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TEXAS Physical Therapy Continuing Education
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Includes the mandatory course: Human Trafficking: Overview for Texas Healthcare Professionals Continuing Education Package for Physical Therapists and Physical Therapy Assistants
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What’s Inside
This course fulfills the Texas Human Trafficking prevention training requirement and is approved by the Texas Physical Therapy Association. Chapter 1: Human Trafficking: Overview for Texas Healthcare Professionals (Mandatory) [1 CCU] 1 This basic-level course for healthcare professionals is an introduction into the complex crime of human trafficking, with a focus on sex and labor trafficking and the common symptoms and conditions that occur in trafficked persons. Healthcare professionals who complete this course will be able to recognize the signs and symptoms of trafficked persons and identify the interventions needed to care for these individuals. Additionally, this course lists national resources that provide vital services to trafficked persons and makes recommendations for patient and staff safety when addressing these potentially volatile scenarios. Chapter 2: Alzheimer’s Disease and Other Dementias: Medical Overview and Rehabilitation Management, 2nd Edition [4 CCUs] 12 The purpose of this course is to provide useful, pragmatic information to rehabilitation therapists to facilitate successful rehabilitation for individuals with Alzheimer’s and other dementias. Too often, those with dementia are excluded from rehabilitation opportunities based on the assumption that they will not benefit, or they are given a brief trial of rehabilitation that does not take into consideration the special needs of this population and, as a result, they do not make gains. This course will provide an overview of Alzheimer’s disease and its medical management, practical information on optimal interactions with individuals who have Alzheimer’s disease, research findings related to motor learning in this population, existing evidence on rehabilitation with individuals with dementia, and strategies to facilitate successful outcomes. Chapter 3: Functional Assessment of the Older Adult, 2nd Edition [4 CCUs] 37 Adults age 65 and older represent the fastest growing population both in the United States and in the world. Physical therapy practitioners and other rehabilitation providers play a pivotal role in maximizing function, participation, and well- being for older adults. This intermediate-level course will enable physical therapy practitioners to understand and assess functional performance in older adults using a multidimensional approach. Client factors (including physical, cognitive, and psychosocial factors) and their impact on performance skills will be reviewed. Chapter 4: Preventing Falls in Older Adults [5 CCUs] 59 An older adult falls every second of every day, with more than 29 million falls occurring in 2014, resulting in more than 7 million injuries. This intermediate-level course provides healthcare professionals in the areas of physical and occupational therapy with the knowledge they need to successfully identify those at risk for falls, assess individuals, and develop interventions targeted at reducing fall risk in older adults. Although therapists may be aware of the need to assess and treat older adults for risk for falls, they may not be fully abreast of approaches that are supported by evidence and are proven to truly reduce the incidence of falls. Chapter 5: Supporting Aging in Place: A Physical Therapist’s Toolkit [4 CCUs] 82 This intermediate level course is designed to assist physical therapists and physical therapy assistants in evaluating, planning, and preparing their older adult clients to age in place. This toolkit will highlight the role physical therapy plays in enhancing the quality of life for older adults and to allow them to participate in meaningful activities while remaining in their homes as they age and make the necessary modifications to do so. Chapter 6: Examination and Management of the Client with Parkinson’s Disease, 2nd Edition [5 CCUs] 104 This intermediate course is designed to provide physical therapists and physical therapist assistants with the information needed to appropriately examine and treat the client with PD, including differential diagnosis of individuals who exhibit signs and symptoms indicative of PD. In addition, the learner will be able to manage clients with PD by designing a comprehensive treatment program based on the use of appropriate outcome measures. Equipped with the most current evidence, the learner will be able to discuss and critically evaluate interventions directed at the specific body structure and function, activity, and participation deficits associated with PD. Chapter 7: Exercise Prescription Management of the Older Adult: An Evidence-Based Approach, 2nd Edition [5 CCUs] 125 The purpose of this intermediate level course is designed to educate physical therapists and physical therapist assistants on the implementation of exercise prescriptions in older adults. This course will review the multiple age-related systemic changes that take place in the cardiovascular, respiratory, endocrine and musculoskeletal systems and describe how exercise may mitigate these changes. This course will also provide recommended exercise prescriptions according to the most recent American College of Sports Medicine guidelines for older adults and discuss common barriers for exercise participation in older adults. Final Examination Answer Sheet 148
©2024: 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.
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PHYSICAL THERAPY CONTINUING EDUCATION
What are the requirements for license renewal? Licenses Expire Contact Hours Frequently Asked Questions
Mandatory Subjects
Must complete a Human trafficking prevention training course approved by the Texas Health and Human Services Commission (HHSC). 2 CCUs of Texas Jurisprudence Assessment Module (TX JAM) which is available on the board website.
