Texas Massage Therapy Ebook Continuing Education - MTX1323

This interactive Texas Massage Therapy Ebook contains 13 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.

TEXAS Massage Therapy Continuing Education

Elite Learning

Inside: Recognizing and Responding

to Human Trafficking in Texas

ELITELEARNING.COM/BOOK Complete this book online with book code: MTX1323 13-hour Continuing Education Package $60.00


Chapter 1: Recognizing and Responding to Human Trafficking in Texas (Mandatory) [1 CE Hour] The purpose of this course is to provide clinicians with the strategies for identifying, assessing and responding to patients who may be current or past victims of human trafficking. This course details venues for human trafficking, techniques for identifying potential trafficked persons, and resources their assistance. Chapter 2: Care for Special Populations [2 CE Hours] Touch is the first sense to develop in humans and may be the last to fade. Touch can reduce the heart rate and lower blood pressure, even for people in comas. Touch also triggers the release of endorphins, the “feel good” chemicals that are also pain suppressants. Studies document positive results using massage to treat conditions as varied as hyperactivity, diabetes, asthma, autism, and burns. Therapeutic massage has been shown to alleviate pain and stress, reducing the need for narcotic or psychotropic medications, and reducing the potential for negative side effects that are associated with medication. This chapter will focus on the benefits of therapeutic massage among individuals requiring specialized care, and suggest important considerations for clients with special needs, including: Chronic pain, chronic illness, the elderly, cancer care, and terminal illness and palliative care. Chapter 3: Carpal Tunnel Syndrome: A Comprehensive Guide for Massage Therapists [1 CE Hour] This course provides a comprehensive overview of carpal tunnel syndrome for massage therapists. This overview allows the reader to gain greater knowledge of anatomy, perspectives on how carpal tunnel syndrome affects individuals, as well as specific bodywork methods to alleviate classic symptoms of the condition. Chapter 4: Ethics for Therapeutic Massage and Bodywork [3 CE Hours] This course emphasizes the principles and standards of ethical practice for massage therapy and bodywork, and ethical issues that impact the professional in daily practice. The course includes steps to identify potential ethical conflicts, and strategies for ethical decision-making to avoid and resolve ethical issues before they become problematic. The components of informed consent, documentation and records maintenance, establishing boundaries, and collaboration with supervisors and colleagues for integrated healthcare, are detailed based on ethical standards of best practice Chapter 5: Massage Therapy for Sports Injuries [4 CE Hours] This course is designed to familiarize massage therapists with the techniques most commonly used to treat sports injuries, the general terminology associated with sports injuries, the most common sports injuries, the anatomy and physiology involved, and the sports each injury is usually associated with. The course also reviews several tips for helping athletes avoid specific injuries. In several instances, learners will discover that massage






therapy is contraindicated given the specifics of an athlete’s condition. Chapter 6: Working With Clients with Health Problems


[2 CE Hours] Massage in chronic illness can offer relaxation, stress reductions and some relief of muscle ache and tension, learn the basic information about these chronic conditions that may be present in clients, what causes the

condition, the symptoms and treatments. Final Examination Answer Sheet


©2022: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.



Book Code: MTX1323


What are the requirements for license renewal? Licenses Expire CE Hours

Mandatory Subjects

In addition to your 12 CE hours, you must also take a Human Trafficking course approved by Texas Health and Human Services. This course does not count toward the 12 required CE hours, and is an additional requirement.

12 (All hours are allowed through home-study)

Licenses expire biennially on the day of issuance.

How much will it cost?

Course Title

Hours Price Course Code

Chapter 1: Recognizing and Responding to Human Trafficking in Texas (Mandatory)

1 2

$11.95 $10.00 $10.00 $15.00


Chapter 2: Care for Special Populations

Chapter 3: Carpal Tunnel Syndrome: A Comprehensive Guide for Massage Therapists 1

Chapter 4: Ethics for Therapeutic Massage and Bodywork

3 4 2

Chapter 5: Massage Therapy for Sports Injuries

$20.00 MTX04SI21 $10.00 MTX02WW21 $60.00 MTX1323

Chapter 6: Working With Clients with Health Problems

Best Value - Save $16.95 - All 13 Hours


How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you a Texas board-approved provider?

Colibri Healthcare, LLC is approved by the Texas Board of Massage Therapy (Provider #CE1988) and the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) (Provider #450215-06). The Recognizing and Responding to Human Trafficking in Texas course is approved through Texas’ Health and Human Services Commission (HHSC). Are my hours reported to the Texas board? No, the Texas Department of Licensing and Regulation performs random audits at which time proof of continuing education must be provided. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Massage-Therapists you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-866-344-0973, Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.

