our vision really is to unite health professionals who are 

working on the issue of human trafficking. 

We are divided into working groups that are working on the 

issues that are the crux of health and trafficking, including education and training protocols, research, direct service, prevention, 

and advocacy. 

HEAL Trafficking brings together a broad range of health providers, including administrators, researchers, dentists, social workers, nurse practitioners, and physicians. And we are pleased to 

work very closely, especially our education and training group, with 

the SOAR initiative within the Department of Health and Human 

Services. 

I am going to share with you a story from the emergency room. 

This was early on in my training, and it was a busy overnight 

shift, seeing lots and lots of patients. And I took care of this young 

woman, who was Cantonese-speaking, who came into the emergency room, and her chief complaint, the main reason that she was 

there, was she had abdominal pain. 

And from a medical perspective, it was a really straightforward 

case. We diagnosed her with a sexually transmitted infection. We 

treated her appropriately. And then we discharged her home. 

I knew that something wasn’t right. I couldn’t put my finger on 

it. And there was this dynamic in the room with an older, also 

Cantonese-speaking woman, but I didn’t have any training on 

human trafficking. And so I missed this case of human trafficking. 

Later on, as I learned what trafficking was and that it was actually happening in the United States, I realized that I missed this 

opportunity with this young woman, this opportunity to intervene 

at her time of need in her interface with the healthcare setting. 

Unfortunately, this happens all too often. Victims of trafficking 

are coming to our hospitals and clinics, and they are leaving unrecognized and uncared for. 

38 

There are three crucial considerations when we look at developing a healthcare initiative for education of our health providers 

nationally. These considerations are who, what, and then, ‘‘Then 

what?’’ 

So the ‘‘who.’’ And Katherine Chon alluded to this. But we really 

need to train all healthcare providers across disciplines as well as 

across specialties. In terms of the disciplines, we need to train social workers, EMTs that are responding in ambulances, physicians, 

nurse practitioners. 

And we need to train across specialties. We need to train obstetrics and gynecology specialists, dermatologists, emergency room 

providers, surgeons, family medicine providers. We need to train 

the full spectrum. 

And, in addition, we need to train them across the spectrum of 

their education. So from the physician perspective, from medical 

school all the way on up to my board-certification process, this 

needs to be integrated at every stage. 

The second is the ‘‘what.’’ The content of the training—you know, 

the Department of Health and Human Services is working on developing the evidence-based content, and I think crucial in that is 

having trauma-informed, survivor-led expertise. 

When I talk to survivors, their everyday ‘‘live’’ experience is often 

a very deep-seated, complex experience of PTSD due to the repeated physical and emotional and sexual abuse that they experienced during the time that they were exploited, and our health settings and our health providers need to be sensitive to that. 

They need to provide a welcoming environment where they aren’t 

even inadvertently revictimizing victims of trafficking. And, if they 

don’t trust the health provider, if they don’t trust that setting, 

there is no way that that health provider is going to get the information they need to be able to identify them as a victim. 

The last piece here is that we need to develop a strong referral 

infrastructure. The current state of resources for survivors is inadequate and disorganized. Just imagine, as we identify further victims of trafficking, what that is going to do to burden our already 

burdened system. 

Survivor care is a long-term process, and survivors need to know 

that they are better off in our healthcare system than they are in 

the arms of their exploiter. 

So, in summary, who should we train? We should train all 

healthcare providers. In terms of the ‘‘what,’’ it needs to be traumainformed and survivor-led, and we need to expand resources for referral. 

Thank you so much. 

[The prepared statement of Ms. Stoklosa follows:] 

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Mr. PITTS. The Chair thanks the gentlelady. 

And I now recognize Dr. Miller for 5 minutes for an opening 

statement. 

STATEMENT OF KENNETH P. MILLER 

Mr. MILLER. Thank you, Chairman Pitts, Ranking Member 

Pallone, and members of the subcommittee. I appreciate the opportunity to speak with you today on behalf of the American Association of Nurse Practitioners, the largest full-service professional 

membership organization for NPs of all specialties. 

With nearly 52,000 individual members and over 200 organization members, we represent the more than 192,000 nurse practitioners across the Nation. 

