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Human trafficking is a pandemic human rights violation with an emerging paradigm shift that reframes an issue traditionally seen through a criminal justice lens to that of a public health crisis, particularly for children. Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma-informed, and culturally responsive care from trained health care providers (HCPs). The purpose of this article was to engage and equip pediatric HCPs to respond effectively to human trafficking in the clinical setting, improving health outcomes for affected and at-risk children. Pediatric HCPs are ideally positioned to intervene and advocate for children with health disparities and vulnerability to trafficking in a broad spectrum of care settings and to optimize equitable health outcomes.
) with an emerging paradigm shift reframing an issue traditionally seen through a criminal justice lens to that of a public health crisis, particularly for children (
estimates the total number of victims easily ascends into the hundreds of thousands when including both adult and child sex and labor trafficking victims. Over the past decade, the National Human Trafficking Resource Center (
Child trafficking (CT; with the term CT encompassing both labor and sex trafficking) is both underreported and understudied. In a recent literature review, a mere 9.7% of over 22,000 articles reviewed specifically addressed CT (
). Accurately collected estimates of CT incidence and prevalence do not exist, partly because of the illicit nature of trafficking, underreporting of victims, and absence of both standardized terms and a consolidated common database. Existing evidence reports potential victims of CT present in all health care environments, creating an opportunity for pediatric health care providers (HCPs) to act as first responders in prevention efforts, victim identification, and treatment referral (
Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America.
). Misconceptions regarding the nature and scope of trafficking persist and impede efforts to improve outcomes. Although the United States is one of the most significant locations for CT victims (
), many U.S. HCPs mistakenly believe that trafficking mainly occurs internationally and rarely affects U.S. residents, although most of those affected in the United States are American citizens and not foreign nationals (
Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America.
). Child victims present in a variety of clinical environments, but most HCPs do not receive adequate training on identification or referral services appropriate to the pediatric population (
Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma-informed, and culturally responsive care. The purpose of this article was to engage and equip pediatric HCPs to effectively respond to CT in the clinical setting as a critical effort to improve health outcomes for affected and at-risk children.
BACKGROUND
CT is an illicit enterprise, making accurate analysis difficult because there are few uniform mechanisms for data collection. In particular, sex trafficking is often hidden and difficult to detect (
). Moreover, affected children and adolescents often do not self-identify as victims or may not seek services for fear of criminal prosecution, deportation, stigmatization, and/or blame. Many consider victim identification as the “tip of the iceberg,” and some argue that lack of attention to CT creates an environment that allows traffickers to evade criminal detection and prosecution (
The Victims of Trafficking and Violence Protection Act, now referred to as the Trafficking Victims Protection Act, was established in 2000, defining HT at the federal level for the first time. Child sex trafficking (CST), also known as commercial sexual exploitation of a child or domestic minor sex trafficking, involves youth under the age of 18 years who are obtained, harbored, transported, advertised, recruited, solicited, or enticed to engage in commercial sexual exploitation (e.g., exotic dancing, massage parlors, escort services, pornography production, prostitution, pornography, or any other sex-related work) for some form of payment, either in money or goods. It is important to note that this includes all types of commercial sex work for victims under the age of 18 years, even in the absence of force, fraud, or coercion, which are elements required for prosecution in adult victims (
found that approximately 31% of child victims were subjected to sexual acts, and 25% of children engaged in pornography related to family member coercion, typically involving selling the child for money, drugs, food, shelter, or something else of value. Child labor trafficking (CLT) involves forcing a child into labor acts through physical or psychological threats or debt bondage. Service, domestic (i.e., hospitality industries, such as hotels), and agricultural industries are most likely to involve CLT (
Emerging research forms a consensus of commonly identified risk factors (Table 1). The varied nature of CST and CLT make the creation of a singular risk profile difficult (
); therefore, pediatric HCPs should know individual risk categories and include these in the routine assessment of youth. This information is particularly relevant to pediatric HCPs because many victims enter trafficking during adolescence. In a survey of 913 survivors of CST and CLT from Florida state records,
Although some risk factors of CST and CLT overlap, other risk factors are more distinct. The most significant risk factor for CST is childhood trauma, especially experiencing sexual abuse (
). The longer or more frequent the abuse, abuse perpetrated by father figures, co-existing emotional or physical abuse, and penetrative sexual abuse confer the greatest risk (
). The actual reasons for these connections remain speculated; however, it is believed that neurologic changes from toxic stress, damage to interpersonal skills caused by abuse, and emotional numbing that frequently occurs after abuse provide susceptibility to CST and/or CLT (
) examined categories of abuse, neglect, and household dysfunction experienced before the age of 18 years. ACEs are associated with downstream health consequences occurring over the life span, including the adoption of health-averse behaviors, disrupted neurodevelopment, cognitive impairment, chronic disease burden, disability, and premature death. Higher ACE scores reveal a graded dose-response risk for adverse health outcomes and should be considered when encountering a child at risk for trafficking.