Licensing board contact information:

Texas Department of Licensing and Regulation (TDLR) Massage Therapy P.O. Box 12157, Austin, 78711

Phone: (512) 463-6599 | (800) 803-9202 [in state only] Fax: (512) 463-9468 Website: http://www.tdlr.texas.gov


Book Code: MTX1323


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 evaluation. We offer three ways for you to complete. Choose an option below to receive credit and your certificates of completion. How to complete continuing education

Fastest way to receive your certificate of completion

Online • Go to EliteLearning.com/Book . Use the book code MTX1323 and enter it in the example box that pops up then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your final exam. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online survey. By mail • Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to Elite, PO Box 37, Ormond Beach, FL 32175 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.

By fax • Fill out the answer sheet and evaluation found in the back of this booklet. Please include credit card information and e-mail address. Fax to (386) 673-3563 . • All completions will be processed within 2 business days of receipt and certificates e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.



Book Code: MTX1323

Recognizing and Responding to Human Trafficking in Texas (Mandatory) 1 Contact Hour

By: John Makopoulos, MD and Dawn Demangone-Yoon, MD Learning objectives After completing this course, the learner will be able to: Š Describe the types and venues of human trafficking in the United States. Š Discuss communication strategies to assist with identification of trafficked persons. Course overview Human trafficking has been called a form of modern-day slavery. 1,2 It is a crime involving the exploitation of someone for the purpose of compelled labor or a commercial sex act through the use of force, fraud, or coercion. 1 Victims can be women or men, adults or children, citizens or noncitizens and occurs across the United States and throughout the world. Human trafficking does not require crossing of international or state borders.

Š Discuss the importance of safety planning and protocols. Š Identify resources for reporting suspected victims of human trafficking.

For clinicians and health care workers, human trafficking can be viewed as a serious health risk associated with significant physical and psychological harms. 3 The abuses suffered by people who are trafficked include many forms of physical violence or abuse (e.g., beating, burning, rape, confinement) as well as many psychologically damaging tactics such as threats to themselves or their family members, blackmail, extortion, lies about the person’s rights, and confiscation of vital identity documents. 3


What Is human trafficking? Human trafficking is defined as:

● Being disabled. ● Belonging to a marginalized or stigmatized gender, ethnic, or cultural group. Traffickers use various techniques to control their victims and keep them enslaved. Some traffickers hold their victims under lock and key. More frequently, however, more subtle techniques ○ The public by limiting contact with outsiders and making sure that any contact is monitored or superficial in nature. ○ Family members and friends. ● Control: ○ Confiscation or control of passports or other identification documents. ○ Debt bondage through enormous financial obligations or an undefined or increasing debt. ○ Control of the victims' money. ● Intimidation/threat: ○ Use or threat of violence toward victims or their family members. ○ Shaming victims by exposing humiliating circumstances to their families. ○ Telling victims they will be imprisoned or deported for immigration violations if they contact authorities. “Victim” or “Survivor”? The terms “victim” and “survivor” can both be used to refer to individuals who were trafficked. The term “victim” has legal implications within the criminal justice process and generally means an individual who suffered harm as a result of criminal conduct. 1 are used such as: 9 ● Isolation from: “Survivor” is a term used by many in the health services field to recognize the strength it takes to continue on a journey toward healing in the aftermath of a traumatic experience.

“The recruitment, transportation, transfer, harboring or receipt of persons by means of the 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 receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.” 4 The phrase “human smuggling” is often confused with “human trafficking” but they are two quite different crimes. Human smuggling involves the provision of a service—typically transportation or fraudulent documents—to an individual who voluntarily seeks illegal entry into a foreign country. 5 Also sometimes confused is the difference between sex trafficking and consensual commercial sex (sex work). Sex trafficking is when an adult takes part in the sale of sex through threat, abduction, or other means of coercion, whereas sex work involves the willing and consensual exchange of money for sex and does not infringe on the human rights of the participants. 6 ( Note : Children cannot technically be prostitutes or sex workers because they cannot legally consent to commercial sex.) Many victims of human trafficking are forced to engage in sexual practices through threats or other types of coercion, but trafficking also occurs as labor exploitation in urban, suburban, and rural areas. Many victims are lured with false promises of well-paying jobs or manipulated by people they trust. 1 They are forced or coerced into prostitution, domestic servitude, or other types of forced labor (e.g., agriculture, construction, fisheries, mining industries). Victims can be found in legitimate and illegitimate labor industries, including sweatshops, massage parlors, agriculture, restaurants, hotels, street peddling, door to door sales, begging, and domestic service. 1 Although anyone can be at risk for being a victim of human trafficking, most are women and girls. 7 Risk factors for being vulnerable to human trafficking include: 8 ● Extreme poverty. ● Minimal education. ● A history of abuse or family instability.