My name is Ken Miller, and I am currently serving as the President of the American Association of Nurse Practitioners. I have 

also served in many different academic administrative roles across 

the country. I have also worked as a family nurse practitioner in 

New Mexico, Delaware, and the District of Columbia. 

NPs have been providing primary, acute, and specialty care for 

a half a century. We are rapidly becoming the healthcare provider 

of choice for millions of Americans. In fact, we conducted over 900 

million patient visits throughout the United States in 2013. 

NPs practice in every community in this country, both urban and 

rural, and see patients from all economic and social backgrounds. 

We provide care in all types of settings, which include clinics, hospitals, emergency rooms, urgent care sites, private physician or NP 

practices, nursing homes, schools, colleges, retail clinics, public 

health departments, and homeless clinics. 

It is also important to remember that, in many of these settings, 

NPs are the lead provider on site. In fact, there are many NPowned and -managed clinics across the United States. It is in these 

various settings, particularly public health departments and primary care clinics, where NPs play a key role in recognizing many 

of the at-risk, vulnerable populations they treat. 

NPs, with their emphasis on primary care, health promotion, and 

education, coupled with their nursing background, approach the 

care of their patients holistically. 

Their expert assessment and interviewing skills, combined with 

their education and preparation, uniquely positions them to gather 

information which not only allows them to treat symptoms, but 

also research causality, crucial to effective prevention of emotional, 

physical or sexual abuse. 

Knowing the correct assessments to perform and the right questions to ask when treating patients that are victims of other types 

of violent crime and abuse is a skill set similar to what NPs must 

call upon when recognizing and treating victims of human trafficking. 

We know today that practicing NPs are confronted with patients 

whom they suspect are victims of human trafficking and that we 

must lead and work with other provider groups to develop best 

practices and procedures that will allow all providers to attain the 

skills needed to ensure that these victims are identified, treated, 

and assisted. 

44 

It is imperative that providers are given clear instruction and 

guidance on how to identify these victims as well as the steps to 

be taken to ensure that victims receive the proper protection and 

care. These best practices need to be carefully developed, given the 

variety of providers and the different care settings in which these 

victims may surface. 

Victims of human trafficking can be extremely difficult to locate 

after their initial healthcare visit due to the transient nature of 

these criminal acts. 

It is critical that best practices include a program that provides 

guidance and gives providers the tools necessary to assist victims 

as quickly as possible. We must ensure that providers and victims, 

working together, can develop these evidence-based best practices 

and work to implement them across the healthcare spectrum. 

In closing, it is important to note that strategies may vary from 

clinic to clinic and from State to State. Developing best practices 

to identify signs and symptoms and best screening tools is paramount to identifying those who are trafficked. 

Reporting procedures are key to removing the victim from their 

deplorable situation. For any program to be effective, all healthcare 

professionals that come into contact with suspected victims of 

abuse must be educated and clinically trained to identify these individuals. 

We are pleased to continue to work with Congresswoman 

Ellmers and other members of the subcommittee to develop legislation that addresses this issue in a provider-neutral manner. 

This ensures that all practicing providers and healthcare personnel who may come in contact with victims of human trafficking 

are able to identify and assist them. 

As the voice of nurse practitioners, AANP can reach the rapidly 

growing NP profession throughout the country with this important 

information. 

We thank you for your time and respectfully request that we continue to work together on this important issue. 

[The prepared statement of Mr. Miller follows:] 

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Mr. PITTS. The Chair thanks the gentleman. 

Thanks to all the witnesses for your very important testimony, 

very moving testimony. 

I will begin questioning and recognize myself, 5 minutes for that 

purpose. 

Ms. Carter, let me start with you. While anyone can become a 

victim of trafficking, are there certain populations that are especially vulnerable to trafficking? 

Ms. CARTER. Yes. There really are. I think the Native American 

community and African-American women are very highly—they are 

preyed upon. They are preyed upon. 

And those are the communities that—Breaking Free is in Minnesota. And so Minnesota is—less than 10 percent of the population are African-American. Less than 2 percent are Native American. 

Yet, still the majority of the 500 women and girls we work with 

a year are African-American and Native American. So those are 

the populations that are very highly susceptible to being trafficked. 

Mr. PITTS. Thank you. 

Ms. Lederer, because human trafficking is considered to be one 

of the fastest growing criminal industries, the U.S. Government 

and academic researchers are currently working on an up-to-date 

estimate of the total number of trafficked persons in the United 

States annually. 

