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TEXAS Massage Therapy Education
Elite Learning
INCLUDES HUMAN TRAFFICKING COURSE: Recognizing and Responding to Human Trafficking in Texas, 2nd Edition
13-hour Continuing Education Package $60.00 ELITELEARNING.COM/BOOK Complete this book online with book code: MTX1325
WHAT’S INSIDE
THIS COURSE FULFILLS THE HUMAN TRAFFICKING PREVENTION TRAINING REQUIREMENT Chapter 1: Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) [1 CE Hour] This course focuses on an overview of human trafficking; how human trafficking occurs; ways to identify those who may be trafficked, including the health and mental health impact; response and safety protocols; and victim resources. It meets the one-hour Texas requirement for healthcare professionals. Chapter 2: Ethics for Therapeutic Massage and Bodywork 10 [4 CE Hours] 1 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. Chapter 3: Introduction to Pharmacology for Massage Therapists 60 [4 CE Hours] This course is intended for all manual therapists that use massage as part of their practice. It gives a general outline to the contraindications, precautions, and considerations connecting medications and massage therapy. The course informs the therapist with pertinent information about pharmaceuticals that can interact with their treatment in an easy understand layout. Chapter 4: Pharmacology for Therapists: Common Gastrointestinal and Pain Conditions 80 [4 CE Hours] This course will review the interactions between therapeutic massage and certain medications, taking a closer look at common gastrointestinal (GI) and pain pathologies and the medications used to treat them. This course will help manual therapists develop a safe and effective treatment plan by identifying which medications are used to treat these common pathologies. Having a broader understanding of common symptoms and side effects of these medications will help therapists provide a more informed and effective treatment session. The goal of this course is to give therapists the confidence and knowledge particularly surrounding common GI and pain medications. Final Examination Answer Sheet 100
©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. i MASSAGE THERAPY CONTINUING EDUCATION Book Code: MTX1325
What are the requirements for license renewal? License Expires CE Hours Required Frequently Asked Questions
Mandatory Subjects
In addition to your 12 CE hours, you must also take a Texas Health and Human Services approved course on Human Trafficking. This Human Trafficking course does not count toward the 12 required CE hours, which is INCLUDED IN THIS BOOK.
12 + a Human Trafficking training course (All hours are allowed through home-study).
Licenses expire biennially on the day of issuance.
How much will it cost? If you are only completing individual courses in this book, use the code that corresponds to the course when completing online. COURSE TITLE HOURS PRICE COURSE CODE
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory)
Chapter 1:
1
$11.95 MTX01RH
Chapter 2: Ethics for Therapeutic Massage and Bodywork
4
$40.00 MTX04TM
Chapter 3: Introduction to Pharmacology for Massage Therapists
4
$40.00 MTX04PA
Pharmacology for Therapists: Common Gastrointestinal and Pain Conditions
Chapter 4:
4
$40.00 MTX04GP
Best Value - Save $71.95 - All 13 Hours
13
$60.00 MTX1325
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 an Texas board-approved provider? Colibri Healthcare, LLC is approved by the National Certification Board for Therapeutic Massage and Bodywork (Provider #450215-06) and the Texas Board of Massage Therapy (Provider #CE1988). The Recognizing and Responding to Human Trafficking in Texas, 2nd Edition course is approved by the 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-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 1-866-344-0973, Monday - Friday 9:00 am -
6:00 pm and Saturday 10:00 am - 4:00 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, TX 78711
Phone: (512) 463-6599 Fax: (512) 463-9468 Website: https://www.tdlr.texas.gov/mas/masce.htm
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Book Code: MTX1325
MASSAGE THERAPY CONTINUING EDUCATION
How To Complete This Book For Credit
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• Go to EliteLearning.com/Book and enter code MTX1325 in the book code box, then click GO . • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your exam and finalize your purchase. Upon completion, you’ll receive access to your completion certificate. ONLINE FASTEST AND EASIEST!
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ALL 13 HOURS IN THIS CORRESPONDENCE BOOK 13 $60.00 MTX1325 If you are only completing individual courses in this book, enter the code that corresponds to the course below when completing online. Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) 1 $11.95 MTX01RH Ethics for Therapeutic Massage and Bodywork 4 $40.00 MTX04TM Introduction to Pharmacology for Massage Therapists 4 $40.00 MTX04PA Pharmacology for Therapists: Common Gastrointestinal and Pain Conditions 4 $40.00 MTX04GP
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MASSAGE THERAPY CONTINUING EDUCATION
Book Code: MTX1325
Chapter 1: Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) 1 CE Hour
By: Laura Palombi, PharmD, MPH, MAT Learning outcomes
Discuss the importance of safety planning and protocols. Identify ways to respond and follow up when encountering a potential trafficking victim, including resources for reporting suspected victims of human trafficking.