Page 1

Book Code: MTX1323


The life situations of people who are trafficked are almost always complicated, whether they are under a trafficker’s control, trying to leave, or are already out of a trafficking environment. In addition, trafficked people may not self-identify as trafficked. Rather they may feel that these are merely the restrictions of their circumstance. They are usually beset with physical, psychological, social, legal, and financial circumstances that can be overwhelming. 3 Human trafficking became a federal crime with passage of the Trafficking Victims Protection Act of 2000 (TVPA) revised and Human trafficking in Texas In 2009, the Texas legislature created the Texas Human Trafficking Prevention Task Force to respond to the growing human trafficking crisis and designated the attorney general as the presiding officer. 11 The Task Force develops legislative recommendations to attack the crime and policies to protect victims. A 2016 report by the University of Texas at Austin, School of Social Work estimated that there are approximately 79,000 minor and youth victims of sex trafficking and 234,000 workers who are victims of labor trafficking. 12 Minor and youth sex trafficking has an estimated economic impact to the state of nearly $6.6 billion while labor trafficking victims are exploited at an annual cost of almost $600 million. 12 In 2020, the latest year for which data are available, there were 987 human trafficking cases reported in Texas, 185 arrests for human trafficking, and 28 convictions. 11,13 There were also 97 arrests for compelled prostitution with 18 convictions. 11 Of the 1,080 cases of human trafficking in 2019, most were for sex trafficking (739 cases), with labor trafficking being the next- most common (116 cases). 13 Most victims were female (824 cases

updated in 2015. 10 The goals of the TVPA were to prevent severe forms of human trafficking, both in the United States and overseas; to protect victims and help them rebuild their lives in the United States; and to prosecute traffickers and impose federal penalties. Prior to enactment of the TVPA, no comprehensive federal law existed to protect victims of trafficking in the United States or to prosecute their traffickers. Congress has reauthorized and amended the TVPA several times, but its fundamental purpose and legal authorities remain the same. vs. 131 for men), and adult (659 cases vs. 216 cases involving minors). [ Note : statistics are non-cumulative because cases may involve multiple victims.] An important caveat to all statistics about human trafficking is the difficulty of obtaining accurate data, which is a limitation of research into this issue that has been pointed out in the reports of the Texas Human Trafficking Prevention Task Force and other organizations working to reduce human trafficking. 11 Barriers to acquiring accurate data include the avoidance by victims of the criminal justice system due to fears of reprisal, deportation, or incarceration; failure of health care workers or emergency responders to ask about human trafficking or to probe causes of apparent violence; and a lack of coordination and data integration between the various levels of governmental agencies (local, state, federal) and other organizations (e.g., non-profits, hospitals) that may have data on human trafficking. These barriers and the limitations of existing data suggest that the true scope of human trafficking is larger than can be reliably estimated at the present time. 8


A number of organizations representing healthcare providers have issued statements recognizing human trafficking as a public health issue and acknowledging the importance of building awareness of human trafficking among health care providers. 14-17 The American Medical Association, for example, in its 2015 statement, says: "Physicians should be aware of the definition of human trafficking and of resources available to help them identify and address the needs of victims. The AMA will help encourage the education of physicians about human trafficking and how to report cases of suspected human trafficking to appropriate authorities to provide a conduit to resources to address the victim's medical, legal and social needs." 15 Healthcare professionals are uniquely positioned to identify and intervene on behalf of trafficking victims. Outside of law enforcement, healthcare settings are among the few places Identifying potential victims of human trafficking Certain patient behaviors and/or companion behaviors can alert health care professionals to a potential human trafficking case. 9,22 One common clue is the presence of a person who seems to control both the patient and the situation. Survivors report that their traffickers completed health-related paperwork for them and communicated with clinic staff and health care providers on their behalf. 9 The physical proximity of the traffickers perpetuated their coercion and control of the victims, preventing them from communicating with health care personnel directly. 9 The presence of an overbearing or controlling companion should trigger concern, and most recommendations suggest that in order to allow patients the opportunity to speak for themselves, clinic or hospital staff should attempt to interview and assess all patients privately. This may require the use of an independent interpreter, since many survivors have limited English proficiency. 9 Trained non-clinical workers could be instrumental in helping to maintain separation during potential victim identification interviews in a manner that does not alert potential traffickers to victim identification efforts. Non-clinical staff, such as

where the lives of human trafficking victims may intersect with the rest of society, if only for brief periods. 18 In a study of 98 sex trafficking survivors, 88% had at least one encounter with a health care provider while they were being trafficked, with 63 percent of these encounters happening in an emergency department. 19 One study noted that human trafficking victims in the U.S. may interact with a range of health care personnel, including primary care providers, sexual and reproductive health care workers, dentists, and providers of traditional or alternative remedies. 9 Trafficking victims may even be found working within health care facilities. Unfortunately, studies have demonstrated that medical care providers are often unprepared to identify trafficking victims. 20,21 receptionists, security guards, and accounting personnel, who are made sensitive to these matters through training, may observe patterns and know when and how to respond if a potential trafficker repeatedly presents for multiple patients as a companion, translator, or medical bill payer, regardless of whether these personnel interact with the patients themselves. Multilingual non-clinical staff who may share a common language with trafficked persons of limited English proficiency may be able to develop a rapport with trafficked persons that facilitates trust and frank communication based on their language or cultural commonalities. It is recommended, therefore, that health care organizations think broadly about the types of employees who are appropriate to receive training about human trafficking in order to enhance opportunities for identification of and response to potential trafficking situations. 23 A human trafficking victim may develop a mindset of fear, distrust, denial, and conflicting loyalties. Foreign victims of trafficking are often fearful of being deported or jailed and, therefore, they may distrust authority figures, particularly law enforcement and government officials. Many victims of both