Gender is also a particular CST risk factor because female survivors outnumber male survivors; however, people of all genders and sexual orientations are sexually trafficked. Youth who identify as lesbian, gay, bisexual, transgender, queer, or intersex (LGBTQI) have a higher risk of CST than their heterosexual peers (
). Because child survivors of maltreatment are more likely to run away, they may have a compounded risk because homeless youth and runaway youth are at a significant risk for a trafficking experience (
) because of shelter, food, and resource insecurity. It is estimated that the United States has one to almost three million homeless youth. Approximately 20% of U.S. teens run away from home at some point during adolescence. Of these, one-third are recruited into CST within days, and almost 90% are sexually exploited within 3 months (
). Although youth substance abuse and mental illness are known risk factors for CST, it is unclear whether these conditions occurred before trafficking or are the result of surviving trafficking (
Environmental influences on the likelihood of CST and/or CLT include single-parent families, poor family interpersonal relations, dysfunctional family systems, unsafe or insecure living conditions, placement in foster care or juvenile justice, and significant financial insecurity (
). These circumstances make children more vulnerable to sexual grooming lured by money, a feeling of being loved, or having somewhere “safe” to go. In addition, financial insecurity and unsafe living conditions may result in parental decisions to offer them for domestic labor, making the children vulnerable to debt bondage (
Trafficking adversely affects physical, social, mental, emotional, psychological, and spiritual health. Acute and chronic headaches are among the most frequently reported physical conditions experienced by victims of HT (
). Additional complaints include memory problems, acute or chronic pain (especially headaches, backaches, and abdominal pain), and sleep disturbances (
). Other physical signs include unexplained or repeated traumatic injuries, such as bruising, fractures, ligature marks, and/or cuts. Victims may experience frequent exposure to infectious diseases, including tuberculosis and vaccine-preventable illness (Richards, 2014). Because of preventive care neglect, victims may experience long-term dental or oral health problems resulting in dental pain (
). Victims of CST often experience sexual and reproductive health problems from sexual violence and unsafe sex practices including urinary tract infections, pelvic inflammatory disease, and unplanned pregnancy (
). Forced and unsafe abortions may occur (Richards, 2014). Similar to victims of CLT, those who experience CST may endure inhumane working and living conditions.
Victims of CLT work long hours with little rest and may be exposed to pesticides and other hazardous chemicals. Children are at risk for physical injury if they lack protective gear or operate machinery without proper training or oversight (
). Victims of CLT may develop musculoskeletal issues from repetitive motions and limb injuries. Children may work in extreme weather conditions and develop skin infections from being exposed to poor sanitation and bacterial hazards (
) and injury (e.g., limb amputations). Child victims often live in overcrowded, unclean conditions where they are further exposed to communicable diseases (
CT victims experience repetitive traumatic events that result in cumulative psychological harm. The most common mental health conditions reported include anxiety, depression, post-traumatic stress disorder, and suicidal ideation (
). Recent studies have demonstrated the inadequacy of identification and health care services of CT victims. The variability of each trafficking experience adds to the difficulty of recognizing victimization (
). HCPs are critical to identifying children at high risk for trafficking and offering timely, comprehensive, and multidisciplinary services.