After completing this course, the learner will be able to: Understand definitions that relate to human trafficking. Describe the types of human trafficking and dynamics of human trafficking in the U.S. Describe identification and assessment strategies that can be utilized when working with potential trafficking victims. Course overview This course focuses on an overview of human trafficking; how human trafficking occurs; ways to identify those who may be trafficked, including the health and mental health 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 Implicit bias in healthcare Implicit bias significantly affects how healthcare
impact; response and safety protocols; and victim resources. It meets the one-hour Texas requirement for healthcare professionals.
outcomes. Addressing 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.
INTRODUCTION
because of this, it is impossible to estimate the actual number of human trafficking victims. Other inherent systemic difficulties—such as lack of coordinated data and inconsistent definitions of key terms—add further challenges to accurately estimating the number of trafficked people regionally as well as globally (Sprang et al., 2022). Because of this, healthcare providers and organizations involved with trafficked persons have been called to “increase their capacity to identify and refer people in trafficking situations and provide sensitive and safe services to people post- trafficking” (World Health Organization [WHO], 2012). Healthcare professionals are uniquely positioned to identify and intervene on behalf of trafficking victims, as outside of law enforcement, healthcare settings are among the few places where the lives of human trafficking victims may intersect with the rest of society, if only for brief periods (Trossman, 2008). Despite numerous multidisciplinary and multiagency efforts to reduce human trafficking in the U.S., this public health crisis persists. In 2021, the National Human Trafficking Hotline (NHTH) received a total of 51,073 substantive signals (phone calls, SMS, webchats, online tip reports, or emails) regarding instances of human trafficking, which resulted in 10,360 confirmed unique cases of human trafficking (NHTH Data Report, 2023). Because of this, healthcare providers across the U.S. must become well- versed in identifying individuals who may be in a trafficking situation and supporting them to safety.
Human trafficking is an extreme and heinous violation of human rights that persists around the globe, including throughout the U.S., despite extensive efforts to eradicate this atrocious crime. Human trafficking is a crime involving the exploitation of victims for the purpose of compelled labor or commercial sex acts through the use of force, fraud, or coercion. Force in the context of human trafficking includes physical restraint, physical harm, sexual assault, and/or beatings, and may also include monitoring and confinement to control victims (National Human Trafficking Hotline, 2023). Fraud includes false promises of employment, living conditions, love, marriage, or a better life, and may also include withholding promised wages, or contract fraud (National Human Trafficking Hotline, 2023). Coercion may include threats of harm to self or others, debt bondage, psychological manipulation, or document confiscation, as well as fear-inducing threats to share information or pictures with others or report to authorities (National Human Trafficking Hotline). The most vulnerable victims are typically women and children; however, victims of human trafficking can be any age and any gender. Although multiple organizations publish data and statistics concerning human trafficking, at present there is no consensus on the total number of human trafficking victims in the U.S. Many victims of human trafficking never disclose the nature of their situation, and
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Important terms: 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 refers to an individual who suffered harm because of criminal conduct (Department of Justice [DOJ], 2014). Much of the current body of literature uses this term to denote a patient/individual who is actively being trafficked (Combs & Arnold, 2021). 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 (Texas Attorney General, 2024). The goals of the Task Force are to serve as a collaborative and multidisciplinary body that strives to coordinate anti– human trafficking efforts at the local, state, and federal levels (Texas Attorney General, 2024). It serves as a communication hub that brings together coalitions from across the state to provide direction, consistent messaging, and sharing of best practices (Texas Attorney General, 2024). A report released by the National Human Trafficking Hotline for the state of Texas indicated the organization received a total of 3,534 substantive signals that originated from a Texas location, which was the second highest signal volume among all 50 states and Washington, D.C. (NHTH Data Report–Texas, 2023). Each request submitted to the Hotline is evaluated for potential human trafficking. Of the 3,534 signals received, 917 were determined to be unique instances of human trafficking (NHTH Data Report–Texas, 2023). Over 70 percent of the incidents were determined to be sexual in nature and included venues such as illicit massage/spa businesses, hotel/motel-based or residential- based commercial sex, pornography, escort/delivery services strip club– and bar-based, truck stop-based, and online or unknown venues (NHTH Data Report–Texas, 2023). Fourteen percent of incidents were labor related and included incidents such as domestic work, construction,
Survivor is a term used by many in the health services field to recognize the strength it takes to continue a journey toward healing in the aftermath of a traumatic experience. This term is also used to refer to a patient/individual who has been rescued and is no longer being trafficked (Combs & Arnold, 2021).