Physical Therapists (30) 28 CCUs are allowed through home-study Physical Therapy Assistants (20) 18 CCUs are allowed through home-study
Biennial renewal. Licensees are required to renew by the end of their birth month every two years.
How much will it cost? If you are only completing individual courses in this book, enter the code that corresponds to the course below online.
Course Code
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PTA 18-Hour Package
Price
Course Title
Chapter 1: Human Trafficking: Overview for Texas Healthcare Professionals (Mandatory) Chapter 2: Alzheimer’s Disease and Other Dementias: Medical Overview and Rehabilitation Management, 2nd Edition
PTTX01HH
1
1
$11.95
4
4
$48.00 PTTX04AD24
Chapter 3: Functional Assessment of the Older Adult, 2nd Edition
4 5 4
4 5 4
$48.00 PTTX04FA24 $60.00 PTTX05PF24 $48.00 PTTX04SA24
Chapter 4: Preventing Falls in Older Adults
Chapter 5: Supporting Aging in Place: A Physical Therapist’s Toolkit Chapter 6: Examination and Management of the Client with Parkinson’s Disease, 2nd Edition Chapter 7: Exercise Prescription Management of the Older Adult: An Evidence-Based Approach, 2nd Edition Physical Therapist - 28 Hour Package - Best Value - Save $139.95 PT Assistant - 18 Hour Package - Best Value - Save $89.95
5
$60.00 PTTX05PD24
5
$60.00 PTTX05EP24
28
$196.00 PTTX2824 $126.00 PTATX1824
18
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 an approved provider by the Texas Physical Therapy Association (Provider #2411048TX). The assignment of Texas CCUs does not imply endorsement of specific course content, products, or clinical procedures by the TPTA or TBPTE. Unless otherwise indicated, all PT courses meet continuing competence requirements for license renewal in Texas. The Human Trafficking: Overview for Texas Healthcare Professionals course is approved through the Texas Health and Human Services Commission (HHSC). Are my hours reported to the Texas board? No. The board performs random audits at which time proof of continuing education must be provided. How do I complete the TX JAM? Individuals renewing their license will be required to take the Texas Jurisprudence Assessment Module (TX JAM). This will cover both the Jurisprudence Exam and the Ethics/Professional Responsibility requirement. To complete this requirement you will need to go to the board website www.ptot.texas.gov and follow the link for registration and access. 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. 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. 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.com/Physical-Therapy 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 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm, EST.
Licensing board contact information: Texas Board of Physical Therapy Examiners George H. W. Bush State Office Building I 1801 Congress Avenue I Suite 10-900 I Austin, TX 78701 Phone (512) 305-6900 I (512) 305-6970 I Website: https://www.ptot.texas.gov/
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PHYSICAL THERAPY CONTINUING EDUCATION
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PT HOURS PTA HOURS CODE TO ENTER
PTTX01HH
Human Trafficking: Overview for Texas Healthcare Professionals (Mandatory)
1
1
Alzheimer’s Disease and Other Dementias: Medical Overview and Rehabilitation Management, 2nd Edition
4
4
PTTX04AD24
Functional Assessment of the Older Adult, 2nd Edition
4
4
PTTX04FA24
Preventing Falls in Older Adults
5
5
PTTX05PF24
Supporting Aging in Place: A Physical Therapist’s Toolkit
4
4
PTTX04SA24
Examination and Management of the Client with Parkinson’s Disease, 2nd Edition Exercise Prescription Management of the Older Adult: An Evidence-Based Approach, 2nd Edition
5
PTTX05PD24
5
PTTX05EP24
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18
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PHYSICAL THERAPY CONTINUING EDUCATION
Chapter 1: Human Trafficking: Overview for Texas Healthcare Professionals (Mandatory) 1 CCU
By: Hanni Stoklosa, MD, MPH Learning objectives After completing this course, the learner will be able to: Describe human trafficking, including the types of trafficking and those populations most vulnerable to trafficking. Identify potential trafficked persons using clinical signs and screening tools. Course overview Human trafficking is a global public health and human rights issue (United Nations Office on Drugs and Crime [UNODC], 2018) involving the exploitation of 18.7 million people and yielding profits of $150 billion (USD) per year worldwide (International Labour Office [ILO], 2014). Although organizations from all sectors have emerged to fight against and prevent human trafficking, healthcare professionals are in a unique position to identify and care for trafficked persons. One study reported that 88% of trafficked persons interacted with a healthcare professional during their time being trafficked (Lederer & Wetzel, 2014). Despite a high frequency of contact with trafficked individuals, there is a documented lack of both education available to healthcare providers on the signs of human trafficking and protocols on caring for trafficked individuals (Ahn et al., 2013). Healthcare providers are on the front lines of recognizing signs of trafficking and advocating for their patients. However, when the healthcare provider does not have accurate knowledge of Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing
Describe components and implementation of trauma- informed care. Review appropriate national organizations and local resources when intervening in human trafficking cases.