Victims commonly present with a variety of behavioral clues that should raise CT suspicion. Often, illness or injury history is inconsistent with physical findings. The presence of a controlling accompanying adult who does not allow the child or adolescent to speak, or observation of overly submissive, withdrawn, or fearful behaviors should be concerning. Identification documents may be absent or “misplaced” (
). Victims may be unaware of the current date or time and their current location or may be unable to provide a home address. Other warning signs include aggression, extreme fear, or withdrawal manifested by flat affect (
A variety of physical signs should alert the HCP to suspect HT. Note the discrepancy between stated age and observed age. Suspected victims who state their age to be over 18 years but appear to be younger should have age correlation with a physical examination and Tanner staging, although early-onset sexual abuse is associated with earlier pubertal onset (
). Physical signs of trafficking include evidence of physical or sexual violence, such as ligature marks, broken teeth or bones, and vaginal or rectal injury. Malnutrition or unmanaged chronic illness may be noted. Illegal substance abuse, especially when testing results positive for multiple drugs, should raise trafficking suspicion. Recurrent visits for urinary tract infections, sexually transmitted infections, pelvic inflammatory disorder, and partial or traumatic abortion are high-risk indicators (
). Assess the entire body and document any tattoos because traffickers often brand their victims with permanent markings. In the United States, marking a youth under the age of 16 years with a tattoo is illegal in most states and should raise suspicion (
). Commonly reported tattoos include using dollar signs, bar codes, or the words “daddy,” “bottom” (designating a “bottom girl” or a victim who moved up in the victim hierarchy and may receive better treatment), or “___’s girl” (
IMPLEMENTING A TRAUMA-INFORMED AND CULTURALLY RESPONSIVE APPROACH
A trauma-informed approach minimizes triggers, stabilizes the patient, and de-escalates potentially volatile situations. Trauma response has significant impacts on psychological and physical outcomes, including long-term sequelae such as post-traumatic stress disorder (
). A trauma-informed framework encourages HCPs to adeptly recognize signs of trauma and its widespread impact while integrating trauma-related policies and procedures to help prevent retraumatization (
). Through this process, HCPs provide care that empowers survivors by considering their wishes, maximizing their input in care-related decisions, reassuring safety, and providing care with transparency and trustworthiness (
). The trauma-informed approach assists HCPs in identifying subtle indicators of trauma while creating a safer space for self-disclosure of victimization (
A primary tenet of trauma-informed care is developing trust. An initial step is to provide safety and privacy for the health care encounter, away from the accompanying person (Barnet et al., 2018). Be aware that a child may be a victim of familial CST or CLT, or the “friend” may be someone appointed by the trafficker to supervise and ensure victimization is not disclosed (
). Separate them via a required procedure that only the patient can attend, such as an x-ray or a urine test. Equally important is limiting the number of staff who are aware of the suspected trafficking situation to limit conversation and lessen the risk of the trafficker overhearing the conversation and leaving. Another aspect of establishing a trusting relationship and providing culturally responsive care is ensuring the patient can speak to HCPs in their native language. Three federal laws (The American with Disabilities Act, Title VI of the Civil Rights Act of 1964, and the Affordable Care Act) require HCPs or institutions who receive federal funds to provide qualified interpreters to patients with limited English proficiency and patients who are deaf or have impaired hearing, and explicitly bans the use of minor children or adult family members and friends as interpreters (
). People who accompany the suspected victim should never be translators. Never question potential victims about their immigration status.
Demonstrate respect for the child or adolescent by offering choices and control during the encounter. Ask patient permission before initiating a detailed history and physical. Throughout the encounter, ask, “How are you doing?” or “May I continue?” Use developmentally appropriate language and start with less invasive parts of the examination by asking, “Are you comfortable with me listening to your lungs?” and then request permission to ask more probing questions and perform more intimate examinations (
Just as with other forms of trauma, many child victims, when questioned, are not willing to self-disclose as victims, and many do not recognize their victimization yet (
). HCPs can provide support during the encounter (Table 2). Do not force, deceive, or coerce a patient to disclose with the intent to “save” or “rescue” them. Understand that survivors may express anger or be accusatory and/or belligerent as manifestations of survival behaviors. Do not be discouraged if a patient does not disclose victimization. It may take several visits for a child to feel safe enough to disclose their trafficking situation. Validate and normalize their feelings (
), and discreetly, verbally provide the information they may choose to act on in the future. This information may include providing them with the National Human Trafficking Hotline number (Figure 1). Avoid judgmental statements that may be abrupt or insensitive, such as, “Why didn't you ask for help?” or “How could this have happened?” Be open to unfamiliar narratives. Although there is currently no universal screening tool recommended for routine use, HCPs can use therapeutic communication to ask open-ended questions (Table 3).