Book Code: MTX1323

Page 2

sex and labor trafficking fear that if they escape their servitude and initiate investigations against their trafficker, the trafficker and his/her associates will harm the victims, the victims’ family members, or others. Additional patient situations, behaviors, or emotional states may suggest human trafficking: 2 ● Paying cash or having no health insurance. ● Lacking control of identification documents (ID or passport). ● Having few or no personal possessions. ● Being reticent for additional testing or services due to large debt. ● Inability to: ○ Leave home or place of work. ○ Speak for oneself or share one’s own information. ● Feelings of helplessness, shame, guilt, self-blame, and humiliation. ● Loss of sense of time or space, not knowing where they are or what city or state they are in. ● Emotional numbness, detachment, or disassociation (i.e., “flat affect”). Responding to victims of human trafficking Victims of trafficking do not often disclose their trafficking situation in clinical settings. 8 Health care providers must, therefore, be thoughtful and careful about engaging patients if human trafficking is suspected. Before beginning any conversation with a patient, assess the potential safety risks that may result from asking sensitive questions of the patient. Recognize that the goal of your interaction is not disclosure or rescue, but rather to create a safe, non-judgmental place that will help you identify trafficking indicators and assist the patient. 2 This may be challenging in the context of busy, time-constrained schedules, but it is possible. Clinicians should: ● Allow the patient to decide if he or she would feel more comfortable speaking with a male or female practitioner. ● If the patient requires interpretation, always use professional interpreters who are unrelated to the patient or situation. ● If the patient is accompanied by others, try to find a time and place to speak with the patient privately. ● Take time to build rapport with potential victims, or if you do not have the time yourself, find someone else on staff who can develop rapport with the patient. ● Ensure that the patient understands confidentiality policies and practices, including mandatory reporting laws. ● Use multidisciplinary resources, such as social workers, where available. ● Refer to existing institutional protocols for victims of abuse/ sexual abuse. ● Contact the National Human Trafficking Resource Center (NHTRC) hotline (1-888-373-7888) for assistance. Information available at: https://humantraffickinghotline.org/ If a patient has disclosed that he or she has been trafficked: 2 ● Ensure that safety planning is included in the discharge planning process. ● Provide the patient with options for services, reporting, and resources. ○ Provide the patient with the NHTRC hotline number. If the patient feels it is dangerous to have something with the number written on it, have them memorize the

While not all victims of trafficking have physical indicators that aid identification, many victims suffer serious health issues, which may include: 2 ● Addiction to drugs and/or alcohol as a way to cope with or “escape” their situation, or as a method of control used by their traffickers. ● Symptoms of post-traumatic stress disorder, phobias, panic attacks, anxiety, and depression. ● Sleep or eating disorders. ● Untreated chronic illnesses, such as diabetes or cardiovascular disease. ● Signs of physical abuse, such as bruises, broken bones, burns, and scarring. ● Chronic back, visual, or hearing problems from work in agriculture, construction, or manufacturing. ● Skin or respiratory problems caused by exposure to agricultural or other chemicals. ● Infectious diseases, such as tuberculosis and hepatitis, which are spread in overcrowded, unsanitary environments with limited ventilation. ● Reproductive health problems, including sexually transmitted diseases, urinary tract infections, pelvic pain, and injuries from sexual assault or forced abortions. number or designate someone in your staff that they can call back to in order to provide that number. ● In situations of immediate, life-threatening danger, follow your institutional policies for reporting to law enforcement. Whenever possible, try to involve the patient in the decision to contact law enforcement. ● If the patient is a minor, follow mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth. Most state laws require immediate intervention if the trafficked victim is a minor. ● Ensure that any information regarding the patient’s injuries or treatment is accurately documented in the patient’s records, recognizing that, similar to sexual assault examinations, the medical record serves both medical and legal purposes. Legal requirements regarding mandatory reporting of human trafficking differ from state to state, and situations may require mandatory reporting under related statutes even if the situation is not human trafficking (e.g., child abuse or domestic violence). State-specific information is available at: https://polarisproject. org/resources/state-ratings-on-human-trafficking-laws/ Refer to your local or state requirements for additional information regarding mandatory reporting. Four fundamental principles have been recommended for healthcare professionals who come into contact with people who have been, or are being, trafficked: 8 1. Use a trauma-informed, resilience-oriented, human rights- focused, and culturally sensitive approach to the care of all patients. 2. Collaborate with and seek advice from colleagues who have been engaged in anti-trafficking or other violence prevention work. 3. Partner with advocates, social service providers, case managers, and others from outside the health sector to improve referral services and achieve a more effective overall response to human trafficking. 4. Play an active role in self-directed education and training about human trafficking.


