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Texas Continuing Medical Education
TEXAS MEDICAL LICENSURE PROGRAM
MANDATORY TRAINING REQUIRED FOR TEXAS LICENSE RENEWAL ENCLOSED PROGRAM INCLUDES: • 5 Hours Human Trafficking • 5 Hours Medical Ethics • 3 Hours Pain Management/Opioids • 3 Hours Natural Psychedelics
Need to complete the DEA’s new one-time MATE requirement? See inside for more details.
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
AVAILABLE ONLINE AT: TX.CME.EDU
TEXAS PHYSICIAN
MANDATORY CME REQUIREMENTS ON PAIN MANAGEMENT/OPIOIDS AND HUMAN TRAFFICKING
Dear Colleagues,
All physicians (MD/DO) licensed by the state of Texas must complete a one (1) hour approved human trafficking course, two (2) hours of pain management/opioids, and one (1) hour of medical ethics and/or professional responsibility. These hours count toward the total amount of formal hours required by the Texas Medical Board. The InforMed Texas Medical Licensure Program is designed to streamline the education requirements for physicians (MD/ DO) licensed in the state of Texas. Licensees who complete this program satisfy the human trafficking requirement, two (2) hours of pain management/opioids, and one (1) hour of medical ethics.
To complete the program online, visit BOOK.CME.EDU , enter the book code MDTX1625 in the box, then click GO .
Thank you for choosing lnforMed as your CME provider. We strive to create a high quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act. Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act?
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Texas Medical Board | 333 Guadalupe Tower 3, Suite 610 Austin, TX 78701 | (512) 305-7010
1-800-237-6999
BOOK CODE: MDTX1625
BOOK.CME.EDU
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What’s Inside
01
HUMAN TRAFFICKING AND EXPLOITATION: THE TEXAS REQUIREMENT COURSE ONE | 5 CREDITS Satisfies the Human Trafficking Training Requirement (HHSC Approved) Today, some label human trafficking as a form of “modern day slavery,” and frequently, human trafficking has been linked to sex work and prostitution, although there are other forms of trafficking, such as forced labor and domestic work. Human trafficking can involve women, men, and children. Its victims experience a host of psychological problems, including post-traumatic stress, helplessness, and depression, due to the physical, sexual, and psychological abuse they have experienced. This course encompasses a basic overview of human trafficking. The course will attempt to provide practitioners with a glimpse of the realities of human trafficking victims’ lives and the physical, psychological, social, and sexual abuse they experience. Specific interventions and responses are covered, including mental health, social services, educational, prevention, and legal efforts.
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MEDICAL ETHICS FOR PHYSICIANS COURSE TWO | 5 CREDITS Satisfies 2 Credits on Medical Ethics
Medical ethics, also known as bioethics, is an amalgam of medicine, law, and religion. It is also influenced by cultural beliefs. In this course, we will define the most common ethical principles and note their relationship to the basic theories of ethics. Some of the prominent court cases that have dictated the basis of physician-patient relationships, especially in end-of-life care, are presented. Also, the Patient Self-Determination Act is outlined with explanations of advance directives—better known as physician directives and durable power of attorney for health care. Finally, a possible method of setting up a workable ethical decision-making framework is presented in some detail. Hopefully, this will be useful in the event of a conflict or when a decision involving ethical issues confronts us or our fellow physicians. This course should allow us to comprehend the basic precepts of medical ethics and afford us the general knowledge of how to apply them in our everyday practice of medicine.
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RESPONSIBLE AND EFFECTIVE OPIOID PRESCRIBING COURSE THREE | 3 CREDITS Satisfies 2 Credits on Pain Management/Opioids
Opioid analgesic medications can bring substantial relief to patients suffering from pain. However, the inappropriate use, abuse, and diversion of prescription drugs in America, particularly prescription opioids, has increased dramatically in recent years and has been identified as a national public health epidemic. A set of clinical tools, guidelines, and recommendations are now available for prescribers who treat pain patients with opioids. By implementing these tools, clinicians can effectively address issues related to the clinical management of opioid prescribing, opioid risk management, regulations surrounding the prescribing of opioids, and problematic opioid use by patients. In doing so, healthcare professionals are more likely to achieve a balance between the benefits and risks of opioid prescribing, optimize patient attainment of therapeutic goals, and avoid the risk to patient outcome, public health, and viability of their own practice imposed by deficits in knowledge.