Do you know how they collect this information? 

Ms. LEDERER. In the United States? 

Mr. PITTS. Yes. 

Ms. LEDERER. Chairman Pitts, I don’t believe that there is a solid 

number yet. 

I would like to add to what Vednita said. I absolutely agree that 

those populations are vulnerable, but there are also many other 

populations that are vulnerable to being trafficked. 

We know that runways and the homeless and what we call the 

throwaway kids, the kids who don’t really have homes where they 

have a loving environment, are very vulnerable to trafficking. 

And in all of the survivors that I have interviewed, there was 

something that happened in the home early on, some abuse, either 

physical, sexual, that drove these children out on to the streets. 

And then out on the streets they are much more vulnerable. 

We have some estimates of those vulnerable populations. We 

have heard that it is somewhere between a million and 1.5 that are 

these runaway, homeless and throwaway youth, and they are all 

susceptible to trafficking and are preyed upon by traffickers who 

know exactly what to look for and where to find them. 

And so I think that part of what we have done is we have begun 

to identify large, vulnerable populations, and what we need to do 

next is take a much more critical laser-like look at what is happening in those populations. 

For instance, we know that street gangs are now preying on children in middle schools and that they are literally going to middle 

schools and high schools and recruiting from there, but we don’t 

know the who, what, when, where, how of that. And we will need 

specific studies to be able to identify that. 

58 

And I am with you. I think we need to be able to figure out on 

the front end who are these vulnerable populations and prevent the 

trafficking so that we are not constantly doing the cleanup that we 

have been doing over the past 10, 15 years. 

Mr. PITTS. Thank you. 

Dr. Stoklosa, you mentioned your specific patient. You said you 

missed the stage of trafficking—I think that is what you said—and 

you must establish trust. 

What are the indicators that you look for to identify trafficking 

victims, in your experience as a physician in Boston? 

Ms. STOKLOSA. Thank you for the question. 

I would couch this by saying we need more evidence and we need 

more research to show us what those signs and symptoms are. 

But in talking to survivors and from the studies that we have 

thus far, some of the signs and symptoms—and I kind of go head 

to toe whenever I train healthcare providers on this—general malnutrition, a discrepancy between their story and what you are seeing. 

So they say—just very similar to intimate partner violence, they 

are saying, ‘‘Oh, I fell down the stairs’’ when there are bruises that 

are at multiple stages of healing on their body, cuts or lacerations 

without an explanation, tattoos where they are afraid to talk about 

them. 

Maybe it is a pimp or maybe it is his branding on them. I have 

spoken with survivors that have been literally hogtied and branded. So that is on the skin side of things. 

They may have eye damage from either being beaten or being 

kept in dark places. And so their vision may be impaired from that. 

Signs of oral trauma, including sexually transmitted infections that 

may even present in the mouth. Pulmonary disease. Lung trauma. 

And then, on the reproductive side of things, scar tissue that is 

unexplained, presentations of sexually transmitted infections that 

have gone farther than one would expect before they sought medical care, and retained foreign bodies either in the vagina or in the 

rectum, from a female perspective, being forced to have sex during 

her menses. 

I could go on from there, but those are some of the signs and 

symptoms that would be concerning. 

Mr. PITTS. Thank you. 

Dr. Miller, health clinics, hospitals, social welfare offices, police, 

frequently and unknowingly experience face-to-face contact with 

trafficking victims. 

How do you think this bill will help improve identification of trafficking victims from among healthcare providers? 

Mr. MILLER. I think one of the most important things that it will 

do is it will establish a program to educate all healthcare providers. 

I think many of us get pieces of that throughout our programs 

when we are working for our degrees, but I don’t think there is any 

real focus that is totally limited to trafficking. 

I think we talk a lot about abuse and we get a lot of information 

about that, but there is nothing specific to trafficking. And I think 

having this program will really aid us in being much more astute 

in identifying patients who are in human trafficking. 

59 

Mr. PITTS. Chair thanks the gentlemen, all the witnesses, for 

your answers. 

I have gone over my time. I yield 5 minutes to the ranking member, Mr. Pallone, for questions. 

Mr. PALLONE. Thank you, Mr. Chairman. 

