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White Paper: Recognizing Child Trafficking as a Critical Emerging Health Threat

      ABSTRACT

      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.

      KEY WORDS

      Human trafficking (HT) is a pandemic human rights violation (
      • Scannell M.
      • MacDonald A.E.
      • Berger A.
      • Boyer N.
      Human trafficking: How nurses can make a difference.
      ) 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 (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;
      • Speck P.M.
      • Mitchell S.A.
      • Ekroos R.A.
      • Sanchez R.V.
      • Messias D.K.H.
      Policy brief on the nursing response to human trafficking.
      ). Globally, it is estimated that eight million children and youth are trafficked annually, 5.7 million for labor and another 1.8 million for sex (
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ). The International Labour Organization estimates one in four of the 21 million worldwide victims of forced labor are children (

      International Labour Organization. (2018). Forced labour, modern slavery and human trafficking. Retrieved from https://www.ilo.org/global/topics/forced-labour/lang–en/index.htm

      ). The United Nations Office on Drugs and Crime found that children comprise 33% of 40,000 identified victims of trafficking (
      • Greenbaum J.
      • Bodrick N.
      Global human trafficking and child victimization. Policy statement.
      ). HT is a growing problem in the criminal industry with estimates of more than 40 million people currently victimized worldwide (
      • Gordon M.
      • Fang S.
      • Coverdale J.
      • Nguyen P.
      Failure to identify a human trafficking victim.
      ). The number of HT victims in the United States is unclear, although

      Polaris. (2018a). 2018 U.S. National Human Trafficking Hotline Statistics. Retrieved from https://polarisproject.org/2018statistics

      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 (

      National Human Trafficking Resource Center. (2019). Comprehensive human trafficking assessment. Retrieved from https://humantraffickinghotline.org/resources/comprehensive-human-trafficking-assessment-tool

      ) reported more than 40,000 cases of domestic HT with the majority originating in California, Texas, Florida, Ohio, and New York (
      Joint Commission
      Identifying human trafficking victims.
      ). Women and girls account for up to 99% of victims in the sex trafficking industry and 58% of victims in other categories, including forced labor (

      International Labour Organization. (2018). Forced labour, modern slavery and human trafficking. Retrieved from https://www.ilo.org/global/topics/forced-labour/lang–en/index.htm

      ;
      • Owens C.
      • Dank M.
      • Breaux H.
      • Banuelos I.
      • Farrell A.
      • Pfeffer R.
      • McDevitt J.
      Understanding the organization, operation, and victimization process of labor trafficking in the United States.
      ).
      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 (
      • Sweileh W.M.
      Research trends on human trafficking: A bibliometric analysis using Scopus database.
      ). 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 (

      Polaris. (2018b). Healthcare providers play a crucial role in victim identification. Retrieved fromhttps://polarisproject.org/blog/2016/11/03/healthcare-providers-play-crucial-role-victim-identification

      ;
      • Sinha R.
      • Tashakor E.
      • Pinto C.
      Identifying victims of human trafficking in central Pennsylvania: A survey of health-care professionals and students.
      ). The Joint Commission issued a Quick Safety bulletin in June 2018, urging health care environments to identify potential victims of HT (
      Joint Commission
      Identifying human trafficking victims.
      ). Although well-designed evidence-based CT education has an important role in effectively equipping clinicians, awareness among HCPs remains low (
      • Barron C.E.
      • Moore J.L.
      • Baird G.L.
      • Goldberg A.P.
      Domestic minor sex trafficking in the medical setting: A survey of the knowledge, discomfort, and training of pediatric attending physicians.
      ;
      • Sprang G.
      • Cole J.
      Familial sex trafficking of minors: Trafficking conditions, clinical presentation, and system involvement.
      ;
      • Donahue S.
      • Schwien M.
      • LaVallee D.
      Educating emergency department staff on the identification and treatment of human trafficking victims.
      ;
      • Fraley H.E.
      • Aronowitz T.
      • Jones E.J.
      School nurses’ awareness and attitudes toward commercial sexual exploitation of children.
      ;
      • Katsanis S.H.
      • Huang E.
      • Young A.
      • Grant V.
      • Warner E.
      • Larson S.
      • Wagner J.K.
      Caring for trafficked and unidentified patients in the EHR shadows: Shining a light by sharing the data.
      ;
      • Lutx R.M.
      Human trafficking education for nurse practitioners: Integration into standard curriculum.
      ;
      • Recknor F.H.
      • Chisolm-Straker M.
      Human trafficking: It's not just a crime.
      ;
      • Sinha R.
      • Tashakor E.
      • Pinto C.
      Identifying victims of human trafficking in central Pennsylvania: A survey of health-care professionals and students.
      ;
      • Viergever R.F.
      • West H.
      • Borland R.
      • Zimmerman C.
      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 (
      Joint Commission
      Identifying human trafficking 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 (
      • Viergever R.F.
      • West H.
      • Borland R.
      • Zimmerman C.
      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.
      ). Most notably, up to 88% of child and adult victims encounter at least one HCP without being identified as trafficked (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ). 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 (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;

      US Department of Health and Human Services [USDHHS]. (2019). The role of healthcare providers in combating human trafficking during disasters. Retrieved fromhttps://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking.aspx

      ).
      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 (
      • Rajaram S.S.
      • Tidball S.
      Survivor's voices - Complex needs of sex trafficking survivors in the Midwest.
      ). 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 (
      • Rajaram S.S.
      • Tidball S.
      Survivor's voices - Complex needs of sex trafficking survivors in the Midwest.
      ).
      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 (

      United States Department of State. (2019). United States Advisory Council on Human Trafficking: Annual Report 2019. Retrieved fromhttps://www.state.gov/wp-content/uploads/2019/05/US-Advisory-Council-2019-Report.pdf

      ). Contrary to common misconceptions, not all children in CST entered through stranger coercion or abduction.
      • Sprang G.
      • Cole J.
      Familial sex trafficking of minors: Trafficking conditions, clinical presentation, and system involvement.
      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 (
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ).