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NATURAL PSYCHEDELICS COURSE FOUR | 3 CREDITS
Interest in the use of psychedelics in general, as well as natural psychedelics, has been increasing over the past few years. Patients may be using these substances recreationally or may be asking about these options for the treatment of various medical conditions. Healthcare professionals should be well informed about the unique considerations associated with the safe, effective, and legal use of these substances.
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FINAL EXAMINATION & ANSWER KEY REQUIRED TO RECEIVE CREDIT
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MOC/MIPS CREDIT INFORMATION
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABOHNS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program.
ABPath
American Board of Pathology’s Continuing Certification program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M 5 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM 3 AMA PRA Category 1 Credits TM 3 AMA PRA Category 1 Credits TM
Activity Title
ABA
ABIM ABS
ABPath ABP
5 Credits LL 5 Credits LL 3 Credits LL 3 Credits LL
5 Credits MK 5 Credits MK 3 Credits MK 3 Credits MK
5 Credits SA + AC 5 Credits SA + AC 3 Credits SA + AC 3 Credits SA + AC
5 Credits LL 5 Credits LL 3 Credits LL
5 Credits LL+SA 5 Credits LL+SA 3 Credits LL+SA
Human Trafficking and Exploitation: The Texas Requirement
Medical Ethics for Physicians
Responsible and Effective Opioid Prescribing
-
-
Natural Psychedelics
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDTX1625 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDTX1625
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM • Human Trafficking and Exploitation: The Texas Requirement • Medical Ethics for Physicians • Responsible and Effective Opioid Prescribing • Natural Psychedelics
$109
MDTX1625 16 Credits
$35
Human Trafficking and Exploitation: The Texas Requirement
MDTX05HT 5 Credits
$35
Medical Ethics for Physicians
MDTX05ME 5 Credits
$21
Responsible and Effective Opioid Prescribing
MDTX03OP 3 Credits
$18
Natural Psychedelics
MDTX03NP 3 Credits
1-800-237-6999
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______________________________________ Human Trafficking and Exploitation: The Texas Requirement Systemic Lupus Erythematosus _________________________________________________________________ MDTX05HT — 5 CREDITS R elease D ate : 02/01/24 E xpiration D ate : 01/31/27
Human Trafficking and Exploitation: The Texas Requirement
In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 5 ABIM MOC Points, 5 ABS MOC Points, 5 ABA MOCA Points, 5 ABP MOC Points, 5 ABPath CC Points.
6. Utilize interviewing strategies to assess and identify victims and promote the ethical treatment of traffick- ing victims. 7. Outline the healthcare professional’s responsibilities in identifying and assisting survivors of trafficking, including best practices for referral and collaboration. Faculty Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correc- tional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families. Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon Uni- versity, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online cur- riculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities. Faculty Disclosure Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners John M. Leonard, MD Mary Franks, MSN, APRN, FNP-C
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for Texas physicians, nurses, social workers, pharmacy professionals, therapists, mental health counselors, and other members of the interdisciplinary team who may intervene in suspected cases of human trafficking and/or exploitation. Course Objective As human trafficking becomes an increasingly more common problem in the United States, healthcare and mental health professionals will require knowledge of human trafficking patterns, the health and mental health needs of human traf- ficking victims, and successful interventions for victims. The purpose of this course is to increase the level of awareness and knowledge about human trafficking and exploitation so health and mental health professionals can identify and intervene in cases of exploitation. Learning Outcomes Upon completion of this course, you should be able to: 1. Define human trafficking. 2. Identify the forms of human trafficking. 3. Identify individual, family/relationship, community/ organizational, and societal/cultural factors that contribute to human trafficking. 4. Analyze the trafficking experience, including how traffickers recruit and the financial implications of trafficking. 5. Explain the psychological, health, and social consequences of human trafficking.
Margaret Donohue, PhD Randall L. Allen, PharmD
Mention of commercial products does not indicate endorsement.
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Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to pro- vide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 3 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program ® and MOCA ® are registered certification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trademark of the American Board of Anesthesiology ® . Please consult the ABA website, www.theABA. org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®.
Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 3 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 3 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evi- dence-based source, are also included so you may determine the validity or relevance
of the information. These sections may be used in conjunction with the course material for better ap- plication to your daily practice.
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Because victims of trafficking are often viewed as criminals, this law states that victims of severe trafficking should not be penalized for any illegal behaviors or acts they engaged in as a result of being trafficked, including entering the United States with false documents or no documentation or work- ing without appropriate paperwork [6]. This law also allows T Nonimmigrant Status (T visas) to be granted to victims of trafficking so they may remain in the United States with the purpose of collaborating with the federal authorities to pros- ecute the perpetrators. During this time, victims are offered a range of benefits and services, including access to the Witness Protection Program [6]. After three years, victims can apply for permanent resident status [7]. One of the criticisms of the Act is that it places the burden of demonstrating innocence and coercion on the victim [8]. The Act also fails to recognize the complex dynamics of human traf- ficking. For example, it focuses more on sex trafficking versus other forms [9]. Many victims have been abused and terrorized by the perpetrators, who they must now provide information and evidence against to stay in the country. Victims are con- tinually fearful that they will be deported [8]. Victims who are of minor age are eligible for Unaccompanied Refugee Minors programs, the Children’s Health Insurance program, and Temporary Assistance to Needy Families [10]. Furthermore, victims between 16 and 24 years of age are eligible for work permits and can apply for the Job Corps program [10]. It is important to remember that the key to this law is that the victim must have experienced a “severe form” of trafficking and must be willing to assist in the apprehension and prosecution of the perpetrator to receive services [11]. DEFINITIONS OF HUMAN TRAFFICKING The United Nations defines human trafficking as [12]: The recruitment, transportation, transfer, harbour- ing or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiv- ing of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude, or the removal of organs.
INTRODUCTION Human trafficking is not a new social problem; it has always existed. Trafficking has recently received increased attention as a result of awareness and outreach efforts. It has garnered attention from feminists, religious conservatives, labor activists, immigration specialists, and the mental health professions [1]. This course will provide a basic overview of human traffick- ing (e.g., the scope, definitions and frameworks, contributing factors, different forms). The course will attempt to provide practitioners a glimpse of the lives of human trafficking victims, including the physical, psychological, social, and sexual abuse that human trafficking victims experience and the types of control tactics that perpetrators use. Specific interventions and responses will be covered, including mental health, social services, educational, prevention, and legal efforts. Finally, for practitioners who work with human trafficking victims, the emotional toil that it takes on practitioners as well as the importance of self-care will be discussed. Practitioners will be encouraged to view films and documentaries about human trafficking, as this is one way to “enter the lives” of human trafficking victims and better understand the dynamics of the complex world of human trafficking. BACKGROUND Because human trafficking is a complex issue, it is difficult to determine the scope of the problem. Many scholars and researchers believe that published estimates are just educated guesses. On a global level, the International Labour Organiza- tion has estimated that there were 49.6 million people living in modern slavery in 2021, 27.6 million in forced labor, and 22 million in forced marriage [2]. The estimates for the United States are not totally clear, but there were approximately 78,000 human trafficking victims reported to the U.S. State Department in 2016; only an estimated 0.2% are rescued [3]. According to Polaris, which founded and runs the National Human Trafficking Hotline, there have been a total of 40,200 cases of human trafficking reported since 2007 [3]. According to statistics from the U.S. Department of Justice, the number of persons prosecuted for human trafficking increased from 729 in 2011 to 1,343 in 2020, an 84% increase [4]. A wide range of laws have been established to protect human trafficking victims and to prosecute perpetrators. A general knowledge of these laws is helpful when caring for victims and seeking appropriate social services. The Trafficking Victims Protection Act (TVPA) was enacted in 2000 and reauthorized in 2003, 2005, 2008, 2013, 2018, and 2022 by the Trafficking Victims Protection Reauthorization Acts [5]. It emphasizes the three Ps: prevention, protection, and prosecution [5]. The prevention component consists of training and awareness; the protection dimension gives trafficked victims the ability to receive services using federal funds like other refugees; and the prosecution component focuses on laws and policies for the prosecution of traffickers.