agriculture, restaurant/food services, health and beauty services, illicit activity, and retail/other small businesses. Six percent of incidents were both sex and labor related, and in 8% of incidents, the type trafficking was not specified (NHTH Data Report– Texas, 2023). This same 2023 report indicated 67% of victims were adults and 26% were minors; 83% of victims identified as female, 15% identified as male, and 1% identified as another gender; and 7% of victims were U.S. citizens/legal permanent residents and 17% were foreign nationals (NHTH Data Report–Texas, 2023). 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 (Texas Human Trafficking Prevention Task Force, 2020). Barriers to acquiring accurate data include victims avoiding the criminal justice system due to fears of reprisal, deportation, or incarceration; the failure of healthcare 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., nonprofits, 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 any given time (Alpert et al., 2014).
WHAT IS HUMAN TRAFFICKING?
Human trafficking became a federal crime when the Trafficking Victims Protection Act (TVPA) was enacted in 2000; it was the first comprehensive federal law to address human trafficking and offered protections through immigration relief for foreign national victims of human trafficking while also focusing on prevention through public awareness programs (Federal Bureau of Investigations, 2024). The TVPA was later revised and updated in 2015, and reauthorized in 2017 (DOJ, 2023). The goals of the TVPA are to prevent severe forms of human trafficking, both in the U.S. and overseas; to protect victims and help them rebuild their lives in the U.S.; and to prosecute traffickers and impose federal penalties. The Texas legislature created the Texas Human Trafficking Prevention Task Force in 2009 (House Bill 4009) to respond to the growing human trafficking crisis; the Texas attorney general was designated as the presiding officer (Texas Attorney General, 2024). The Texas Human Trafficking Prevention Task Force consists of more than fifty member organizations, including non- governmental organizations, state agencies, local law enforcement agencies, and district attorney’s offices (Texas Attorney General, 2024). The Task Force has expanded a network of local and regional educational efforts that strive to educate the public to recognize human trafficking, identify victims and directing them to services, and ensure traffickers are investigated and prosecuted effectively (Texas Attorney General, 2024).
Human trafficking is “the recruitment, harboring, transporting, provisioning, obtaining, patronizing, or soliciting of a person for the purpose of involuntary servitude, peonage, debt bondage, slavery, or sexual exploitation, induced by force, fraud, or coercion, or in which the person induced to perform a commercial sex act is under 18 years of age” (Texas Health and Human Services, 2024). Many victims are lured with false promises of well- paying jobs or manipulated by people they trust (DOJ, 2014). 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 (U.S. Immigration and Customs Enforcement [ICE], 2017. While transportation is often a component of human trafficking, victims of human trafficking are still held against their will while being transported, and transportation does not need to be across state or international borders to meet the criteria for trafficking. Human trafficking commonly involves three components: An act (referring to the role the trafficker is playing by exploiting the victim), means (use of force, fraud, or coercion to exploit the victim), and a purpose (referring to the type of labor the victim is exploited for (Stoklosa & Beals, 2022).
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Types of human trafficking Human trafficking includes multiple forms of exploitation such as sex, labor, and organ trafficking (note that organ trafficking will not be specifically addressed in this course). Victims may be forced, coerced, or defrauded 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 (DOJ, 2014). Inaccurate and misleading information propagated through social media and various Internet news sites has sensationalized the domestic minor sex trafficking domain of human trafficking while minimizing and simplifying other domains of human trafficking. This creates a dangerous situation that detracts vital energy and resources from efforts that seek to combat other forms of exploitation and may ultimately lead to a rise in different forms of human trafficking (Prakash et al., 2022). Often the difference between sex trafficking and consensual commercial sex (sex work) is misinterpreted or Vulnerability factors Although individuals of any age and any gender may fall victim to human trafficking, it is known that women and girls are the most vulnerable (Inter-Agency Coordination Group against Trafficking in Persons, 2017). Current data for the state of Texas indicates that in 2020 and 2021, 85% of victims in human trafficking–related cases were female compared to 8% males and 7% unknown (Texas Human Trafficking Prevention Task Force, 2022). The same report indicates that African American was the most vulnerable race/ethnicity with 38.1% of victims, followed by Caucasian (32.3%), Hispanic (18.7%), and Asian/Pacific Islander (2.2%); in 8.4% of cases, the victim’s race/ethnicity was recorded as unknown (Texas Human Trafficking Prevention Task Force, 2022). Vulnerability factors are often regarded as either “push” or “pull” factors (Stoklosa & Beals, 2022). Push factors are circumstances that drive victims from their current living situation into trafficking, for example, abuse, poverty, or family conflict. Pull factors lure a victim into trafficking by providing access to a desired resource such as income, Victim–Trafficker dynamics Research and firsthand accounts from victims of trafficking indicate that traffickers may use a number of tactics designed to isolate, control, and intimidate/threaten victims such as: ● Physical/sexual/emotional violence. ● Threats or intimidation of victims and/or victims’ family members. ● Withholding basic necessities (food, water, clothing, shelter). ● Social isolation or limiting contact with family members, friends, and outsiders; making sure any contact is monitored. ● Economic coercion (weaponized/predatory debt through enormous financial obligations, controlling or withholding victim’s money). ● Confiscation or control of passports/identification documents.