Earlier this morning we heard from Ms. Chon about the SOAR 

to Health and Wellness Training initiative at HHS, a pilot program 

to improve healthcare professionals’ response to human trafficking. 

I wanted to ask Dr. Stoklosa, since you participated in the technical working group for SOAR, I would like to get your thoughts 

on this new initiative. The pilot training for SOAR began this 

week, and it is happening in five States over the next month. 

So will you be involved in the training in Boston next week? And 

what did you see for the type of training that SOAR offers in your 

community? 

Ms. STOKLOSA. Thank you so much for the question. 

So both on the HEAL national level as well as individually, I 

have been really pleased to be involved in the SOAR initiative to 

health and wellness, and part of it is based on a very well-thoughtout process in the development of the curriculum and really addressing this unmet need in terms of educating our health providers. 

The HEAL trafficking group, especially the education and training group, has been interfacing both in terms of input on the technical advisory group, both in terms of myself as well as others, and 

we are really pleased with the ultimate outcome of the pilot training. 

But it is that. It is a pilot training. And we are pleased that what 

this is going to do is add to the evidence base on educating and 

training our health providers. 

Mr. PALLONE. Have you seen much interest in the SOAR program in Boston? And what types of healthcare providers have already signed up for the SOAR pilot training. 

Ms. STOKLOSA. So I will be—along with a couple other colleagues, 

will be doing the training in Boston. And there has been an overwhelming response within the Boston healthcare community, both 

within my own hospital system as well as across the city of Boston. 

And those that have signed up have come from the spectrum of 

healthcare disciplines as well as specialties, including social workers, dentists, from obstetrics and gynecology to trauma surgeons. 

So we are very thrilled to see that response, and I think it is reflective of the hunger for this education and training and the realization that we are interfacing with victims of trafficking, but we 

don’t have the tools, as health providers, to identify them or care 

for them. 

Mr. PALLONE. Well, thanks. 

After the pilot sessions this month, participants in SOAR training will complete evaluations of their experience, which will help 

HHS to assess the effectiveness of the program and determine how 

to move forward. 

What are your hopes for the future of the SOAR training program? 

Ms. STOKLOSA. So this is the pilot round, as you said, and my 

hope is that this will provide an evidence base so that we can have 

60 

fidelity for the education and training of health professionals nationally. As Katherine Chon mentioned, this is kind of the 101. 

This is the general awareness piece. 

Certainly every health provider in the United States, once we 

have shown that this is an effective model, should be trained, and 

that should be incorporated at all stages, as I mentioned earlier, 

of our education and training, from the very early stages within 

professional school all the way along through our accreditation 

processes as—in whatever board certification or professional accreditation processes are specific to those individual disciplines. 

And I see HHS really taking a lead in facilitating this effort. 

Mr. PALLONE. Well, thanks. 

And I want to say I look forward to learning more about the results of this pilot program so we can determine how the Federal 

Government can best help healthcare professionals along with any 

other individuals likely to interact with the trafficking victims. 

I did want to ask you one more thing, though. This would be either to you or Dr. Lederer. 

Current statistics on human trafficking in the U.S. are limited. 

And as Ms. Chon noted in her testimony, while researchers like Dr. 

Lederer have begun to look at the health effects of trafficking, more 

research is clearly needed to better understand the health needs of 

victims of human trafficking as well as how healthcare professionals can best address the needs. 

Could either of you answer: What need do you see for further research regarding the interaction of victims of human trafficking 

with the healthcare system? Either Ms. Lederer or Dr. Stoklosa or 

both of you? 

Ms. LEDERER. Thank you for the question, which is an excellent 

question. 

I think we are in the foothills of consciousness in terms of figuring out what kind of research needs to be done. I believe that we 

need to—like Dr. Stoklosa’s head to toe, we kind of need to go very 

beginning and track. 

So I have talked to 150 survivors across the United States over 

the last year, and I have heard recurring themes. And I would 

start with those recurring themes. One of them is abuse in the 

home. 

Once somebody’s been abused, they have been sexually assaulted, they have been raped, they have been molested by a relative, they are pushed out into the streets. And so we need to do 

a lot more research on the link between early abuse in the home 

and trafficking. 