how to recognize and care for patients who are being trafficked, those trafficked persons will return from medical encounters to their lives of coercion and manipulation. Intervening and advocating for trafficked persons become difficult when healthcare providers do not know the signs of trafficking, what steps to take in providing aid, and how to empower patients to leave their current abusive situation. This course for healthcare professionals is an introduction into the complex crime of human trafficking, with a focus on sex and labor trafficking and the common symptoms and conditions that occur in trafficked persons. Healthcare professionals who complete this course will be able to recognize the signs and symptoms of trafficked persons and identify the interventions needed to care for these individuals. Additionally, this course lists national resources that provide vital services to trafficked persons and makes recommendations for patient and staff safety when addressing these potentially volatile scenarios. implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
DEFINING HUMAN TRAFFICKING
What Is human trafficking? Human trafficking happens globally and occurs when an individual is recruited, transported, transferred, harbored, and/ or received by force, fraud, or coercion for the purpose of exploitation by a trafficker. The exploitation may take various forms, such as sex trafficking or labor trafficking. Human trafficking is often confused with smuggling. While trafficking What are the types of trafficking? Providing effective aid to trafficked individuals requires that healthcare providers recognize and understand the many types of trafficking that occur, including sex trafficking, labor trafficking, debt bondage, organ and egg trafficking, child soldiers (youth forced to serve in armed conflict), and trafficking for forced criminal activities (Interpol, n.d.).
involves exploitation for forced labor or sexual exploitation, smuggling is providing a service such as transportation or fraudulent documents, often to illegally gain entry to a foreign country (U.S. Immigration and Customs Enforcement, 2017). Ultimately, three distinct elements validate a case of trafficking: the act, the means, and the purpose (UNODC, 2014). In the United States, the Victims of Trafficking and Violence Protection Act of 2000 (TVPA) dichotomizes trafficking into sex trafficking and labor trafficking. Organ trafficking is less prevalent, referring to the illegal sale or exchange of a person’s organs. According to the TVPA, any commercial sex act is considered sex trafficking in those individuals younger than 18
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● Domestic work, including cooking, cleaning, other household work, and care giving. ● Restaurants and small businesses, including waitstaff, kitchen staff, bussers, or dishwashers. ● Traveling sales crews, and peddling and begging rings, including selling candy, magazine subscriptions, and other goods or soliciting money. ● Health and beauty services, including nail salons, hair salons, spas, or massage parlors. ● Escort services through agencies and online sex sites. ● Brothels, which can be home-based, lodge-based, or road (truck stop)-based. (National Human Trafficking Resource Center [NHTRC], 2015a; Polaris s, n.d.b) In some cases, the trafficked person may not understand that he or she is being trafficked according to the law (International Organization for Migration [IOM], 2009). With such varied experiences among trafficked individuals, it can be challenging for healthcare providers to recognize cases of trafficking. Having a clear comprehension of the definition of trafficking, as well as its scope, enables healthcare providers to more accurately identify and provide intervention for those being trafficked, including individuals who may be unaware of the full consequences of their current situation. ● American Indians and Alaska Natives. ● Migrant laborers. ● Foreign national domestic workers in diplomatic households. ● Employees of businesses in ethnic communities. ● Populations with limited English proficiency. ● Persons with disabilities. ● Rural populations. ● Lesbian, gay, bisexual, and transgender (LGBT) individuals. (U.S. Department of State, 2015) Certain factors, such as previous abuse or homelessness, make individuals more vulnerable to trafficking. Traffickers target marginalized persons, often those with a weaker social support system, as well as those who have limited financial support. Traffickers seek individuals with limited communication abilities, such as limited knowledge of the indigenous language, because this vulnerability makes it more difficult for trafficked persons to leave the trafficker or report the abuse. Living in rural areas increases vulnerability to human trafficking, because sparsely populated regions make the act of trafficking easier to hide.