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LIMITATIONS OF DATA ON HUMAN TRAFFICKING
In essence, this definition involves three elements: the trans- port of the person, the force or coercion of the victim, and the abuse and exploitation [13]. The United Nations Office on Drugs and Crime divides the definition of human traf- ficking into three sections: the act, means, and purpose [14]. The act, or what is done, generally refers to activities such as recruitment, transportation, transfer, harboring, or receipt of persons. The means of trafficking consists of threats or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or giving payments or benefits to a person in control of the victim. Finally, these acts are carried out for the purpose of exploitation, which includes prostitution, sexual exploitation, forced labor, slavery or forced servitude, and the removal of organs [14]. The TVPA defines human trafficking to include both sex traf- ficking and labor trafficking [15]: Sex trafficking is the recruitment, harboring, trans- portation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a com- mercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age. Labor trafficking is the recruitment, harboring, transportation, provi- sion, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. A victim need not be physically transported from one location to another for the crime to fall within this definition. In many cases, women and children are considered the typical victims of human trafficking. Hart posits that women are more vulnerable to trafficking due to the lack of social safety nets in many developing countries [16]. Coupled with women’s subordinate social status in many cultures, this leads to the “feminization of poverty.” Although the social conditions may make women and children more vulnerable to human traffick- ing, the reality is that men are also victims of human trafficking. Overall, the definition of human trafficking is ambiguous because of the many intersections with other issues (e.g., sexual abuse, domestic violence, forced marriage, forced labor) [17]. It occurs both domestically and internationally, but is primarily a hidden problem. This makes research efforts, the prosecution of perpetrators, and policy and community efforts to protect victims even more challenging [17]. It is vital to remember that trafficking, as defined by U.S. law, does not require crossing international or even state borders. The transport of victims from one locale to another is not a necessary component of determining whether human trafficking has occurred.
Although the United Nations definitions are used in this course, scholars, practitioners, researchers, and policy makers have not come to a consensus definition of human trafficking. Consequently, terms such as sexual slavery, human smuggling, and modern-day slavery have all been used [18]. When the term human trafficking is utilized, it often has connotations of sexual exploitation affecting mainly women and girls, the most visible victims, but this is not accurate [18]. This perspec- tive is partially attributable to the large number of religious and feminist organizations who have worked to eradicate non-consensual sex work [19]. This lack of consensus defini- tion also raises questions about the study population in the research. The involved parties (i.e., the trafficker, those who are trafficked, and the networks) are continually changing in time and space [20]. Defining these terms is essential because it will ultimately influence responses to human trafficking. As stated, all social problems are competing for attention and resources, and the response is influenced by how the social problem is defined and portrayed [21]. Ultimately, the lack of a consensus definition is one of the reasons studying human trafficking has been a chal- lenge and that research yields unreliable prevalence estimates. Another reason human trafficking has been a difficult topic to research is the hidden and invisible nature of its victims and perpetrators. This makes it difficult for researchers to use traditional sampling methods. Even if trafficked victims are identified, perpetrators can move them to new locations [22]. If and when researchers access this hidden population, victims are often reluctant to talk due to fear, shame, and the stigma associated with their experiences. Consequently, much of what has been studied has relied on interviews with professionals (e.g., lawyers, advocates, police/law enforcement, and other service providers), which has led to recommendations that are not based on firsthand accounts [23]. A host of ethical issues also arise for those conducting research in this area. Protecting study participants’ identities is para- mount, and consequently, study participants signing informed consent forms, which are often required by institutional review boards, becomes complicated. Understandably, victims and perpetrators often will not want to sign forms using their real names for fear of deportation, arrest, and/or reprisals [22].