At a glance, it is easy to appreciate the trauma of a massive motor vehicle accident, but a patient who is trafficked is experiencing a similarly powerful, but far less visible, traumatic event. The task for clinicians is to recognize trafficking when they see it and respond appropriately. The patient’s experiences can be dehumanizing, shocking or terrifying, can involve singular

or multiple compounding events over time, and often include betrayal of a trusted person or institution and a loss of safety. 24 These experiences can mean that ordinary medical procedures, such as asking a patient to undress for an exam, performing a gynecological exam, or even simply checking blood pressure, can be threatening or anxiety-provoking.

Page 3

Book Code: MTX1323


Trauma-informed care (also known as trauma-sensitive or trauma- aware care) is one way to provide effective and compassionate care for patients who may be trafficked or are otherwise traumatized. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a program, organization, or system that: 24 1. Realizes the widespread impact of trauma and understands potential paths for recovery. 2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system. 3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices. 4. Seeks to actively resist re-traumatization. Taking a history No evidence-based recommendations guide assessment and evaluation processes in the context of known or suspected human trafficking. Practice-based evidence, however, has been used to generate recommendations for screening and inquiry in these situations. Survivors of trauma report that disclosure may be more likely if health care providers are perceived to be knowledgeable about abuse and violence, nonjudgmental, respectful, supportive, and use a trauma-sensitive approach to evaluation and treatment. 8 Given the impact of adverse childhood experiences and other traumatic exposures on later physical and mental health and well-being, some experts recommend embedding specific questions about trafficking after a trusting relationship has been established. The length of time it takes to establish such a relationship with a victimized individual varies widely—it may take just a few minutes or require multiple separate visits. Once rapport has been developed with the patient, and confidentiality (along with its limits) has been communicated clearly, questions about possible human trafficking and other forms of coercive control can be asked. If you suspect human trafficking, try to start with indirect questions. Enlist the help of a staff member and/or interpreter who has knowledge of the patient’s language and culture after confirming there is no conflict of interest. Attempt to interview the patient alone without raising suspicions. You may need to be creative in finding opportunities to interview the patient alone, Physical examination A physical examination should be performed carefully and sensitively, guided by the clinical presentation and by information gleaned from the history. In cases involving sexual violence and other forms of trauma, forensic evaluation and evidence collection should be offered when appropriate (e.g., if the most recent sexual assault has occurred within 120 hours of presentation, and with the patient’s consent or in conjunction with mandated reporter responsibilities).8 Forensic evaluation and evidence collection should be performed using approved sexual assault evidence collection kits. If available in your area, sexual assault/forensic nurse examiners, who have specific training in forensic evaluation and evidence collection, should be used. Case study: Clinical consideration part 1 A young woman, Jessica, presents to the local clinic requesting evaluation for genital sores and vaginal discharge. You notice on her intake information that she is paying cash for this visit, and further review of her records reveals that she does not have a permanent address and has presented on multiple occasions to the clinic with similar symptoms. She is accompanied by her boyfriend, Mark, who largely speaks for Jessica, answering the

Trauma-specific intervention programs generally: ● Acknowledge the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. ● Address the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. ● Collaboratively work with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers. Other trauma-informed approaches support the need for fundamental safety throughout the healthcare system (e.g., the Sanctuary model. Information at http://sanctuaryweb. com/) Additional intervention information can be found in a manual about trauma-informed care published by SAMHSA and available at: https://store.samhsa.gov/product/TIP-57-Trauma- Informed-Care-in-Behavioral-Health-Services/SMA14-4816 as traffickers may accompany patients to their visits and insist on staying with the patient throughout the encounter. Requesting that the patient leave the room for specific tests, such as x-rays, or urine testing, even when not necessary, may provide time away from the escort to ask questions in a confidential environment. Examples of probing questions: 1. Has your identification or documentation been taken from you? 2. What are your working or living conditions like? 3. Where do you sleep and eat? 4. Can you leave your job or situation if you want? 5. Do you sleep in a bed, on a cot or on the floor? 6. Do you have to ask permission to eat, sleep or go to the bathroom? 7. Can you come and go as you please? 8. Have you ever been deprived of food, water, sleep or medical care? 9. Are there locks on your doors and windows? Do you lock them or does someone else? (e.g., so you cannot get out) 10. Have you been threatened if you try to leave? 11. Have you been physically harmed in any way? 12. Is anyone forcing you to do anything that you do not want to do? 13. Has anyone threatened your family? Abuse and violence, including that resulting from human trafficking, should be suspected when any of these physical findings are noted: ● Bilateral or multiple injuries. ● Evidence consistent with rape or sexual assault. ● Evidence of acute or chronic trauma, especially to the face, torso, breasts, or genitals. ● Pregnant woman with any injury, particularly to the abdomen or breasts; vaginal bleeding; or decreased fetal movement. ● Body tattoos that are the mark of a pimp or trafficker. ● Occupational injuries not linked clearly to legitimate employment. questions, while she remains sitting quietly on the examination table. Jessica appears withdrawn and does not make eye contact with you. She appears to have superficial abrasions and bruises in various stages of healing on her upper extremities. 1. Take a moment to consider the many clues of this encounter that could indicate this young woman may be a victim of human trafficking.