TABLE 2Health care provider response to CT victims in the clinical setting
Practice within the scope of your education, license, certification and training Adhere to mandatory reporting laws in your state Seek high quality continuing education from reputable entities Provide appropriate care for presenting clinical concerns (i.e. injuries or illnesses) Advocate for use of scientifically-designed screening tools with evidence of reliability and validity Facilitate appropriate referral and connection to interprofessional holistic service entities
Trauma-Informed
Safety- Ensure emotional and physical safety for all involved parties in the clinical setting Avoid unintentional re-traumatization by using well-intentioned but ill-informed interview techniques Make every effort to provide privacy during clinician interaction with the individual, separate from individuals potentially posing threats (i.e. traffickers) Choice- Provide individuals with control and clear, appropriate messages about their rights and responsibilities Do not attempt to force the patient to self-disclose Know and adhere to federal and state laws as well as organizational policy governing mandatory reporting Collaboration- Share power in decision making and planning Collaborate with interprofessional disciplines Trustworthiness- Maintain respectful and professional boundaries Do not make promises you cannot keep Empowerment- Prioritize empowerment and skill building Do not “rescue” the patient Communicate messages of hope This is a safe place You are not alone This is not your fault You deserve to receive help
Culturally-Responsive
Identify your personal potential biases Use a professional interpreter or interpreter service(s) to provide linguistically appropriate services to individuals who speak a different language Recognize the differences between the cultures of law enforcement, the health care profession, trafficked individuals, and other interprofessional disciplines involved in care Advocate trafficking response teams that are inclusive and representative of diverse perspectives
What type of work do you do? What are your work hours? How often do you get to see your family? Does someone prevent you from contacting them? Can you get another job if you want? Come you come and go as you please? How many people live with you? Are you being paid? Do you have a safe place to go? Do you owe money to your employer? Do you have control over your money and ID/documents?
Do you ever feel pressure to do something you don't want to? Have you been physically hurt? Did someone tell you what to say today? Has your family been threatened? Has anyone asked you to have sex with someone else? Have you ever felt you had to have sex to get what you need, such as food or to stay in where you live? Has anyone asked you to dance at a gentleman's club or take your clothes off in front of someone?
*Note: Some questions overlap and may be appropriate for concern for both sex and labor trafficking. Principles of trauma-informed care should be implemented with any clinician-patient interaction. These may present a starting place for conversation to explore potential risk in the absence of a scientifically-designed screening tool with established validity and reliability.
Pediatric HCPs play a pivotal role in raising CT awareness. Recommended calls to action are summarized in Table 4 with resources contained in Table 5. All pediatric HCPs should seek evidence-based, survivor- and trauma-informed, culturally responsive continuing education to inform their clinical practice. Questioning and examining children in a well-intentioned but poorly informed manner can cause further trauma, jeopardize subsequent criminal proceedings, and risk violating the limits of clinician licensure (
Seek evidence-based continuing education specific to HCPs Memorize the Human Trafficking Hotline phone and text numbers Learn how to be an effective advocate and clinician for victims presenting in the clinical setting Keep abreast of published scientific literature related to child trafficking Advocate for the implementation of a protocol within your institution Advocate for prevention of Adverse Childhood Events (ACEs) Educate children and families about risk factors for trafficking Volunteer with a local anti-trafficking advocacy group Serve on a city, state, or federal taskforce or committee
Health Systems/Clinical Environments
Establish an interprofessional workgroup to develop and implement an interprofessional protocol Designate an organizational taskforce to respond in the clinical setting Require annual training for ALL employees, not just clinical personnel Make trafficking awareness part of orientation or onboarding Work collaboratively with local/state/federal law enforcement task forces Develop and evaluate the use of order sets Take steps toward becoming a trauma-informed institution (5 primary principles include safety, transparency and trustworthiness, choice, collaboration and mutuality, empowerment- consider the Missouri Model as an exemplar) Consider scientific development of screening tools with evaluation for reliability and validity Create an evidence-based, trauma-informed and culturally-responsive organizational protocol Ensure mandatory reporting protocols follow state and federal law Implement and evaluate the use of trafficking-related ICD-10 CM codes Include trafficking survivors in interprofessional teams to promote survivor-informed practices Consider the potential impacts of vicarious trauma and ensure adequate support services are available and accessible
Academic Institutions
Implement evidence-based education in interprofessional health sciences curricula Support research agendas including social determinants of health, theory-based interventions and upstream prevention approaches with a public health paradigm Implement trafficking awareness training for ALL employees Establish policies and procedures to support employees and students who are identified as potential victims of trafficking
U.S. Department of Health and Human Services; National Human Trafficking Training and Technical Assistance Center; Administration for Children and Families; Office on Trafficking in Persons; Office on Women's Health
SOAR to Health and Wellness Online Training Modules: Trauma-Informed Care; Culturally and Linguistically Appropriate Services; SOAR for: Behavioral Health, Public Health, Health Care, Social Services, School-Based Professionals
Blue Campaign- A national public awareness campaign designed to educate the public, law enforcement and other industry partners to recognize and respond to human trafficking
Note. ACT, Alliance for Children in Trafficking; HCPs, health care providers; HEAL, Health, Education, Advocacy, Linkage; PEARR, Privacy, Educate, Ask, Respect and Respond; SOAR, Stop, Observe, Act, Respond.