Then foster care systems. Once they are out of their homes, they 

are into our foster care system. And we need more research on how 

foster care system is working. I believe that those systems are failing and are facilitating trafficking at this point in time. So we need 

more research in that area. 

Educational systems. We need more research on the link between 

bullying and trafficking, on the link between the ways that street 

gangs and others prey on—what is the role of the educational system right now? How do they facilitate or how are they failing to 

counter trafficking? 

61 

And I can go through each of the various sectors. I think that 

is important. 

I agree with Dr. Stoklosa that all of this needs to begin from the 

listening to survivors. If we listen to survivors, they can tell us how 

to proceed. They know the hell of this. They know what works and 

what doesn’t work. They can tell us better than any textbook what 

we need to do. And so we need to incorporate survivors into all our 

programs. 

And then the last thing I would say is that the huge, huge need, 

which is the elephant in the room, is the resources and referral. 

Once we have got these trainings in place—and, Representative 

Ellmers, thank you so much for taking the lead on this. This has 

been such a long time coming. 

But once we do have these trainings and we begin to identify 

these victims, we will need thousands of Breaking Frees and we 

will need to have them up and running so that they can do their 

work properly. 

So there is a lot of research. I would be happy to do a fledgling 

list for you, just a beginning, and think about this further with my 

colleagues, but that is a start. 

Mr. PALLONE. Thank you. 

Ms. STOKLOSA. And, if I may, I would like to add on to that and 

concur with Laura Lederer’s comments. 

One of the gaps that I see is the populations that we have data 

on thus far in terms of intersection with health care. So there is 

more information, though it is still not as much as I would like, 

on sort of the pediatric or the child populations specific to sex trafficking. 

We don’t know a lot about labor trafficking. We don’t know as 

much as I would like about the adult populations and transgender 

population and boys. 

There are a lot of men and boys that are involved in trafficking, 

and they are largely in a hidden population hidden within that. 

And they are especially vulnerable, and we don’t have much data 

on them. 

The other thing that I would like to add here in terms of the 

need to add to the evidence base is in terms of going back to trauma-informed care. 

Trauma-informed care is something that healthcare providers 

really have no training on at all. And I mentioned earlier victims 

of trafficking especially are in this reality that we are not trained 

to deal with and, as a result, we accidentally, in most cases, re-victimize them when they enter into our health facilities. And, therefore, they are not going to disclose what is really going on. 

We need more data around trauma-informed care to show what 

works and what doesn’t work, and we need to train our healthcare 

workforce in it. And it is not only applicable to victims of trafficking, but we, as healthcare providers, interact with patients that 

have experienced violence along the entire span of their life, unfortunately, from child abuse to elder abuse, to intimate partner violence. And, yet, we still have no training in trauma-informed care. 

So I think, in some ways, this give us an opportunity to expand 

that very much needed tool kit for healthcare providers. And I 

would echo Laura’s comments in terms of needing more resources 

62 

dedicated both to the research as well as to the aftercare for victims of trauma. 

Doctors—and I am speaking from that perspective just personally. You don’t want to ask the questions if you don’t have a plan, 

if you don’t have a solution, to be able to provide. 

And so, if you know that the shelters are limited for somebody 

that is being trafficked, in some ways, it is like an unconscious decision, but you would rather not even ask and explore that. And so 

we are also missing opportunities because of that. 

Mr. PALLONE. Thank you. 

Mrs. ELLMERS [presiding]. Thank you. The gentleman yields 

back. 

I am now going to finish up. If any of our other colleagues come 

in, we will certainly allow them time for questions. 

I want to start off—and, at first, I just want to say thank you 

to our panel. Thank every one of you. Ms. Carter, especially for 

your bravery for taking your experience and turning it into something positive. It is hard for me to talk about without getting emotional. So I apologize. 

We should have done this a long time ago. The fact that we are 

here today on September 11th—in recognition on a very emotional 

day for us, as Americans—and talking about this issue, I think is 

significant. 

Ms. CARTER. It is. 

Mrs. ELLMERS. And, again, I thank all of you. Because it is all 

of us working together on this issue where we are going to solve 

this problem in this country. My goal is to eradicate human trafficking. 

And, Dr. Stoklosa, you touched on the labor trafficking that occurs. We are also looking at that, as well, because that is another 

area that, although we, as Americans, know that it exists, we really don’t want to accept that it exists. And we need to be able to 

identify that. 