Book Code: MTX1323

Page 4

Documentation Clinicians should carefully and accurately document all findings in the medical record, not only because this is standard care for all patients, but because such data may be valuable if the patient seeks legal redress. The patient’s medical history, physical findings, and oral disclosures, should be documented in writing, in an unbiased manner, using direct, unaltered quotes from the patient, to the extent possible. Photographic documentation of physical findings may be appropriate, with the patient’s permission. Images should contain the patient’s face and the injury or lesion measured with a ruler or other common object (such as a coin). Additional photographs can document close up views of each relevant injury or lesion. Patients should be informed that they have a right to refuse photographic documentation altogether or to restrict photographic

documentation to certain specific areas if they so choose. The words “suspected human trafficking” as a finding, diagnosis, or problem should be included in the chart when appropriate. 8 The Clinical Goal : The clinician’s goal should not be to “get a disclosure” from a patient suspected of being trafficked or otherwise abused. 8 Instead, the health care provider should work to create a climate that allows every patient to feel safe, secure, cared for, validated, and empowered to disclose if he or she chooses. Disclosure might occur later if the patient does not feel ready to disclose in the immediate clinical setting. Therefore, each individual clinical encounter should be viewed as a step on a pathway to safety for at-risk patients.


● Increasing or new threats of homicide (or suicide by the trafficker) if the patient discloses. ● The presence or availability of lethal weapons in the residence. Detailed safety planning and related case management are best undertaken by those with specific expertise in this area: advocates, social workers, and case managers. These expert partners are generally equipped with the time and expertise needed to address each patient’s immediate, short- term, and long-term needs, and to arrange for appropriate follow-up with known and trained community-based resources. ● Restrict access to all doors except the main entrance. ● Pre Program 911 into all phones. Quality improvement programs of various kinds can create and support policy changes regarding safety and high quality health care systems. One training program specific to human trafficking is SOAR to Health And Wellness Training. (SOAR is an acronym for Stop, Observe, Ask and Respond to Human Trafficking.) The program is available at https://www.acf.hhs.gov/otip/training/ soar-to-health-and-wellness-training the autonomy patients deserve and need for making informed decisions for their own safety and future. As in cases of intimate partner violence, therefore, health care providers must follow the lead of the patient and respect the decisions of those who decide not to contact law enforcement or accept referrals to other services. Domestic as well as international victims of human trafficking have specific legal rights under federal and state law, but may not know of these rights or be in a position to exercise them. If the patient is willing, a referral to law enforcement, attorneys, or legal service providers is appropriate. she accompany you to the restroom to provide a urine sample. Mark offers to go with her and wait outside of the restroom. You explain that it is not possible as the route to the restroom may pass other patients’ rooms, that the restroom is in a location shared with other patients, and you must protect their privacy. Mark quickly replies that it is impossible for Jessica to be pregnant, as she is compliant with her oral contraceptives, her periods are normal and questions the necessity of the test. You indicate she will not be treated until the test is complete, and Mark reluctantly agrees.

If trafficking has been disclosed, clinicians can help the patient by: ● Having the patient assess his or her own personal risk. ● Making an independent judgment about that risk and communicating this opinion to the patient. ● Talking about safety planning. ● Making referrals to appropriate case management services for more detailed safety planning and case management. Patients may minimize or deny the danger they face, hence clinicians should note the following “red flag” signs of heightened risk: ● More frequent or severe threats or assaults. ● New or increasingly violent behavior by the perpetrator. Safety and training of health care workers Since traffickers may be involved in various criminal enterprises, protecting health care workers is essential. The following suggestions include general safety measures as well as those specifically applicable to health care workers who may help victims of human trafficking: 16 ● Build relationships with local police or security personnel. ● Review emergency plans periodically. ● Restrict after-hours access. ● Improve lighting at entrances and parking areas. ● Install security cameras, mirrors, and panic buzzers. Legal considerations “Health care providers are not required to—and in fact may not—report suspected instances of human trafficking that involve a competent adult victim, without the patient’s express consent.” 8 Clinicians should not involve law enforcement and/or social service providers (e.g., housing/shelter services, legal services, and case management) without first obtaining the explicit informed consent of the patient, or unless otherwise required under relevant law. These laws may include mandatory reporting laws for children, disabled adults, elders, and others. Privacy breaches can erode the provider-patient relationship and remove Case study: Clinical consideration part 2 Continuing Jessica’s visit, you are now beginning her physical examination. Mark indicates he would like to remain in the room during the examination, Jessica agrees and consents to his presence. He stands next to the head of the bed during the pelvic examination. Upon completion, you have identified an outbreak of Genital Herpes, and microscopic examination of the discharge reveals Trichomoniasis, two sexually transmitted diseases. Mark seems unusually undisturbed by the diagnoses. You are concerned about Jessica’s current living situation and would like to question her privately. In discussing the diagnoses with Jessica and Mark, you indicate that she must undergo urine pregnancy testing before beginning treatment and request that