misrepresented. Sex trafficking occurs 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 participants' human rights (Baldwin et al., 2011). Note that children cannot technically be sex workers because they cannot legally consent to commercial sex. In instances of sex trafficking, victims perform commercial sex through the use of coercion, force, or fraud. It more commonly affects women but frequently involves children of both sexes (Inter- Agency Coordination Group against Trafficking in Persons 2017). Victims of forced labor trafficking are often found in industries that require a large number of workers yet have little regulation or oversight, including agriculture, restaurants/food services, bars/clubs, domestic work, factories, and the hospitality industry (hotels/motels). Forced labor affects both adults and minors (under the age of 18), and migrant populations are considered to be the most vulnerable to this form of trafficking. housing, or recreational substances (Stoklosa & Beals, 2022). Much of the current body of research and literature indicates that vulnerability factors for human trafficking include: ● Children in the welfare/juvenile justice systems (especially children ages 12–14 years). ● Unhoused youth. ● Migrant laborers/foreign national domestic workers. ● Patient with limited English abilities. ● Patients with disabilities. ● Patients with limited education. ● Patients using substances/suffering from substance use disorders. ● Individuals of color. ● Indigenous individuals. ● Individuals with a history of abuse (physical, emotional, sexual). ● Individuals who have experienced the death of a parent, guardian, or caretaker that has triggered family instability. ● False claims of imprisonment or deportation if victims contact authorities/law enforcement. Self-Assessment Question 1 Which of the following is not an example of human trafficking (either labor or sex trafficking)? a. Migrant/undocumented workers coerced into working as farmhands after being transported into the U.S. b. A consenting adult (>18 years of age) engaging in sexual acts in exchange for money. c. Massage therapists at an unregistered massage parlor compelled to engage in sexual acts under threat of legal action being taken against them if they refuse. d. Hospitality/housekeeping service workers made to work for little to no pay due to threats made against members of their family.
THE HEALTH IMPACT OF HUMAN TRAFFICKING
The impact of human trafficking on its victims’ quality of life is devastating (Stoklosa et al., 2022; Richie-Zavalet et al., 2021). Victims frequently suffer physical abuse that
results in traumatic injuries and chronic pain; suffer sexual abuse that increases their risk/occurrences of sexually transmitted infections (STIs), pregnancies, and abortion-
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While not all victims of trafficking have physical indicators that aid identification, many victims suffer serious health issues, which may include (National Human Trafficking Resource Center, 2016): ● Addiction to drugs and/or alcohol to cope with or “escape” their situation, or as a method of control used by their traffickers. ● Symptoms of PTSD, 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, that are spread in overcrowded, unsanitary environments with limited ventilation. ● Reproductive health problems, including sexually transmitted infections, urinary tract infections, pelvic pain, and injuries from sexual assault or forced abortions. and to offer additional resources when appropriate. It is not the responsibility of healthcare providers to elicit/coerce a disclosure of human trafficking or to investigate/confirm human trafficking. The responsibility of healthcare providers is to provide patient-centered care; to empower victims to seek additional support when appropriate; and above all, to respect the autonomy of the patient. and who largely speaks for Rebecca, answering questions while she remains sitting quietly on the examination table. Rebecca appears nervous and avoids making eye contact with you and other staff members. She has superficial abrasions and bruises around her eyes and mouth as well as on both upper extremities. Take a moment to consider any potential red flags that you, as the healthcare provider caring for Rebecca, notice that would indicate Rebecca is a victim of human trafficking.