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of force, fraud, or coercion is not necessary, as the victims are children and inherently vulnerable [30]. In the United States, the children most vulnerable to domestic minor sex trafficking are those who are homeless, abused, runaways, and/or in child protective services [29]. Although controversial, it is said that sex trafficking victims differ from consensual sex work in that sex trafficking victims are forced to involuntarily perform sexual services and are often not paid for their “work.” Sex trafficking involves the use of force and coercion and can encompass other forms of criminal sexual activities, including forced erotic dancing, “mail-order brides,” and pornography [28]. On the other hand, individuals involved in consensual sex work make a decision to provide sex services for a fee. The decision to enter sex work does not eliminate the possibility of being a victim of traffick- ing if one is held against his/her will through physical and/ or psychological abuse [4]. It is also important to remember that this does not necessarily mean sex work is a choice these individuals would have made if other options were available or that they have a choice in selecting their sexual partners and/or sexual activities [31]. BONDED LABOR/FORCED LABOR The United Nations has defined debt bondage as [32]: The status or condition arising from a pledge by a debtor of his personal services or of those of a per- son under his control as security for a debt, if the value of those services as reasonably assessed is not applied towards the liquidation of the debt or the length and nature of those services are not respec- tively limited and defined. Essentially, because the individual does not have money as col- lateral for the debt owed, the individual pledges his/her labor or, in some cases, the labor of a child or another individual for an unspecified amount of time [33]. These individuals may be transported or trafficked into another country for the purpose of forced labor. In many cases of bonded labor, the initial loan may be wel- comed by the individual. However, the victims do not realize that with the low wages, unspoken high interest rates and other continually accruing fees, and the perpetrator’s manipulation of the “accounts,” laborers can never repay the loans. Some estimate that half of all persons in forced labor are bonded laborers. The majority of bonded labor cases occur in India, Bangladesh, and Pakistan [34]. Some families find themselves in a cycle of poverty as the debt cannot be paid off and is passed down from generation to generation [33]. Bonded labor can involve laborers in brick kilns, mines, stone quarries, looming factories, agricultural farms, and other manufacturing factories [33]. In the United States, individuals may be trafficked to work long hours in garment factories, restaurants, and other manufacturing sectors. Frequently, the employer/captor will take away victims’ identifications, monitor their movements, socially isolate them, and/or threaten deportation if they do not comply [35]. Migrant workers are at high risk of forced labor [4].
FORMS OF TRAFFICKING The social realities of victims of human trafficking are difficult to comprehend, and some may wonder why victims remain silent and comply with their traffickers. The Silence Compli- ance Model was created to explore the factors that promote victims’ seeming willingness to comply with their traffickers’ demands [24]. This model has three categories: coercion, col- lusion, and contrition. Victims are coerced, brutalized, and threatened, and basic necessities of life are withheld from them. Methods of psychological coercion include isolation, induced exhaustion, threats, degradation, and monopolizing percep- tion [25]. This serves to silence victims and create a sense of helplessness. By isolating and controlling victims’ movements and limiting their exposure to the outside world, traffickers have complete monopoly of their attention and perception of reality [25]. Victims are then forced to collude with the traf- fickers as a result of their relative isolation, fear, false sense of belonging, and complete dependence on the trafficker. Finally, victims feel contrite, ashamed, stigmatized, and remorseful of the things they have been made to do [24]. Another model, the Action-Means-Purpose (AMP) Model, is a device used to illustrate and articulate the federal definition of a “victim of severe forms of trafficking in persons” [26]. The Action category consists of the actions a perpetrator takes to induce, recruit, harbor, transport, provide, or obtain a victim. The Means of force, fraud, or coercion are used for the ultimate Purpose of commercial sex or labor/services trafficking [26]. It is important to remember that human trafficking is not human smuggling. Human smuggling involves an individual being brought into a country through illegal means and is voluntary. The individual has provided some remuneration to another individual or party to accomplish this goal [7]. SEX TRAFFICKING The TVPA of 2000 is a U.S. federal statute passed by Congress to address the issue of human trafficking and offers protection for human trafficking victims [15]. This statute defines sex trafficking as, “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a com- mercial sex act” [15]. A commercial sex act is, “any sex act on account of which anything of value is given to or received by any person” [15]. In other words, it usually involves the illegal transport of humans into another country to be exploited in a sexual manner for financial gain [27]. However, it does not always involve the transport of victims from one region to another; such cases are referred to as “internal trafficking” [28]. Victims of sex trafficking could be forced into prostitu- tion, stripping, pornography, escort services, and other sexual services [29]. Victims may be adult women or men or children, although there is a higher prevalence of women and girls. The term “domestic minor sex trafficking” has become a popular term used to connote the buying, selling, and/or trading of children younger than 18 years of age for sexual services within the country, not internationally [29; 30]. An element
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In the United States, forced labor is predominantly found in five sectors [35]: • Prostitution and sex industry (46%) • Domestic servitude (27%) • Agriculture (10%)
social consequences [41]. Work that is exploitative for children has been defined as working long hours at a young age, work that is poorly compensated, and work that produces physical, social, and psychological stress that will hamper development, access to education, and self-esteem [42]. The ILO adds that child labor is work that “interferes with their schooling by: depriving them of the opportunity to attend school; oblig- ing them to leave school prematurely; or requiring them to attempt to combine school attendance with excessively long and heavy work” [40]. It is important to remember that child labor occurs in the United States. Runaway and homeless youths are at greatest risk, often lured by promises of work and housing [43]. The Polaris Project found that the top three forms of child labor trafficking in the United States were begging, peddling, and traveling sales crews [43]. CHILD CONSCRIPTION In some cases of trafficking, children are kidnapped and traf- ficked to serve as soldiers. Other times, children are coerced by a narrative indicating they will be serving a higher purpose and avenge the deaths of family and friends; this is known as comradeship [44; 45]. Some children are actively recruited and may be promised a small salary to “voluntarily” join. It is estimated that at any one time up to 300,000 children younger than 18 years of age are serving as child soldiers [46; 47]. Traffickers prefer to recruit children to serve as soldiers because they are inexpensive and more easily molded and shaped to comply and obey without question [48]. It can be difficult to comprehend the atrocities that these children wit- ness and experience [49; 50].