years of age. For adults, sex trafficking occurs when there is an element of force, fraud, or coercion along with commercial sex acts, which differentiates it from consensual commercial sex. Labor trafficking encompasses those individuals actively manipulated into situations of labor exploitation through involuntary servitude or slavery. A person does not need to be transported physically from one location to another for the crime to fall within the trafficking definitions stated here (U.S. Department of State, 2000). There are various ways to exploit individuals within sex and labor trafficking. One form of exploitation is bonded labor, or debt bondage. In this type of trafficking, a trafficker uses financial indebtedness to prevent an individual’s freedom (U.S. Department of State, 2000). Coercion is another way trafficked persons are exploited and can include blackmailing, social marginalization, physical threat, and fear of being criminalized or deported. Sex and labor trafficking can occur in a variety of licit and illicit settings. Formal industries and ways in which sex and labor trafficking occurs in the United States include: ● Agriculture, including seasonal harvesting work or caring for animals. Who is trafficked? Although human trafficking is rampant, the data on numbers of victims are limited. No international database for the number of victims exists. Victims are often reluctant to report their plight for fear of retribution by the traffickers or of deportation. The Polaris Project, an organization working against human trafficking, coordinates the National Human Trafficking Resource Center (NHTRC) hotline [(1-888-373-7888, Text BeFree (233733)] and provides vital services to trafficked individuals. Since 2007, Polaris has collected data from the hotline to document where human trafficking is taking place in the United States (NHTRC, 2016). In 2019, 22,326 victims and survivors were identified (NHTRC, 2019). The 2015 Trafficking in Persons (TIP) Report identifies a list of populations that have increased vulnerabilities to trafficking in the United States. These groups may seem to have little in common, but they are all at a greater risk for trafficking. These populations include ● Children in the child welfare and juvenile justice systems.
● Runaway and homeless youth. ● Children working in agriculture.
RECOGNIZING HUMAN TRAFFICKING
Trafficking is often a cyclical process, with several stages and reiterations of a similar chain of events. Individuals who are trafficked may return to this cycle multiple times for a multitude of reasons. Understanding the process allows healthcare Elements of human trafficking Healthcare professionals can use the elements of human trafficking – the act, the means, and the purpose – to recognize human trafficking (UNODC, 2014). This knowledge enables healthcare professionals to identify scenarios in which screening for trafficking is appropriate and gives them a better understanding of what trafficked persons may have experienced. The act The act refers to the traffickers’ actions. These actions, which may include recruiting, transporting, transferring, and harboring, are common among traffickers who seek to profit from the lives of others. A complex dynamic exists between traffickers and those they are exploiting; the means and purpose that drive the acts provide a deeper perspective into the crime. The means The means used by traffickers are integral to the definition of this element of human trafficking. Use of threats or force, coercion,
professionals to better aid and recognize potential trafficked persons. Additionally, recognizing the means by which traffickers manipulate and use coercion is a first step toward prevention.
and fraud define human trafficking. A common misconception of trafficking is that it always involves physical force; that is, a weaker individual is physically forced to live with and provide services for the trafficker. However, not all traffickers use physical force to exert control. Instead, traffickers use a myriad of powerful coercive techniques, such as deception and legal threats, to groom and exploit others (UNODC, 2014). Traffickers may use deception to insert themselves into the lives of those they are controlling. False promises and offers evolve into a more sinister reality of abuse and exploitation. Threats of legal or social repercussions may control the individual; many traffickers prey upon the person’s fear of being deported or arrested. Conversely, traffickers may show intimacy and affection toward the person, who may have been deprived of both before and during trafficking (Zimmerman, Hossain, & Watts, 2011), and
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Factors such as proximity to international borders, larger immigrant populations, numerous ports and airports, and industries that attract forced labor increase trafficking. The NHTRC data from 2007 to 2012 show the highest reports of potential human trafficking cases arose from California, Texas, Florida, New York, Illinois, the District of Columbia, Virginia, Ohio, North Carolina, and Georgia (Polaris Project, n.d.a). Traffickers used these states as both entry and exit points for transporting individuals. Labor-trafficked individuals supply human resources and profits for industries such as agriculture, construction, domestic work, manufacturing, the hospitality sector, sales crews, shipyards, health and elder care, salon services, fairs and carnivals, and even peddling and begging (U.S. Department of State, 2015). Exploitation Travel and transit lead to the next stage of the human trafficking process: exploitation. Traffickers use various exploitation methods to control individuals (Baldwin et al., 2011; Zimmerman et al., 2011). Exploitation can range from sexual, psychological, or physical abuse to poor living conditions and captivity. Detention Traffickers commonly continue their exploitation of others until a greater force, such as law enforcement or possibly a natural disaster, stops them. Upon leaving the exploitation, the trafficked person becomes a survivor – an empowering term used to describe trafficked persons who have escaped trafficking, either temporarily or permanently. Survivors may or may not enter the