Page 5

Book Code: MTX1323


You lead Jessica to a private conference room and emphasize that everything the two of you discuss will remain confidential. You preface your questions by stating, “I am worried about you, and would like to ask some questions about your current living conditions and situation so that I might help you.” Conclusion Clinicians, as “first contacts,” have an imperative to make a difference for their patients. Human trafficking poses many health risks, including physical injury, death, and/or long-lasting psychological damage. In the absence of validated tools to screen for victims of human trafficking, health care providers may need to consider implementing universal methods and Resources Texas Resources ● Texas Office of the Attorney General humantrafficking@oag.texas.gov 512-463-1646 ● Texas Child Protective Services 800-252-5400 ● Texas Department of Public Safety, Victim Services 512-424-2211 dps.texas.gov/administration/staff_support/victimservices/ pages/index.htm National Resources ● Coalition Against Trafficking in Women www.catwinternational.org References 1. Department of Justice. Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States, 2013-2017 . 2014. 2. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to look for in a healthcare setting. http://www.acf.hhs.gov/ endtrafficking/resource/fact-sheet-identifying-victims-of-human-trafficking. Published 2016. Accessed November 30, 2016. 3. International Organization for Migration. Caring for Trafficked Persons; Guidance for Health Providers . Geneva, Switzerland 2009. 4. United Nations Office on Drugs and Crime. Trafficking in persons: universally defined in the UN Trafficking in Persons Protocol . https://www.unodc.org/ documents/data-and-analysis/glotip/Annex_II_-_Definition_and_mandate.pdf. Accessed September 22, 2020. 5. U.S. Immigration and Customs Enforcement. Human Trafficking vs. Human Smuggling . https://www.ice.gov/sites/default/files/documents/Report/2017/ CSReport-13-1.pdf. Accessed September 22, 2020. 6. Stop the Traffik. Sex trafficking vs sex work: understanding the difference . https://www.stopthetraffik.org/sex-trafficking-vs-sex-work-understanding- difference/. Accessed June 25, 2020. 7. United States Department of State. 2019 Trafficking in Persons Report . https://www.state.gov/reports/2019-trafficking-in-persons-report/. Accessed September 22, 2020. 8. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting . Boston MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital;2014. 9. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36-49. 10. United States Congress. Justice for Victims of Trafficking Act of 2015 . https:// www.gpo.gov/fdsys/pkg/BILLS-114s178enr/pdf/BILLS-114s178enr.pdf. Published 2015. Accessed January 9 2017. 11. Texas Human Trafficking Prevention Task Force. Report to the Texas Legislature December 2020 . https://texashistory.unt.edu/ark:/67531/metapth1402173/. Accessed May 17, 2022. 12. Busch-Armendariz NB, Nale NL, Kammer-Kerwick M, et al. H uman Trafficking by the Numbers: The Initial Benchmark of Prevalence and Economic Impact for Texas . Institute on Domestic Violence & Sexual Assault, University of Texas at Austin; 2016.

1. Take a moment to consider how you might respond if Jessica refuses to answer any further questions. 2. Take a moment to consider ways you could help Jessica if she did indeed admit to being a victim of human trafficking.

policies to create a safe environment for all patients. Clinicians who encounter a trafficked person or other exploited individual have a unique opportunity to provide essential medical care and supportive referral options that may be an individual’s first step towards safety and recovery.

● Human Rights Watch www.hrw.org ● SOAR to Health and Wellness acf.hhs.gov/endtrafficking/initiatives/soar ● HEAL Trafficking https://healtrafficking.org