related complications; and suffer emotional abuse that may manifest as a variety of psychiatric or mental health illnesses such as posttraumatic stress disorder (PTSD), suicidal ideation, and substance use disorders. This physical, sexual, and emotional abuse also increases an individual’s risk of overdose due to substance use and/or death (Stocklosa et al., 2022). Victims also are frequently subjected to poor living conditions that expose them to malnutrition, dehydration, and other injuries (Stocklosa et al., 2022). Trafficking may be viewed as a process that moves through a series of stages (e.g., recruitment, travel/transit, exploitation, integration, and retrafficking or reintegration) that victims pass through. This view emphasizes the cumulative effect of all health risks across all stages of the trafficking process (Klabbers et al., 2023). Exploitation occurs, while not all trafficked persons are harmed, throughout all stages of the trafficking process, and conceptualizing trafficking as a process highlights the different time points at which different interventions could be more effective (Klabbers et al., 2023). Victims of human trafficking may lose most or all of their autonomy and independence (Stocklosa et al., 2022). The role of healthcare providers As previously mentioned, healthcare providers have a unique position and ability to identify, assess, and respond on behalf of trafficking victims. The primary focus of any interaction with a potential or known victim of human trafficking should be to address the chief complaint (acute illness or injury), establish healthcare facilities and providers as allies and safeguards from trauma and/or exploitation, Case study 1 A young woman named Rebecca presents to a local urgent care requesting evaluation for genital sores and vaginal discharge. You notice on her intake information that she does not have insurance listed and indicates she is paying cash for this visit. Further review of her medical records shows that she does not have a permanent address listed and that she has presented on multiple occasions to this urgent care—in addition to other clinics/healthcare facilities—with similar symptoms. She is accompanied by a man named Derek, whom she claims to be her cousin,
IDENTIFICATION AND ASSESSMENT
Identification Many victims of human trafficking are not willing to disclose the nature of their situation due to trauma and fear stemming from oppressive conditions and lived experiences. However, many victims and traffickers exhibit signs that can be identified. Potential red flags indicating a patient is a victim of human trafficking may be exhibited by both the patient and the patient’s guest/companion. Some potential patient-specific red flags include repeated physical injuries and signs of physical abuse/neglect, sexual health concerns with repetitive STI screenings or reproductive care, body language, and delayed care (Richie- Zavalet et al., 2021; Stocklosa et al., 2022; Tiller & Reynolds, 2020): ● A victim’s body language may convey that they are fearful, hypervigilant, and anxious. Victims may avoid eye contact with providers, may appear disoriented, may be unable to recall or report basic information such as their address, and may even be unable to produce identification documents.
● Victims may present with frequent and repeated injuries or other signs of physical abuse and may be vague/ inconsistent in their description of the injuries. Common physical injuries include broken bones (jaws, legs, arms, ribs, eye sockets, etc.), significant bruising from being hit/punched/thrown, and work-related injuries resulting from unsafe occupational conditions. ● Victims may also present with obvious mental health concerns such as generalized anxiety, major depression, dissociation, and deliberate self-injury/suicidal ideation. A study by Zimmerman et al. (2006) found that survivors of human trafficking reported the following symptoms of anxiety and depression: Nervousness or shakiness inside (91%), terror/panic spells (61%), fearfulness (85%), feeling depressed or very sad (95%), and hopelessness about the future (76%). ● Victims may display obvious sexual health concerns such as risky sexual behavior (having multiple partners), repetitive and frequent STI screenings, frequent visits for reproductive healthcare and/or abortions, and signs of sexual trauma.