First, I want to make a comment just about the prevalence here 

in this country and reference an NIH study in regard to trafficking. 

NIH estimates that 50,000 people are trafficked each year in the 

United States, with as many as 400,000 of our minor children involved in trafficking, resulting in—and this is the question. 

The question is: Why is this happening? What is the precipitating factor that creates trafficking? And the answer is the dollars. 

The dollars. It is a very profitable criminal industry, resulting in 

billions of dollars being generated from it. 

And, Ms. Carter, I want to just go back to your testimony and 

your experience and now what you are learning when you are 

working with victims. 

One of the things that hit me, working as a nurse for so many 

years, Dr. Stoklosa, I know exactly what you say when you know 

something’s wrong, but you just can’t put your finger on it, and 

then what would you do if you were to get that knowledge, that information, from that patient. 

One of the things that I was struck by was the fact that many 

of the pimps or the human traffickers that—it is the attraction, the 

security, and the love that the victim feels that they are receiving 

from that individual. 

63 

Because of their life experience, this may be the most secure 

thing that they have ever, ever encountered, and that is why sometimes it is so difficult to identify them. 

Ms. Carter, can you speak a little bit about that? Is that something that you have also seen? 

Ms. CARTER. Yes. Definitely. I want to say it is a brainwashing 

process because we know that the average age of entry in our country is between 12 and 14 years old. So when you have a 12-yearold that has run away from home, that is out there on the street, 

it doesn’t take a trafficker a lot of effort to convince her that he 

is going to help her and he understands what she has been 

through. 

So it is kind of like a two-phase process. First, he gets her to believe that he is going to do all these things for her. And, second, 

he tells her now that she owes him for doing all these things for 

her. 

So at 12 years old, you are full of fear because you have been 

told that, ‘‘If you don’t do this, I am going to go and I am going 

to do this to your sister,’’ ‘‘I am going to kill your brother,’’ ‘‘I am 

going to’’—you know, just all kinds of threats. So it doesn’t take a 

lot of convincing to get a child involved in this life. 

And there are different types of pimps. You have just your hardcore pimp. He knows you are on the run. He knows you are out 

there, you have no place to go. He immediately just turns you out. 

And then you have the other kind that just convinces you that 

he is everything to you, and she believes it. Why wouldn’t she? She 

can’t go get a job. She can’t rent an apartment. She can’t do anything. And she can’t go back home because that is where all the 

abuse started. So it is a process. 

Mrs. ELLMERS. Thank you, Ms. Carter. 

Dr. Lederer, one of the things in going over the focus group information that you have provided to us—that was the eye-opening experience that I had. 

Again, understanding and knowing the healthcare community 

and how much any healthcare provider would want to be able to 

identify these victims and then to find out from your focus groups 

that 87 percent go to our healthcare providers, to our clinics, to our 

emergency rooms, and receive care, it was difficult for me to accept 

that, because I just assumed that these things were happening behind the scenes, they were not out in the open, and that we, as 

healthcare providers, would not be able to identify those victims. 

But when you think about it, it makes perfect sense, because 

they are the product, and that product has to continue to be sold. 

So, therefore, they do seek health care. Their traffickers do seek 

health care. 

I realize we are just at the tip of the iceberg here. This is going 

to be an ongoing discussion into the future so that we can eradicate 

this terrible, terrible crime. 

But one of the things—Dr. Miller, I would like for you to comment on this as well. 

As far as expanding, we have all discussed areas where we need 

to go with this. I do want to go back to our schools, with our school 

nurses and our social workers. 

64 

Dr. Lederer, do you believe that this is an area that we also need 

to incorporate into these programs? 

And then, Dr. Miller, I would like for you to—— 

Ms. LEDERER. Absolutely I do. And I am not a healthcare provider. So I don’t know all of the various subsectors of that sector. 

But I think the disappointment over the last 15 years is that all 

these trainings have been like a one-off. If there has been a training, it has been two things. It is been a hospital calling and saying, 

‘‘We would like the training to do as part of this seminar that we 

are putting on. Will you come?’’ And then the anti-trafficking organization comes, gives a Tip 101, and goes home. So it is not only 

one off, it is reactive instead of proactive. 