Pediatric HCPs should support evidence-based, scientifically rigorous approaches to the development and subsequent evaluation of CT preventive efforts. Use a holistic assessment approach and recognize that all body systems may be involved. A thorough review of symptoms and a comprehensive physical and mental health assessment should be performed to identify risk factors (
). Victims of forced labor should not be underserved with preferential prevention and intervention efforts diverted or prioritized to vctims of CST.
In the broader context of health care organizations, pediatric HCPs should lead efforts to implement best practices through policies, protocols, and governance for children who experience and are at risk for trafficking. Health care organizations should ensure that trafficking awareness is included in the onboarding process for all new employees and in annual compliance training. Every health care delivery environment should develop and implement a clinical protocol with input from an interprofessional organizational coalition including clinicians, administrative leadership, staff support, institutional security personnel, ancillary care services, social service disciplines, child life specialists, sexual assault nurse examiners, and local and federal law enforcement (
). In particular, the collaboration between health care and law enforcement professions is an area needing further development to maximize resources and optimize patient outcomes. A clinical interprofessional protocol is critical to employ an evidence-based, trauma-informed, and culturally responsive approach. Protocols should address case management, patient referral, and care coordination. Of utmost critical importance, each protocol should address mandated reporting obligations for HCPs, which vary according to state law. Clinicians need clear direction on how to report suspected cases of child trafficking and the differences in reporting adult cases (
). Reporting instructions should comply with federal and state law, including, but not limited to, protections for reporting confidential patient information and avoiding violations of the Health Insurance Portability and Accountability Act. In addition, organizations should be aware of federal and state efforts and legal implications for trafficking victims including: criminalization of trafficking crimes, survivor protections in court, coordination between state and federal agencies, and business regulations (
and the appropriate guidelines for communication therein, considering state laws for mandatory reporting and boundaries for Health Insurance Portability and Accountability Act violations. Protocols should address discharge planning, patient safety counseling, and discreet provision of further resources for those who choose not to self-disclose victimization and who do not qualify for mandated reporting. Other considerations include safety considerations for victims, families, and staff; a procedure for handling care refusal or leaving against medical advice; and potential order sets for evaluation and treatment. HCPs must understand and abide by their education and mandated scope of practice to avoid unintentional revictimization, providing poor care, or potentially damaging criminal cases.
Although there is no diagnostic standard for trafficking, International Classification of Diseases, 10th Revision, Clinical Modification (i.e., ICD-10-CM) codes (Figure 2) were approved in October 2018, offering options for adult or child confirmed or suspected labor or sex trafficking. It is important for clinicians to use these codes to provide a better understanding of the scope of this problem (
Office on Trafficking in Persons (OTIP). (2018). CDC adds new human trafficking data collection fields for health care providers. Retrieved from https://www.acf.hhs.gov/otip/news/icd-10
). When these codes are used in an electronic medical record, consider confidential use to protect victims from potential retribution for seeking health care. It is important to note that there is insufficient evidence to support universal adoption of a standardized screening tool for CST and CLT (
Office on Trafficking in Persons (OTIP). (2018). CDC adds new human trafficking data collection fields for health care providers. Retrieved from https://www.acf.hhs.gov/otip/news/icd-10
Academic institutions should prioritize and support scholarly efforts to research clinician response to CT with emphasis on scientific inquiry inclusive of individual, relationship, community, and societal impacts on social determinants of health (i.e., a public health paradigm construct) and theory-based interventions. Care should be given to thoughtful construction of prevention and intervention efforts, with consideration and implementation of rigorous scientific studies with statistical outcomes measurement. Inclusion of child victimization should be examined scientifically, comparing unique experiences and holistic impacts of child vs. adult victims (
Pediatric nurse practitioners and other pediatric HCPs are ideally positioned to lead efforts for trauma-informed, culturally responsive, and evidence-based care of children who have experienced or are at risk for experiencing trafficking (
). Adopting incremental and evidence-based clinical practice changes amplifies the impact of pediatric HCPs as effective leaders with a cohesive and collective response to child trafficking. By recognizing previously unidentified victims and employing upstream prevention approaches, pediatric HCPs can positively impact health outcomes for children.
Office on Trafficking in Persons (OTIP). (2018). CDC adds new human trafficking data collection fields for health care providers. Retrieved from https://www.acf.hhs.gov/otip/news/icd-10
Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America.
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