next state of the human trafficking process: detention. Detention is the stage during which trafficking survivors are in custody or engaged in closely guarded collaboration with state authorities, such as law enforcement (Zimmerman et al., 2011). Not everyone who is trafficked is detained, however. For those who are, detention plays an integral part in shaping survivors’ experiences and influencing their outcomes (Zimmerman et al., 2011). A person might be held on charges of illegal immigration, prostitution, or other crimes and be unable to implicate his or her trafficker for fear of safety, because of the person’s legal status, or for fear of other negative outcomes. Some trafficking survivors are deported by authorities, returned to their original country only to be retrafficked by traffickers, repeating the trafficking cycle (Jobe, 2010). Detention may also include time spent in legal custody (e.g., prisons, deportation facilities) – a period of time when the person may be separated from the trafficker but not yet integrated back into society. When cooperating with authorities in prosecuting traffickers, survivors may risk retaliation and retraumatization as they recall harmful events that occurred during their trafficking. These stressors may contribute to existing health conditions from the trafficking, making (re)integration difficult and possibly influencing the survivor’s return to trafficking. Negative experiences with authorities may also limit trafficked individuals’ ability to report the crimes committed by their traffickers (Jobe, 2010). Integration/reintegration When a person is able to leave a trafficker’s exploitation (and is no longer detained or never detained), the integration/ reintegration stage of the human trafficking process begins. Integration and reintegration are similar terms that both reflect the long-term process of a person either entering fully into the cultural, civil, and political life in his or her new country or returning in those same domains to his or her country of origin (Zimmerman et al., 2011). The difference between integration and reintegration lies in the differences between trafficked persons who may wish to stay in their current location (integration) or return to their original home (reintegration). Unfortunately, it is likely that the trafficked person will return to
then use that perception of a close relationship to manipulate and exploit the person. The purpose The purpose of human trafficking is often to gain profit from others without their consent. Using complex and dehumanizing means, traffickers have generated one of the largest industries in the world (UNODC, 2014). Human trafficking is estimated to gross more than $150 billion (USD) worldwide (International Labour Office [ILO], 2014). The illegal practice is highly profitable for traffickers because services provided by trafficked persons, whether they involve sex or labor, may be exploited repeatedly. The ILO notes that profits per victimized person are highest within sex trafficking (ILO, 2014). This is because the demand for these services and the prices clients pay far outweigh the low operating costs and capital investments (ILO, 2014). The process of human trafficking The process of trafficking is often complex. A clinician can intervene at any point to disrupt the process. Note that the process can be cyclical, with one trafficked person experiencing retrafficking after periods of reintegration. Recruitment Recruitment ties into the vulnerabilities of the trafficked person. Traffickers look for traits they can exploit, such as a history of abuse, economic instability, and psychological conditions (e.g., depression, self-harm; Zimmerman et al., 2011). Traffickers may target a person who does not have a strong support group, knowing that such a person may find it difficult to withstand their coercion. Substance abuse and other forms of abuse can also predispose individuals to trafficking (Reid & Piquero, 2014). Traffickers may supply the person with an addictive substance as a means of gaining control. Research has indicated that substance abuse may be a tool for both recruitment and exploitation during trafficking (Reid & Piquero, 2014). Traffickers are often master manipulators, and they use a variety of methods during this stage. As the recruitment progresses and the coercion escalates, some individuals still may not recognize that they are being trafficked. Instead, they might believe they are in an intimate relationship with their trafficker (Zimmerman et al., 2011). Travel and transit The second stage of the human trafficking process is travel and transit. Movement is a common feature among trafficking cases, and although trafficking can occur without the physical transportation of people, often individuals are taken to a new city or state to evade detection (NHTRC, 2016; Zimmerman et al., 2011). Traffickers may create a pretext in which such travel seems innocuous, such as protecting the individual, but their actions can rapidly evolve into a pattern of coercion and open the door to further exploitation. Transporting a person usually presents numerous risks for both the person and the trafficker. During this stage of trafficking, traffickers may attempt to maximize their profits by pursuing unsafe transport methods, risking life-threatening journeys, and/ or forging documents to evade authorities (Zimmerman et al., 2011). Media reports occasionally highlight such tragedies, with lives lost to dehydration, drowning, and suffocation as people are transported across international borders (Fitzpatrick, 2010; Santa Cruz, 2010). When moving a person, the trafficker often initiates a pattern of manipulative events, particularly violence and confiscation of documentation (Zimmerman et al., 2011). Traffickers take passports, birth certificates, social security cards, and other legal documents under the guise of completing necessary documentation and paperwork, but they have no intention of returning these items. Instead, they use them as further leverage and control. For women and girls who are trafficked, manipulative events can be the initiation of sexual violence. With sexual violence, trafficked persons may begin to recognize the signs of manipulation.