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● Other potentially obvious red flags include a delay between injury/illness onset and seeking care or concerning prescription filling patterns. By taking a more nuanced history about the presenting complaint, along with a brief social history assessing home and work environments, providers may be able to discern a potential trafficking situation. Carefully reviewing medical records is essential and an effective way to supplement or clarify a patient-reported history when it is vague, misleading, or untrue. A study of sex- trafficking survivors from two major U.S. cities revealed that most participants who took part in the study reported visiting the same healthcare clinic on several different occasions for various injuries (Richie-Zavaleta et al., 2021). The authors use this to highlight the importance Assessment General considerations during physical exams are related to looking for signs of malnutrition, dehydration, and/or physical exhaustion (Stocklosa et al., 2022; Tiller & Reynolds, 2020). Signs may also be visible on the skin. Look for signs of burns, bite marks, ligature wounds, bruising, traumatic alopecia, and tattoos that are sexually explicit or suggestive of ownership (Richie-Zavalet et al., 2021; Stocklosa et al., 2022; Tiller & Reynolds, 2020). When possible, always speak to the patient alone and use an independent, trained interpreter if required. If trafficking is suspected, anyone with the patient could be a potential trafficker. Additional patient situations, behaviors, or emotional states may suggest human trafficking (National Human Trafficking Resource Center, 2016): ● Paying cash or having no health insurance. ● Lacking control of identification documents (e.g., state- issued ID or passport). ● Having few or no personal possessions. ● Due to large debt, being reticent when asked to consent for additional testing or services. ● Inability to: Response and follow-up Victims of trafficking do not often disclose their trafficking situation in clinical settings (Alpert et al., 2014). Research indicates that up to 88% of victims interact with healthcare providers while they are in a trafficking situation (Smith, 2022. Many healthcare systems and facilities do not have policies in place that standardize screening and response protocols. One study found that only 39% of healthcare centers, departments, hospitals, and clinical settings such as dental and OBGYN offices in Michigan and Texas had screening policies in place, and only 62.5% had response protocols in place (Munro-Kramer et al., 2022). Healthcare providers must be thoughtful and careful about engaging with 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. Recognize that the goal of your interaction is not disclosure or rescue, but rather to create a safe, nonjudgmental place that will help you identify trafficking indicators and assist the patient (National Human Trafficking Resource Center, 2016). A trauma-informed approach is crucial in rendering aid to individuals who may have experienced trauma, and includes an understanding of trauma and an awareness of the impact it can have across settings, services and populations (SAMHSA, 2020). A trauma- informed approach involves viewing trauma through an ecological and cultural lens, recognizing that context plays an important role in
of reviewing patients’ medical records when identifying patients who may be victims of human trafficking. Additional red flags may be seen in a victim’s companion/ guest and include behaviors such as refusal to leave when trying to conduct one-on-one patient interviews, insistence on speaking/translating for the patient, controlling/ interrupting the flow of care, having the patient’s documents in their possession, and an employer demanding access to medical information. Traffickers may employ strategies such as pretending to be the victim’s partner, family member, or close friend. Another potentially obvious red flag is a trafficker accompanying multiple victims to the same healthcare facility. Some traffickers may visit a certain healthcare facility so frequently that they try to build rapport with providers in order to deceive these of their “goodness.” ○ Leave home or place of work. ○ Speak for oneself or share one’s own information. ● Feeling helplessness, shame, guilt, self-blame, and humiliation. ● Experiencing a loss of sense of time or space; not knowing where they are or what city or state they are in. ● Feeling emotional numbness, detachment, disassociation. Self-Assessment Question 2 All of the following are potential indicators that a patient is a victim of human trafficking except: a. Presenting with frequent and repeated injuries. b. Being accompanied by an individual who frequently accompanies other individuals for similar acute illness/ injuries. c. Presenting for reproductive care with a history of several STI screenings and multiple terminated pregnancies. d. None of the above. how individuals perceive and process traumatic events (SAMHSA, 2020). The three key elements of a trauma- informed approach include: realizing the prevalence of trauma, recognizing how trauma affects all individuals within the health care system, and responding by putting this knowledge into practice (SAMHSA, 2020). Trauma-informed care is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p.82). Trauma-informed care is crucial when working with victims of human trafficking as it also involves vigilance in anticipating and avoiding processes and practices that could re-traumatize individuals (SAMHSA, 2020). Trauma-informed care can potentially provide a greater sense of safety for individuals who have a history of trauma as well as a space for preventing more serious consequences of traumatic stress (Fallot & Harris, 2002). While many individuals “may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms (SAMHSA, 2020, p.8).
