Evidence-Based Strategies for Common Clinical Questions

Child Sex Trafficking: Awareness and Screening

Author: Roxana Guggenmos, DO | Pediatric Resident

Column Editor: Kathleen Berg, MD | Co-Director, Office of Evidence-Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine 

Providers form differentials by considering the most likely diagnoses, the possibilities they cannot miss, and those remaining to be considered. In ambiguous cases, clinicians can find peace of mind knowing that patients are likely to ultimately “declare themselves.” But what happens when patients cannot declare themselves in your clinical setting? What if the “most likely” cause of a urinary tract infection is that the adolescent is being trafficked by their caretaker? When should sex trafficking be considered?

Sex trafficking is defined as forcing, manipulating or tricking someone into a sex act in exchange for something of value.^1-3 This definition is applicable to adults. But since children are inherently vulnerable, not all of these elements are required for the situation to be considered trafficking. With a child, any perceived consent is illegitimate and considered to be coerced. An estimated 4.8 million people are enslaved in sex trafficking throughout the world; 20% are minors.¹ Most commonly children are 12-16 years of age when first exploited or trafficked.² Who are these victims? We may imagine a vulnerable and battered girl with a domineering (often male) perpetrator. However, of victims evaluated at a childhood advocacy center, 8% were introduced to trafficking by a parent and 53% still lived with at least one parent when they were first trafficked.⁴ 

Pediatric providers need to recognize which of their patients are most at risk. The single greatest risk factor is a history of abuse, notably sexual, with the majority of trafficked victims reporting prior physical and/or sexual abuse.⁵ Additionally, poverty, racial and ethnic minority status, high-risk sexual activity, and homelessness are all well-documented risk factors.^5-7 LGBTQIA+ youth make up a significant proportion of homeless adolescents, and rates of sexual exploitation of transgender youth are disproportionately high.^4,8 However, trafficking is not limited to any age, gender, socioeconomic status or race. Statistically, it is in every community.³

Youth victims of trafficking are at risk for countless adverse effects of their abuse. Of victims identified at one child advocacy center, 78% met diagnostic criteria for post-traumatic stress disorder and 50% had prior suicidal attempts.⁴ In another study, 47% of victims had a sexually transmitted infection (STI) at the time of evaluation and 32% had prior pregnancies.⁹ They are also at risk for physical injury from physical and sexual assault, substance abuse, and depression.²

We as providers are mandated reporters; however, we cannot report what we do not know. It can be very difficult to identify a victim of sex trafficking because there are many barriers to disclosure. Children rarely self-identify as victims. They may have developmental limitations that prevent their acknowledgment of the problem.¹⁰ However, identifying victims can be facilitated by validated screening measures. In a large, multisite, cross-sectional observational study, Greenbaum et al. developed and evaluated a six-question screening tool to identify child sex trafficking, demonstrating a sensitivity of 83%-85% and negative predictive value of 95%-98%.^9,3 This screen inquired about history of drug/alcohol use, running away from home, involvement with law enforcement, traumatic injury, STIs, or sexual activity with more than five partners. A similar tool was used in a separate study with a negative predictive value of 96%.¹¹ As with any screening tool, questions should be asked in a sensitive, trauma-informed manner, with consideration that “the child’s parents may be 1) victims of human trafficking, themselves, 2) the persons trafficking the child, or 3) not the actual parents.”⁵

Most victims seek treatment from a health care provider while being trafficked.³ With identification of at-risk patients, resources can be obtained from local childhood advocacy centers, child abuse specialists or law enforcement. If you are concerned about a child, coordinate with a social worker to make reports to law enforcement, child protective services and the National Human Trafficking Hotline (https://humantraffickinghotline.org). Your patient’s mental, physical and emotional health may depend on it.

Additional training for health care professionals can be found at: https://www.acf.hhs.gov/otip/training/soar-health-and-wellness-training and https://healtrafficking.org.

References:

1. International Labour Organization (ILO). Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. International Labour Organization; 2017. Accessed January 30, 2022.
2. Greenbaum J, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect. Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics. 2015;135(3):566-574. doi:10.1542/peds.2014-4138
3. Greenbaum VJ, Livings MS, Lai BS, et al. Evaluation of a tool to identify child sex trafficking victims in multiple healthcare settings. J Adolesc Health. 2018;63(6):745-752. doi:10.1016/j.jadohealth.2018.06.032
4. Edinburgh L, Pape-Blabolil J, Harpin SB, Saewyc E. Assessing exploitation experiences of girls and boys seen at a Child Advocacy Center. Child Abuse Negl. 2015;46:47-59. doi:10.1016/j.chiabu.2015.04.016
5. Greenbaum VJ. Child sex trafficking in the United States: challenges for the healthcare provider. PLoS Med. 2017;14(11):e1002439. Published online November 22, 2017. doi:10.1371/journal.pmed.1002439
6. Holger-Ambrose B, Langmade C, Edinburgh LD, Saewyc E. The illusions and juxtapositions of commercial sexual exploitation among youth: identifying effective street-outreach strategies. J Child Sex Abus. 2013;22(3):326-340. doi:10.1080/10538712.2013.737443
7. Becker HJ, Bechtel K. Recognizing victims of human trafficking in the pediatric emergency department. Pediatr Emerg Care. 2015;31(2):144-150. doi:10.1097/PEC.0000000000000357
8. Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav. 2009;13(5):902-913. doi:10.1007/s10461-008-9508-8
9. Greenbaum VJ, Dodd M, McCracken C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care. 2018;34(1):33-37. doi:10.1097/PEC.0000000000000602
10. Rafferty Y. Challenges to the rapid identification of children who have been trafficked for commercial sexual exploitation. Child Abuse Negl. 2016;52:158-168. doi:10.1016/j.chiabu.2015.11.015
11. Hurst IA, Abdoo DC, Harpin S, Leonard J, Adelgais K. Confidential screening for sex trafficking among minors in a pediatric emergency department. Pediatrics. 2021;147(3):e2020013235. doi:10.1542/peds.2020-013235