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Previously trafficked persons may find themselves exiting and re-entering the trafficking system at various stages of the cycle (Zimmerman et al., 2011). This can occur for a number of reasons. In some cases, the trafficker may still be nearby and may track the survivor in his or her daily movements (Jobe, 2010). The trafficker may even employ past recruitment techniques (e.g., substance use, threats, violence, intimacy) to regain control of the person. In other cases, the survivor may simply return to the same conditions that made him or her vulnerable initially. For example, the person may have limited economic opportunities or may now have increased debt due to health issues acquired while being trafficked. and occasionally providing indulgences. Table 1 connects these methods to their purpose. Other tactics traffickers use to control others psychologically include threats, degradation, and enforcement of trivial demands.
many of the same factors that led to his or her initial trafficking, such as poverty and/or abuse (Zimmerman et al., 2011). Additionally, many new obstacles can prevent (re)integration; stigmas and the continuation of preceding factors make retrafficking prevalent among survivors. The integration/reintegration process is considered complete when the individual believes he or she has been accepted by the community and included in its economic, cultural, and political aspects (Zimmerman et al., 2011). Retrafficking Psychological methods used in human trafficking Traffickers use numerous psychological methods to manipulate individuals and maintain their compliance (Baldwin et al., 2014). Such methods of coercion include isolating the person, monopolizing perception, inducing debility and exhaustion, Table 1: Human Trafficking Health Risks and Consequences Health Risks
Potential Consequences
Physical abuse, deprivation. Threats, intimidation, abuse.
Physical health problems, including death, contusions, cuts, burns, broken bones. Mental health problems, including suicidal ideation and attempts, depression, anxiety, hostility, flashbacks, and re-experiencing of symptoms. Sexually transmitted infections (including HIV), pelvic inflammatory disease, infertility, vaginal fistula, unwanted pregnancy, unsafe abortion, and poor reproductive health.
Sexual abuse.
Substance misuse: drugs (legal and illegal), alcohol. Social restrictions and manipulation and emotional abuse. Economic exploitation: debt bondage, deceptive accounting. Legal insecurity: forced illegal activities, confiscation of documents. Occupational hazards: dangerous working conditions, poor training or equipment, exposure to chemicals, bacterial or physical dangers. Marginalization: structural and social barriers, including isolation, discrimination, linguistic and cultural barriers, difficult logistics.
Overdose, drug and alcohol addiction.
Psychological distress, inability to access care.
Insufficient food or liquid, climate control, poor hygiene, risk-taking to repay debts, insufficient funds to pay for care. Restriction from or hesitancy to access services, resulting in deterioration of health and exacerbation of conditions. Dehydration, physical injury, bacterial infections, heat or cold overexposure, cut or amputated limbs.
Unattended injuries or infections, debilitating conditions, psychosocial health problems.
Note . Adapted from Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, interven - tion and research. Social Science and Medicine , 73(2), 327-335. Isolation
trafficker’s demands. By enforcing strict demands while depriving the person of basic needs, such as food, water, and health care, traffickers ensure that the trafficked person is too weak to flee or fight (Baldwin et al., 2014). Common exhaustion methods include preventing the trafficked person(s) from sleeping and eating. Traffickers also dehumanize and degrade trafficked persons (Baldwin et al., 2014). This degradation is commonly evident in the lack of medical care trafficked persons receive. Health concerns further weaken the trafficked individual. Demonstrations of omnipresence Traffickers create a sense of always watching those they are trafficking. This often is achieved by involving other people in the trafficking operation or using other trafficked individuals as informants. Trafficked persons may be given cell phones as an indulgence, but these may contain tracking devices that alert the trafficker to the person’s movements and conversations (Baldwin et al., 2014). In other cases, traffickers may simply call those who are allowed to roam frequently as a means of monitoring their actions and movements.
People who are cut off from their social support networks or who have only weak support systems are less resistant to being exploited (Baldwin et al., 2014). Often, traffickers can achieve this type of isolation by transporting the person away from friends and family and cutting off communications and normal networks. (Zimmerman et al., 2011). Those who remain in their original residence may still experience extreme control in all of their social interactions. Monopolization of perception Traffickers typically limit the amount of information that trafficked individuals can access to ensure that the traffickers are the primary focus of attention; this allows the traffickers to mold the trafficked individuals’ thoughts based on their personal needs and wants (Baldwin et al., 2014). This manipulation, combined with restricted communications, makes it possible to control the person’s perspective, which enforces compliance and decreases resistance. Induced debility and exhaustion Trafficked persons are often pushed to the brink of their physical limits in an attempt to make them more malleable to the
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In healthcare settings, another person who poses as the patient’s friend or relative may accompany the trafficked person. The companion to the patient is sent to reinforce the trafficker’s omnipresence, serving as a minder. The minder (companion)
will insist on staying with the patient throughout the clinical encounter (Baldwin et al., 2014). The minder is actively a part of the trafficking system and may report to the trafficker or may even be the trafficker.
CLINICAL SIGNS AND SCREENING TOOLS
clinical symptoms and diagnoses as cues can lead to better identification of trafficked individuals. Clinicians can use social history and contextual cues when identifying trafficked persons. The healthcare professional needs to draw connections between the methods and patterns of trafficking and the health consequences (Table 1).