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Book Code: MTX1325
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and using only medically relevant information with necessary supporting details is vital to providing adequate care for victims (Stoklosa & Beals, 2022; Tiller et al., 2020). It is important to state information objectively, avoid subjective phrasing or terms, and be thorough when describing relevant findings on physical exams (potential findings pointing to abuse, complete skin exams, other pertinent details; Stoklosa & Beals, 2022). Lastly, it is important to remember that medical records may serve both medical and legal purposes if the victim seeks legal justice after making a disclosure. ● Provide resources and information for victims. Once a victim of trafficking has been identified and a conversation has been started, providers may be appropriately positioned to guide the trafficked person to safety. If the provider is appropriately trained and educated on the considerations regarding helping victims find safety, they may be able to assist with developing a plan to connect the victim with local supportive services to provide safety, housing, and other basic necessities. Providers may also offer assistance in other ways such as offering to contact the National Human Trafficking Hotline on behalf of the victim or connecting the victim with a social worker or case manager. Providers may submit tips about potential trafficking cases to the hotline online at https:// humantraffickinghotline.org/, send an email to help@ humantraffickinghotline.org, or call 1-888-373-7888. ● Utilize professional interpreters . When working with individuals who have limited English proficiency and/ or prefer communicating in a different language, it is critical to have trained and qualified interpreters on hand to help you communicate (National Human Trafficking Training and Technical Assistance Center, 2022). In the case for a potential trafficking situation, it is important not to use others accompanying the individual, family members or anyone who has a relationship with the individual as interpreters (National Human Trafficking Training and Technical Assistance Center, 2022). When selecting an interpreter, neutral and trained professionals from accredited agencies should be used, preferably in person; additionally, interpreters should be screened for conflicts of interest (National Human Trafficking Training and Technical Assistance Center, 2022). If possible, the potential trafficking victim should be asked for their preferences for an interpreter (e.g., gender or age of interpreter), and should told that they can refuse a particular interpreter if they are not comfortable speaking in front of them (National Human Trafficking Training and Technical Assistance Center, 2022). Once an interpreter has been selected, a pre-interview meeting should be held in which the interpreter is informed about the risk of hearing traumatic details about the potential victims’ life, is asked to apply a trauma- informed approach, use person- centered language, maintain neutral body language and facial expressions, and translate verbatim all questions and answers (National Human Trafficking Training and Technical Assistance Center, 2022). ● Be aware of mandatory state reporting laws . In Texas, healthcare providers who are concerned that their patient has been trafficked should provide medical care to the patient while also following mandatory state reporting laws and institutional policies regarding abuse to a child, elderly person, or person with a disability, or reporting that a child is unaccompanied by an adult (Texas Health and Human Services, 2024). A professional who becomes aware of child abuse must report it within 48 hours. This reporting duty cannot be delegated and must be made non-anonymously. Health care providers
Beyond utilizing a trauma-informed approach, some additional considerations when interacting with and caring for victims are: ● Don’t ignore potential warning signs . Although victims do not often make explicit disclosures about their trafficking situations, many will share some indications that partially speak to their trauma. Victims may casually or jokingly reveal information that suggests their situation, such as the number of sex partners—if they are victims of sex trafficking—to provide context about their current medical situation (Richie- Zavalet et al., 2021; Stocklosa et al., 2022). If a provider notices potential signs of human trafficking, they should take time to review the patient’s/victim’s medical record to determine if that individual’s acute health concerns fit a pattern consistent with previous encounters (Richie-Zavaleta et al., 2021). ● Ensure the victim feels safe and comfortable . The primary goals when interacting with a potential victim are to provide quality care, empowerment, and a safe space—not to force the patient to make a disclosure if they do not wish or are not ready to (Geller et al., 2023). Providing a secure and supportive care setting creates an environment that fosters positive relationships between victims and providers and may encourage the victim to be more willing to disclose information about their situation. In order to increase the chances of establishing a positive report and fostering trust between the victim and provider, it is imperative to allow the victim to decide if they would be more comfortable speaking with a male or female provider. Additionally, provide privacy to discuss sensitive topics; utilize interpreter services if necessary; explain the need for a private exam; and explain patient confidentiality policies, including mandatory reporting laws (Richie-Zavalet et al., 2021; Stocklosa et al., 2022). ● Ask questions respectfully . Asking questions and gathering information from the victim must be done carefully and respectfully so as to not appear judgmental or dismissive of the victim’s situation, as this could irrevocably damage any established rapport and trust the victim has with individual providers or even providers in general (Palombi et al., 2019; Richie-Zavalet et al., 2021; Stocklosa et al., 2022). Examples of appropriate assessment questions are: ○ Do you feel safe at the moment? ▪ Where do you live? ▪ Who do you live with? ▪ What are your working or living conditions like? ○ Where do you sleep? ○ Do you have access to food whenever you need to eat? ○ Has anyone at home or at work ever forced you to do something you didn’t want to do? ○ Have you ever received anything in exchange for sex (e.g., shelter, gifts, food)? ▪ Has anyone at home or at work threatened you or your family? ▪ Has anyone at home or at work ever hurt you? ○ Can you leave your job or living situation if you want? Are you free to come and go as you please? ○ Have you ever been afraid to leave or quit a work situation due to fear of violence or threats of harm to you or your family? ○ Have your identification documents been taken away from you? ● Document the encounter thoroughly . Along with carefully asking thoughtful and respectful questions, documenting the patient/victim encounter thoroughly