• Sweatshops and factories (5%) • Restaurant and hotel work (4%)
It is speculated that most of the forced labor occurs in California, Florida, New York, and Texas, all major routes for international travel [35]. Domestic servitude refers to a category of domestic workers (usually female) who work in forced labor as servants, house- keepers, maids, and/or caregivers, often in private homes. In some cases, young women are lured with the promise of a good education and work, and when they arrive in the United States, they are exploited economically, physically, and/or sexually. Their passports or identification papers are taken away, and they are told they have to pay off the debt incurred for their travel, processing fees, and any other bogus expenses. Because they do not speak English, they find they have no other recourse but to endure exploitative working conditions [36]. Unfortunately, as in many sectors of forced labor, there are no regulations to monitor the conditions under which domestic servants operate [35]. CHILD LABOR Child labor can be viewed as a specific form of bonded labor or forced labor. However, not all child laborers have been traf- ficked. Child labor is defined by International Labour Organi- zation (ILO) as economic labor performed by a child younger than 15 years of age or hazardous labor done by a child 18 years of age or younger. Child labor is deeply rooted in poverty and the infrastructure and political stability of the country as well as market forces [37]. The ILO estimates that there were 160 million child laborers in the world in 2020 (63 million girls and 97 million boys) [38]. This accounts for nearly one in ten of all children worldwide [38]. Between 2000 and 2020 there was a nearly 35% decrease in the number of children in child labor. The reduction was greater for girls than for boys . The number of children in child labor has increased from 2008 to 2020 in sub-Saharan Africa (from 65.1 million to 86.6 million), while it has declined in other parts of the world (e.g., Asia/the Pacific, Latin America/the Caribbean) [38]. The definition of child labor is controversial because the defi- nitions for “work” and “childhood” are ambiguous and often culturally defined [39]. On a conceptual level, work may be beneficial for the socialization and educational processes of children [39; 40]. So, it is important to differentiate between child work and child labor. Child work has been defined as activities that are supervised by an adult and that promote the development and growth of the child, while child labor does not benefit the child [37]. Many definitions of child labor cre- ate a dichotomy whereby child work is considered not harmful while child labor has negative emotional, intellectual, and
FACTORS THAT CONTRIBUTE TO VULNERABILITY TO HUMAN TRAFFICKING
INDIVIDUAL A variety of individual level factors may predispose an indi- vidual to human trafficking victimization. A history of physical, sexual, or emotional abuse and/or of witnessing violence in the home has been identified at increased rates among traf- ficking victims. Other possible risk factors include adherence to rigid gender roles, acceptance of norms supporting sexual exploitation of women and children, overestimation of prob- lem behavior in peers/others, lack of trafficking awareness, and substance abuse [51]. Adverse Childhood Experiences In more recent years, research has focused on the impact of adverse childhood experiences (ACEs) in general. ACEs are defined as potentially traumatic experiences that affect an individual during childhood (before 18 years of age) and increase the risk for future health and mental health problems (including increased engagement in risky behaviors) as adults
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______________________________________ Human Trafficking and Exploitation: The Texas Requirement
SOCIETAL/CULTURAL Globalization