Individuals who are trafficked are exposed to various health risks, including occupational exposures and physical, sexual, psychological, and social trauma (IOM, 2009; Zimmerman et al., 2011). Health conditions such as mental health disorders, including depression and anxiety, and substance use disorders may persist even after successfully escaping trafficking (IOM, 2009). Potential trafficked patients may present with one telling symptom or multiple comorbidities. Recognizing these Signs and symptoms of trafficking Many maladies can be attributed to the effects of trafficking, and some are more common than others depending on the type of trafficking. Note that some of the signs of trafficking are not unique to trafficking. For example, there may be overlap in cases of intimate partner violence. Regardless, further screening is warranted to help identify patients who may be victims of trafficking or other violent crimes (IOM, 2009). Psychological Trafficked persons often experience posttraumatic stress disorder (PTSD), depression, suicidal ideation, drug addiction, and associated symptoms as a result of psychological violence (Dovydaitis, 2010). Lederer and Wetzel (2014) reported that 54.7% of 106 trafficked individuals reported experiencing PTSD during trafficking; 88.7%, depression; and 41.5%, attempted suicide. According to Lederer and Wetzel (2014), substance abuse was frequently used by trafficked individuals to mentally escape the trafficking and also was used by the trafficker to exert control. Many psychological symptoms that trafficking patients present with are a direct result of the manipulative measures their traffickers use, such as the Biderman’s framework (discussed in Table 1; Baldwin et al., 2014). One study found that restricted freedom is both a core factor of human trafficking and a large risk factor for poor mental health (Kiss et al., 2015). The authors reported that trafficked persons who were severely restricted in their activities were two times as likely to have symptoms of PTSD, anxiety, and depression compared with trafficked individuals with fewer restrictions. Psychological coercion methods affect the mental health of patients as well. Shame, guilt, poor self-esteem, and fear for family members (based on threats by traffickers) create complex psychological stress that affects trafficked individuals negatively and can feed into the cycle of victimization and traumatization (de Chesnay, 2013). It is important to note that a healthcare visit can derail efforts to help the victim if they perceive healthcare providers as judging them or if interactions trigger past traumas. Physical Signs of physical violence are common among trafficking patients, ranging from broken bones to missing hair to bruising. Physical and sexual violence are prevalent among trafficked women. Hossain et al. (2010) reported that 92.6% of trafficked women experienced sexual violence, and 77% experienced physical violence from being hit or kicked. Injuries may appear to be at multiple stages of healing or untreated, suggesting chronic trauma and perhaps a delay in seeking care. Because social isolation is prevalent in this population, trafficked persons may not have access to health care for injury treatment. Screening for trafficking Once there is a suspicion of human trafficking, obtaining information from the patient can be vital in terms of providing the best quality care and empowering the patient by providing the most appropriate resources. It can be challenging to find a balance between asking important questions of the patient
Pelvic inflammatory disease, STIs, ectopic pregnancies, and HIV/ AIDS are a few of the medical conditions seen in sex-trafficked individuals. Labor trafficking can leave a person with physical injuries related to occupational exposures, including accidents related to poor personal safety equipment, abuse from supervisors, or ailments resulting from inadequate living conditions (NHTRC, 2015b). Poor ventilation, sanitation, and nutrition, as well as airborne and bacterial contaminants, are health risks associated with labor exploitation (IOM, 2009). Working long hours with little rest can also contribute to work-related injuries. Other common physical health symptoms seen with labor and sex trafficking include headache, fatigue, dizziness, back pain, and memory problems (Kiss et al., 2015; Oram, et al., 2012). Branding (i.e., intentionally inflicting burns or cuts to create symbols) is a common way for traffickers to demonstrate ownership (IOM, 2009; Oram et al., 2012). Those who are being trafficked may have their trafficker’s name, a pseudonym, or a bar code tattooed or etched into their skin to signify the trafficker’s permanent ownership. Asking about a tattoo’s significance during a healthcare visit may elicit details about the patient’s social history. Social Contextual indicators are important to help the clinician identify potential trafficking. Clinicians should pay attention to who attends the patient’s appointments and how the patient behaves in the office or examination room. A minder posing as a partner or family member often will speak for the patient when questions are asked (Zimmerman et al., 2011). Separating the patient and minder may free the patient to disclose information during an interview. Even when alone with a healthcare professional, a trafficked person may be fearful or hesitant to answer questions. Separating the trafficked individual from their minder may be difficult. One strategy is that an X-ray may be ordered when the suspected perpetrator is present; the order can be cancelled when the patient gets to the X-ray room if it is not needed. During X-ray procedures, health care providers have an excellent opportunity to separate the victim from anyone accompanying them, allowing the victim to answer questions. In the case of foreign individuals who are being trafficked, English may be a second language, making it even more difficult to discover the trafficking through an interview. In these cases, clinicians should use a professional interpreter, not a family member or the minder.
and limiting the risk of retraumatization. The provider should avoid yes/no response questions, as they do not provide enough accurate information. Questions should be open ended an allow victims plenty of time to respond.