● Caring for Trafficked Persons: A Guide for Health Providers http://publications.iom.int/books/caring-trafficked-persons- guidance-health-providers ● National Human Trafficking Resource Center (NHTRC) Hotline (24/7): 1-888-373-7888 http://traffickingresourcecenter.org/ ● Polaris Project www.polarisproject.org 13. National Human Trafficking Hotline. Texas Statistics . https:// humantraffickinghotline.org/state/texas. Accessed May 17,2022. 14. Emergency Nurses Association. Joint Position Statement: Human Trafficking Awareness in the Emergency Care Setting . https://www.ena.org/docs/ default-source/resource-library/practice-resources/position-statements/ humantraffickingpatientawareness. Accessed September 22, 2020. 15. American Medical Association. Policy Statement: Physicians Response to Victims of Human Trafficking H-65-966 . https://policysearch.ama-assn.org/ policyfinder/detail/H-65.966?uri=%2FAMADoc%2FHOD.xml-0-5095.xml. Published 2015. Accessed September 22, 2020. 16. American College of Obstetricians and Gynecologists. Human Trafficking. Committee Opinion No. 507. Obstet Gynecol . 2011;118:767-770. 17. Harrison SL, Atkinson HG, Newman CB, et al. Position Paper on the sex trafficking of women and girls in the United States. American Medical Women's Association . 2014. 18. Trossman S. The Costly Business of Human Trafficking. American Nurse Today . 2008;3(12). 19. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law . 2014;23:61-91. 20. Wong JC, Hong J, Leung P, Yin P, Stewart DE. Human trafficking: an evaluation of Canadian medical students' awareness and attitudes. Educ Health (Abingdon) . 2011;24(1):501. 21. Chisolm-Straker M, Richardson L. Assessment of Emergency Department (ED) Provider Knowledge about Human Trafficking Victims in the ED (Abstract). Academic Emergency Medicine . 2007;14(5S):S134. 22. Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health . 2010;55(5):462-467. 23. Grace AM, Lippert S, Collins K, et al. Educating health care professionals on human trafficking. Pediatr Emerg Care . 2014;30(12):856-861. 24. Substance Abuse and Mental Health Services Administration. TIP 57: Trauma- Informed Care in Behavioral Health Services . https://store.samhsa.gov/ product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14- 4816. Accessed September 22, 2020.


Book Code: MTX1323

Page 6

RECOGNIZING AND RESPONDING TO HUMAN TRAFFICKING IN TEXAS Final Examination Questions Select the best answer for each question and mark your answers on the Final Examination Answer Sheet found on pages 100, or complete your test online at EliteLearning.com/Book 1. Which of the following is not an industry in which people who are trafficked often work? a. Restaurants. 6. What is one possible way to increase the identification in health care settings of people who are being trafficked? a. Install security cameras in waiting rooms.

b. Education. c. Agriculture. d. Fisheries.

b. Train non-clinical staff (e.g., receptionists, security guards) in ways to identify human trafficking and to communicate with medical personnel. c. Require all patients to fill out a questionnaire about human trafficking. d. Require that all patients are asked about human trafficking when signing in for their visit. 7. If a patient suspected of being trafficked does not speak English, or is not comfortable speaking English, the best approach is: a. Have the patient’s friend or relative translate for them. b. Use printed materials that have been translated into other common languages. c. Use a professional interpreter or someone unrelated to the patient. d. Use the language translation phone application on your smartphone to communicate. 8. Before asking a patient questions about human trafficking, it’s best if clinicians: a. Establish a rapport with the patient and separate the patient from any people who may have accompanied him or her on the visit. b. Use a written questionnaire to screen for potential signs of human trafficking. c. Perform a thorough physical examination. d. Check the patient’s health insurance status using an online database. 9. If a patient discloses that they are a victim of human trafficking: a. Police must be notified. b. Any escort accompanying the patient should be detained by the office staff. c. Injuries must be carefully documented and detailed in their medical record. d. Insist that they take pamphlets and information regarding human trafficking with them at their time of discharge. 10. Why is it important, in the context of human trafficking, to train all clinical and non-clinical staff on safety and security procedures? a. Because victims of human trafficking are often violent. b. Because traffickers may be involved in various criminal enterprises and present a threat of violence. c. Because victims of human trafficking are more likely to be infected with contagious diseases. d. To conform with local or state laws related to the treatment of victims of human trafficking.

2. Which is a common method used by human traffickers to control and manipulate their victims? a. Exposure to loud music. b. Isolation from family members. c. Lawsuits. d. Large payments for illicit or illegal behaviors. 3. Which statement best describes the use of the terms “victim” and “survivor” in relation to human trafficking? a. Both terms may be appropriate depending on the circumstances of the person being trafficked. b. The term “victim” is preferred because it emphasizes how much those being trafficked suffer. c. The term “survivor” is preferred because it recognizes that the individual is “surviving” despite their current situation. d. Neither term is preferred because both are emotionally loaded—the preferred term is “person being trafficked.” 4. In a study of people involved in sex trafficking, what percentage had at least one encounter with a health care provider while they were being trafficked? 5. Which statement best summarizes the finding of several studies about the role or behaviors of health care providers relating to human trafficking? a. Most providers have been educated about the problem of human trafficking but do not have time to adequately address the needs of trafficked patients. b. Many providers are unprepared to identify trafficking victims when they are encountered in clinical settings. c. Many providers can identify trafficking victims, but they often do not follow up with appropriate referrals to external sources of support. d. Most providers are not exposed to the issue of human trafficking in medical school. a. 18%. b. 45%. c. 88%. d. 95%.

Course Code: MTX01RR

Page 7

Book Code: MTX1323


Page i Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 Page 71 Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 Page 80 Page 81 Page 82 Page 83 Page 84 Page 85 Page 86 Page 87 Page 88 Page 89 Page 90 Page 91 Page 92 Page 93 Page 94 Page 95 Page 96 Page 97 Page 98 Page 99 Page 100 Page 101 Page 102 Page 103 Page 104


Powered by