[52]. Abuse and neglect during childhood are clear ACEs, but other examples include witnessing family or community violence; experiencing a family member attempting or complet- ing suicide; parental divorce; parental or guardian substance abuse; and parental incarceration [52]. One study found that youths with human trafficking reports were significantly more likely to have experienced ACEs [53]. Specifically, sexual abuse was the strongest predictor of human trafficking. Girls with a history of sexual abuse were 2.52 times more likely to experience human trafficking, and boys who had been victims of sexual abuse were 8.21 times more likely to be trafficked. Poverty and Economic Disenfranchisement Poverty and incessant economic stressors caused by civil wars, natural disasters, and collapses of government systems all contribute to human trafficking [16; 30; 54]. In one study, the odds of being trafficked were nine times greater for those who felt extremely hopeless about upward mobility compared with those with lower levels of hopelessness [54]. RELATIONSHIP/FAMILY Families marked by instability (e.g., domestic violence, child abuse, continual unemployment) are also at higher risk of hav- ing a member trafficked [30]. In addition, families entrenched in deep poverty may feel they have no other recourse but to sell a child or may be more easily lured with promises of money and a better future [54; 55; 56]. COMMUNITY/INSTITUTIONAL Community factors (such as high social disorganization charac- terized by violence, unemployment, and high crime) contribute to higher risk of trafficking [30]. The rampant use of digital technology, such as the Internet, greatly facilitates sex trafficking. The relative anonymity of online contact can empower traffickers to recruit or sell victims. Graphic images of women and children engaged in sexual acts can be easily disseminated over the Internet [57]. Traffickers may employ the Internet for advertising, marketing to those interested in making pornography [57]. In addition, social media sites such as Facebook, Craigslist, and Instagram have been used as a means of facilitating trafficking (e.g., by connect- ing and grooming potential victims) [58; 59; 60]. Newsgroups offer opportunities for those interested in locating women and children for sexual exploitation. In a 2013 qualitative study, smartphones were found to be inte- gral in the business of trafficking [58]. Researchers indicated the phones were used “to maintain contact with each other, in order to facilitate the business ‘transactions’ and stay in touch with transnational ‘partners’ and other traffickers who remained in the country of origin” [58; 59].
Human trafficking has been called one of the “darkest sides of globalization” [61]. Globalization is the term used to describe the interconnectedness of countries and nations, which facilitates easy communication, exchange of ideas, and flow of goods, capital, and services [61]. Crimes such as human traf- ficking are affected by globalization just as legitimate businesses are [62]. Furthermore, the ideals of Western capitalism may reinforce human trafficking as a business or industry, with its emphasis on the free market and the flow of goods and services across international borders [62]. Globalization has also created the need for cheaper labor [34; 63]. A study involving 160 countries examined the effects of globalization and human trafficking trends [64]. Researchers found a positive relationship between globalization and traf- ficking for forced labor, sex work, and debt bondage. Corruption Human trafficking cannot occur without the existence of cor- ruption within existing infrastructures. Public officials, police officers, and local leaders in many developing countries have been known to take bribes to provide protection to parties involved in various aspects of human trafficking [61; 64; 65]. Racialized Sexual Stereotypes Race and ethnicity have been inextricably linked to sexual violence and victimization. Myths regarding sexuality in certain cultures or racial fetishization may affect trafficking patterns. For example, there is an over-representation of Asian women on American Internet pornography sites in part due to popular myths sexualizing, eroticizing, and exoticizing Asian women. This has translated into trafficking, as traffickers respond to the demand for young Asian women and girls in part fueled by these stereotypes of exotic, docile, submissive, and eager- to-please Asian women [36]. These stereotypes devalue and dehumanize people, which is the underlying core of human trafficking. This contributes to the acceptability of the exploi- tation of individuals, particularly members of marginalized groups [66]. These racial stereotypes go beyond simply framing the victims in a particular manner [67]. They raise implicit questions regarding how the powers of state are depicted. In other words, the patriarchal attitudes of certain countries lead to “bad” or “backward” cultural practices or ways of being that then cause trafficking—setting up a dichotomy of the “West” and “others” [67].