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Several screening tools are available and can be personalized to the patient and his or her situation. At present, none are validated for a healthcare-specific setting. However, the Vera Institute of Justice (2014) created the Trafficking Victim Identification Tool for legal settings, which can be modified for a clinical setting. Table 2 gives more examples of the screening questions. Privacy is key when discussing sensitive matters with a patient suspected of being trafficked. The presence of others may retraumatize the patient and influence his or her answers (IOM, 2009). Therefore, the healthcare provider should limit the number of people present during the interview and asking the questions, especially limiting the presence of any persons who accompanied the patient to the appointment. Youth who are experiencing trafficking may present with a wide variety of health complaints, making it important always to consider the possibility that trafficking may be occurring. Despite the lack of a presenting profile, clinicians should consider the following signs and symptoms to be red flags:
Table 2: Screening Tool for Human Trafficking • Did anyone where you worked [or did other activities] ever make you feel scared or unsafe? • Did anyone where you worked [or did other activities] ever hurt you or threaten to hurt you (including physical, sexual, or emotional harm)? If so, could you tell me what they did or said? • Were you allowed take breaks where you worked [or did other activities], for example, to eat, use the telephone, or use the bathroom? If yes, did you have to ask for permission? What did you think would happen if you took a break without getting permission? • Did anyone where you worked [or did other activities] ever trick or pressure you into doing anything you did not want to do? If you are comfortable talking about it, could you please give me some examples? • Did you ever have sex for things of value (for example, money, housing, food, gifts, or favors)? Were you pressured to do this? Were you under the age of 18 when this occurred? • Were you ever injured or did you ever get sick in a place where you worked [or did other activities]? Were you stopped from getting medical care? If you feel comfortable, could you tell me more about what happened? • Have you ever felt you could not leave the place where you worked [or did other activities]? Could you tell me why you couldn’t leave? Note . Adapted from Vera Institute of Justice. (2014). Screening for human trafficking: Guidelines for administering the Trafficking Victim Identification Tool (TVIT) . New York, NY: Vera Institute of Justice.
● Unexplained injuries. ● Injuries due to assault. ● Delays in accessing health care.
● A suicide attempt. ● Signs of self-harm.
● Acute sexual assault. ● Signs of sexual abuse. ● Recurring STIs. ● Pregnancy/abortion issues or need for reproductive health care at a young age. ● Substance use, misuse, or dependency. ● Tattoos or brands. (Bohnert et al., 2017; Greenbaum, 2014; Lederer & Wetzel, 2014)
TRAUMA-INFORMED CARE
Trauma-informed care encompasses more than just trafficked individuals and is not limited to those who have diagnoses that are typically associated with trauma, such as PTSD. The healthcare professional must keep trauma-informed care in mind when deciding on appropriate interventions for a trafficking patient. Trauma-informed care is imperative for providing the best treatment of patients who have been trafficked and those who have other violence-related health concerns. Human Development, trauma-informed care is changing the fundamental question from “What is wrong with you?” to “What happened to you?” (National Technical Assistance Center for Children’s Mental Health & JBS International, n.d.b.). SAMHSA (2014) dissects trauma into the three E’s: event, experience of the event, and effect. Identifying these elements of trauma helps deepen the healthcare provider’s understanding of how trauma differs among individuals (see Table 3).
The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) defines individual trauma as follows: An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (p. 7) What is trauma-informed care? Trauma-informed care is a broad approach to treating all patients, many of whom have experienced trauma and its physical, emotional, and social repercussions. It is a lens to view all people encountered in the healthcare setting, because any individual may have experienced a trauma that is affecting his or her actions and decisions (National Technical Assistance Center for Children’s Mental Health, n.d.a.). As stated by the team at Georgetown University Center for Child and Table 3: Human Trafficking Health Risks and Consequences Definition
Example
Event
Either single or recurring circumstances of actual or extreme threat of physical or psychological harm or neglect. The individual’s perceptions of the event(s); how he or she labels, assigns meaning to, and is affected physically and psychologically. The results and repercussions of the events, most frequently described as adverse effects, which negatively affect the individual who experienced the traumatic event.
Witnessing violence against others, being sexually violated, verbal abuse and/or threats, etc. Two siblings living in a toxic and abusive environment, one may view the experience as negative, and the other may not. Decreased ability to cope with normal stresses, developing a stress disorder such as posttraumatic stress disorder, etc.
Experience
Effect
Note . Adapted from Substance Abuse and Mental Health Services Administration. SAMHSA’s concept of trauma and guidance for a trauma- informed approach . (HHS Publication No. [SMA] 14-4884). Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
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