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Book Code: MTX1325
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law enforcement, stigma and shame with reporting, and the emotional burden of the judicial system (Canadian Centre to End Human Trafficking, 2024; Palombi et al., 2019). Providers should also offer the patient the National Human Trafficking Hotline number, 888-373- 7888, and text number, 233733 and should encourage the patient to call if they want help or to talk to someone (Texas Health and Human Services, 2024). A practitioner can report to the National Human Trafficking Hotline that they suspect an adult (not 65 or older and not disabled) is being trafficked, but they cannot provide identifying information without the adult’s consent. it is impossible for Rebecca to be pregnant and insists she has been compliant with her oral contraceptives and her periods are normal. Then he begins to question the necessity of the test. You inform them that she will not be treated until the test is complete, and Derek reluctantly agrees. You lead Rebecca to a private conference room and emphasize that everything the two of you discuss will remain confidential. Before continuing, you say to Rebecca, “I have a few concerns and would like to ask you some questions about your current living conditions and situation. Would that be alright?” ● What questions would you ask Rebecca to help determine if she is a victim of human trafficking? ● If Rebecca discloses that she is a human trafficking victim, what are ways that you could help her? What resources would you provide Rebecca? Who else would you contact/involve in the situation? ● How might you respond if Rebecca declines to make an explicit disclosure or refuses to answer any questions? ● Human Rights Watch www.hrw.org ● SOAR to Health and Wellness https://www.acf.hhs.gov/otip/site_search?keyword_ 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 Hotline (NHTH) Hotline (24/7): 1-888-373-7888 https://humantraffickinghotline.org/ ● Polaris Project www.polarisproject.org
should follow institutional policies for reporting to law enforcement if the patient is in immediate, life- threatening danger but should work with the patient in deciding to contact law enforcement to avoid putting the patient in further danger (Texas Health and Human Services, 2024). In Texas, it is mandatory that health care practitioners report the abuse of those 65 or older and adults with disabilities to law enforcement and/ or the Department of Family and Protective Services immediately. Victims of human trafficking may not want law enforcement contacted due to concerns for safety of themselves and their loved ones, fear of reprimand for crimes they have been forced to commit, mistrust of Case Study 1 (continued) Continuing Rebecca’s visit, you are now ready to begin her physical examination. Derek insists he would like to stay in the room during the examination, and Rebecca consents to his presence. He remains standing at the head of the bed during the pelvic examination. The exam helps you determine Rebecca’s presentation is consistent with an outbreak of genital herpes, and microscopic examination of the discharge reveals trichomoniasis. These are two sexually transmitted infections. Derek seems unusually undisturbed by the diagnoses. You are concerned about Rebecca’s current living situation and would like to question her privately. While discussing the diagnoses with Rebecca and Derek, you inform them that you would like Rebecca to have a urine pregnancy test done before beginning treatment and request that she accompany you to the restroom to provide a urine sample. Derek states he will go with her and wait outside of the restroom. You explain that this is not possible because the route to the restroom passes other patients’ rooms and that this may result in an unintentional disclosure of protected patient information. Derek quickly replies that ● Texas Department of Public Safety, Victim Services https://www.dps.texas.gov/section/victim-employment- support-services-vess/victim-support-services 512-424-2211 ● Department of Family and Protective Services (DFPS) 800-252-5400 https://www.txabusehotline.org/Login/Default.aspx National Resources ● Coalition Against Trafficking in Women www.catwinternational.org Conclusion It is imperative that healthcare providers be educated on how to identify, assess, and respond to victims of human trafficking in order to provide them with the necessary care and support to effectively bring these individuals to safety and facilitate the transition from victim to survivor. Human trafficking poses many health risks, including physical injury, death, and long-lasting psychological damage. In the absence of validated tools to screen for victims of human trafficking, healthcare providers may need to consider implementing universal methods and policies to create a safe environment for all patients. Healthcare providers have Resources Texas-Specific Resources ● Texas Office of the Attorney General humantrafficking@oag.texas.gov 512-463-1646 ● Texas Child Protective Services 800-252-5400
a unique opportunity to provide essential medical care and information/resources connecting victims with vital supportive services that could be a victim’s first stop toward safety and recovery.
WORKS CITED https://qr2.mobi/HT2E
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Book Code: MTX1325
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