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Culture Although many are careful in linking cultural factors to the etiology of human trafficking for fear of imposing judgment on a particular culture, many maintain that cultural ideologies that tolerate sexual trafficking, bonded labor, and child labor may be a stronger factor than poverty in predicting trafficking rates [36; 42]. For example, some cultures emphasize collectivism and prioritizing the needs of the family and group first before the needs of the individual. Some children may feel they have to sacrifice themselves for their family when traffickers promise money [36]. Traffickers also know that they can threaten to hurt victims’ families to keep them from escaping [36]. Furthermore, in many cultures, boys are more highly valued than girls, and as a result, girls are considered more dispensable [36]. Sons are considered the family’s social security, staying with the family while daughters marry into other families. Therefore, girls may be more likely to be sold into slavery than boys. Child labor is also inextricably tied to cultural factors. In India, for example, child labor is common because it is believed that children in the lower levels of the caste system (i.e., the “untouchables”) should be socialized early to understand their position in society [42]. It has been observed that when traditional cultural and societal norms about women’s roles were relaxed in some European countries and more women entered the labor force, child labor decreased [42]. Ultimately, it is difficult to unravel the effects of poverty and culture because the pressures of poverty can lead families to use tradition as a justification to sacrifice young men, women, and children [42]. Ultimately, the conversation about human trafficking is com- plex, and to attempt to isolate the causes is beyond challenging. Multiple factors have been suggested as possibly predicting human trafficking, including macroeconomic factors (e.g., gross domestic product per capita), unemployment rates, female inequality, cultural oppression, and lack of protection of women’s rights [68; 69]. In one study, ease of land access to the destination country appeared to be a powerful predictor in terms of the number of individuals trafficked [68]. TRAFFICKERS: AN OVERVIEW Much attention has been focused on the victims of trafficking; however, it is important to also understand the perpetrators. It has been suggested human traffickers employ five general strategies to recruit and traffic victims [6; 70; 71; 72]: • Kidnapping: Traffickers may kidnap their victims. They may lure them with food or treats or take them by force. Victims with few if any social ties are highly vulnerable, as no one will miss them or report their disappearance.
• Targeting poor families: Traffickers may convince families to sell their children (often daughters). Because many families in developing countries live in abject poverty, traffickers will stress to victims’ families how the money will help them to survive. Other traffickers may tell families that selling their daughter will provide her with more promising opportunities. • Developing a false romantic relationship with victim: A tactic often used with young girls, perpetrators pose as boyfriends by romancing victims, buying gifts, and proclaiming their love. Victims have a difficult time believing that their boyfriends would hurt or deceive them, making them easy targets for trafficking. • Fake storefronts: Some employment, modeling, or marriage agencies are fronts for illegal trafficking operations. A potential victim might be lured with the promise of employment, a lucrative modeling contract, or an arranged marriage in the United States. After victims have been lured in, traffickers come to assess their “product.” Perpetrators may be family members or friends. • Legal storefronts: Some legal businesses in the tourism, entertainment, and leisure industries integrate traffick- ing activities into their business structure. • Recruiting local sex workers: Traffickers might purchase sex workers working in local night clubs from brothel owners or simply lure sex workers by promising them a more affluent future. These trafficked sex workers may later recruit younger victims.
IMPACT ON VICTIMS/SURVIVORS
HEALTH CONSEQUENCES In studies of trafficked women, headaches, fatigue, dizziness, back pain, pelvic pain, stomach pain, sexually transmitted infections (STIs), unwanted pregnancies, and gynecologic infections were common, generally the result of continual physical, psychological, and sexual abuse [30; 73]. Victims of labor trafficking also experience health issues related to the type of work, workplace conditions, malnutrition, and violence [74]. It is important to remember that some of these somatic complaints, such as headaches, fatigue, and gastrointestinal problems, may be underlying symptoms of anxiety, depression, and stress [73]. Some cultural groups might not use the terms “depression,” “sad,” or “anxious,” but may use metaphors and somatic symptoms to describe their pain, all of which are embedded within cultural ideologies. The most common culture-based idioms of distress are somatic symptoms. Some groups tend not to psychologize emotional problems; instead, they experience psychological conflicts as bodily sensations (e.g., headaches, bodily aches, gastrointestinal problems, and dizziness).
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