And what we need is both proactive and we need a methodical 

approach. And, again, I like Dr. Stoklosa’s approach of, from the 

beginning, in the academies all the way through all of the sector 

and the subsectors, we absolutely need training. 

And I believe we need training tailored to each of those subsectors. So school nurses will need a specialized training because they 

are dealing with a specialized community, and they will need to 

know not only what to look for, but how to respond, you know, 

properly without driving the kids back out onto the streets, as I 

think, if you are not equipped, you can do if you are a counselor 

or a nurse and don’t know what to do, what to say, and who to 

refer to. 

So that is a perfect place to begin, and it is at the early stage 

where, if we can prevent it from happening, we are way ahead of 

the ballgame. Because once somebody’s been trafficked, they are, as 

we have all been saying, physically, mentally, emotionally, spiritually devastated, and building that person back up again is almost impossible. 

We spend a lot of time and money. No one’s done the cost-benefit 

analysis. That is the other big study that needs to be done. How 

much is this costing to do these rescues, restorations, reintegrations? It is huge. So that is a good place to start. 

Mrs. ELLMERS. Dr. Miller. 

Mr. MILLER. Yes. I believe that the academic institutions, whether it is grade school, high school, or collegiate level, need to be 

much more proactive. And the only way they are going to be 

proactive is if they get the education that they need. 

And, again, I can tell you that, in many of the programs around 

the country, what you hear on abuse is—you may have one or two 

classes and that is it. And what they really need is to have a workshop, and that workshop needs to be incorporated throughout the 

entire curriculum for the entire length of time that the person is 

in the program. 

But I also concur that one of the things that needs to be done 

is it has to be focused on whatever level. If it is a school nurse, if 

it is a nurse practitioner, if it is a physician, if it is a social worker, 

whatever their program of study is, it really has to be focused in 

that area. So that means we are going to have to be developing programs that are really attentive to those types of disciplines. 

Mrs. ELLMERS. Thank you. 

65 

And my last question—or discussion, really, because I am going 

to direct this to Dr. Stoklosa, but I would like anyone else who 

would like to comment as well. 

Getting back to the objective that we have—or, obviously, our 

goal is to incorporate programs, if you figure out ways, protocols, 

for best practices on all of these issues. 

And to the point of prevention, it is so important. Ms. Lederer 

was talking about the cost or cost-benefit analysis in the long run. 

One of the other areas that we are working on here on the House 

subcommittee is need for mental health reform. And when I think 

of the number of victims who now fall into and need mental health 

care, that opens up another door to more cost and continued life 

situations. They will be affected their entire lives. 

What I would like to know, Dr. Stoklosa, from your perspective 

right now—I was paying special attention to what you were identifying to the chairman about what you see or some of the identifying signs and symptoms that you see today in the emergency 

room. 

One of them, of course, you had mentioned was tattooing and 

branding, and a light bulb went off in my head and I thought: My 

goodness, we are talking about modern-day slavery. These women, 

these children, these men, are being branded. 

And we attribute much of that, too, to gang activity, and I can 

see how healthcare professionals would just make the assumption 

that this is a gang member or a prostitute on the street and a chosen lifestyle versus someone who would fall into that human-trafficking victim category. 

My mind is going crazy with ideas of what we need to do into 

the future. What do you see now—if a patient comes into the emergency room and you identify them as a potential sex-traffic victim, 

what do you do from that point on? And what barriers exist that 

we need to be identifying today so that we know where to go tomorrow? 

Ms. STOKLOSA. Thank you for that question. 

And you brought up a lot of points along the way that I could 

spend forever kind of commenting on, but I am going to get to the 

‘‘what do you do in that moment.’’ And this gets to that kind of 

‘‘then what?’’ question. 

I am going to speak as a clinician in Massachusetts at the moment. But it depends on age, first of all. So if they are under the 

age of 18, there are mandated reporting requirements. 

And I should say before I even get into the age thing the most 

important consideration is to meet the victim or the survivor where 

they are at in that moment. 

So, for an under-age-18 individual, I am ultimately going to need 

to initiate a mandated reporting pathway. If the patient in front of 

me feels like I am all about rescuing them and doing X, Y, and Z, 

and I am not there in the moment assessing their needs for food, 

maybe for water, for just having that human interaction, all is lost, 

really. 

So, under the age of 18, mandated reporting, and that would initiate child protective services. There is also—in Massachusetts, we 

are lucky enough to have the SEEN Coalition, which is a wraparound set of services for those that are victims of sexual exploiVerDate Mar 15 2010 11:10 Mar 19, 2015 Jkt 037690 PO 00000 Frm 00069 Fmt 6633 Sfmt 6633 F:\113-173 TRAFFICKING - AWAIT SCANS\113-173 TRAFFICKING PENDING WAYNE
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tation under the age of 18, which includes legal services, mental 

health services. 

And we try to limit the number of even health providers that are 

asking them about their traumatic experience to make sure that it 

is not re-traumatizing for them in that situation and then referral 

to services. Obviously, we take care of their medical needs as well. 

If they are over the age of 18, it is finding out where they are 

at and what they want. Maybe it really is just a sandwich. Maybe 

they are not ready to get out of that situation. 

It is very akin, in many ways, to what we have seen with intimate partner violence. They ultimately have agency in that situation. As hard as it is to let them go back out, in some cases, that 

is the choice that is made. 

I see it as a spectrum, that their interaction with caring individuals, whether it be interaction with the healthcare setting or other 

providers—ultimately, they may get to that point where they are 

able to say that, ‘‘I want to be out of this situation.’’ 

We have to recognize that sometimes it is actually less safe for 

them to disclose that information. They may know that, if some information gets back to their pimp, that they are going to be beaten 

that evening if they were to disclose. 

They may have extreme levels of blackmail that are kind of 

wielded over their heads either against their family, told that their 

family’s going to be murdered or that pictures are going to be 

shown to those that love them and care for them. 

So we have no idea what is actually going on in their minds, and 

that is a really important thing for providers to realize. And it is 

really about meeting them where they are at. 

And then, just in terms of the barriers, barriers of judgment on 

behalf of healthcare providers, as you are saying, they may just be, 

like, ‘‘Oh, this is a prostitute. She is choosing it.’’ A lot of these victims present with substance abuse issues. And what I tell health 

providers is that those are opportunities for us. 

There was a case in New England last year where a health provider asked someone who had come in with a heroine overdose, 

‘‘You know, I see you have been here a number of times with us. 

How did you get hooked on heroin?’’ 

And then she reported that it was her pimp. And, from there, 

they were able to uncover this entire trafficking ring. So it is being 

aware of the signs and symptoms and really coming at it with that 

trauma-informed approach. 

And then further barriers are on the referral side. So, like, 

‘‘What then?’’ You know? 

Mrs. ELLMERS. Right. 

Ms. STOKLOSA. Have them call the National Human Trafficking 

Hot Line. They are a great resource for the survivor to talk to. Or, 

if the survivor is not in that position yet, I can speak in a way that 

is HIPAA-compliant with the National Human Trafficking Hot 

Line. So that is also a great resource. 

But there have to be resources under that—there have to be 

roots to that system. If there is no infrastructure for me to refer 

to, maybe he or she is in some ways better off being in the hands 

of their exploiter. I mean, it really is a tough state of affairs. 

67 

Mrs. ELLMERS. Would anyone else like to comment on this situation of even talking about barriers that exist right now and what 

we are doing today that in the future we can improve upon? 

OK. Dr. Stoklosa, you covered that very well. 

I think we are at a point where we can close our meeting. We 

will have 10 business days to submit questions for the record, and 

I ask the witnesses to respond to the questions promptly. 

I would imagine that many of the members who could not be 

here for the subcommittee because of ongoing things that are happening today—that you will probably receive some written questions. 

And then members should submit their questions by the close of 

business day on Thursday, September 25th. 

Before I adjourn, I just want to thank you again for coming and 

testifying on this incredibly emotional and vitally important issue. 

This is something that we can all work on. This is definitely a bipartisan issue that everyone has input on, and we will be able to 

come together. 

And I just feel so strongly that we need to be doing everything 

we can to make this happen, and I look forward to working with 

all of you. 

Please know that my door is open. The committee is more than 

happy to take more of your input. And let’s work together on the 

solutions that we need to find. 

With that, and without objection, the subcommittee is adjourned. 

[Whereupon, at 11:25 a.m., the subcommittee was adjourned.] 

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