      RISK FACTORS FOR CHILD TRAFFICKING

      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 (
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ); 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,
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      found 47% entered trafficking at the age of 13–14 years, 15% entered at the age of 15 years, and 29% entered at the age of 12 years or younger.
      TABLE 1Risk factors for child trafficking
      Source:
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ;
      • Niergarten M.B.
      International child health: Identify, screen, treat and advocate for child victims of human trafficking.
      ;
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ;

      United States Department of State. (2019). United States Advisory Council on Human Trafficking: Annual Report 2019. Retrieved fromhttps://www.state.gov/wp-content/uploads/2019/05/US-Advisory-Council-2019-Report.pdf

      .
      IndividualRelationalCommunity or societal
      Age: early to middle adolescenceParental substance abuseSocial isolation or bullying
      Runaway statusParental abuse or neglectSexualization of children
      Identification as LGBTQIFamily conflict, disruption, or dysfunctionIndigenous or first nations children
      Foster care placementForced out of their homes by family membersRecent immigration or migration
      Juvenile justice system involvementFamily domestic violenceGang involvement
      Substance abuse or misuseSingle-parent familiesChildren from impoverished communities
      Mental illnessChildren with a deceased parentUnderserved neighborhoods and communities
      High ACE scoreUnderresourced schools
      Survivors of abuse or neglectLack of awareness of CT
      Intellectual and other disabilitiesLack of available resources to respond to CT
      Immigrant or refugee status
      Note. ACE, adverse childhood events; CT, child trafficking; LGBTQI, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex.
      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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ;
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ). 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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ). 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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ). The landmark Adverse Childhood Experiences (ACEs) study of more than 17,000 subjects () 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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ). 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 (
      • Chisolm-Straker M.
      • Sze J.
      • Einbond J.
      • White J.
      • Stoklosa H.
      Screening for human trafficking among homeless young adults.
      ) 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 (
      • Niergarten M.B.
      International child health: Identify, screen, treat and advocate for child victims of human trafficking.
      ). 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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ).
      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 (
      • Choi K.R.
      Risk factors for domestic minor sex trafficking in the United States: A literature review.
      ;
      • Niergarten M.B.
      International child health: Identify, screen, treat and advocate for child victims of human trafficking.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). 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 (

      Toney-Butler, T. J., Mittel, O. (2019). Human trafficking. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430910/

      ).

      HEALTH IMPACTS OF TRAFFICKING

      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 (
      • Hemmings S.
      • Jakobowitz S.
      • Abas M.
      • Bick D.
      • Howard L.M.
      • Stanley N.
      • Oram S.
      Responding to the health needs of survivors of human trafficking: A systematic review.
      ;
      • Oram S.
      • Abas M.
      • Bick D.
      • Boyle A.
      • French R.
      • Jakobowitz S.
      • Zimmerman C.
      Human trafficking and health: A survey of male and female survivors in England.
      ;
      • Oram S.
      • Stöckl H.
      • Busza J.
      • Howard L.M.
      • Zimmerman C.
      Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review.
      ;
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ). Fatigue and dizziness are also common (
      • Hemmings S.
      • Jakobowitz S.
      • Abas M.
      • Bick D.
      • Howard L.M.
      • Stanley N.
      • Oram S.
      Responding to the health needs of survivors of human trafficking: A systematic review.
      ;
      • Oram S.
      • Abas M.
      • Bick D.
      • Boyle A.
      • French R.
      • Jakobowitz S.
      • Zimmerman C.
      Human trafficking and health: A survey of male and female survivors in England.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). Additional complaints include memory problems, acute or chronic pain (especially headaches, backaches, and abdominal pain), and sleep disturbances (
      • Hemmings S.
      • Jakobowitz S.
      • Abas M.
      • Bick D.
      • Howard L.M.
      • Stanley N.
      • Oram S.
      Responding to the health needs of survivors of human trafficking: A systematic review.
      ;
      • Oram S.
      • Stöckl H.
      • Busza J.
      • Howard L.M.
      • Zimmerman C.
      Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review.
      ;
      • Oram S.
      • Abas M.
      • Bick D.
      • Boyle A.
      • French R.
      • Jakobowitz S.
      • Zimmerman C.
      Human trafficking and health: A survey of male and female survivors in England.
      ;
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). 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 (
      • Oram S.
      • Stöckl H.
      • Busza J.
      • Howard L.M.
      • Zimmerman C.
      Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review.
      ;
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ) from trauma or injuries to the mouth sustained during physical and sexual abuse (
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). 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 (
      • Hemmings S.
      • Jakobowitz S.
      • Abas M.
      • Bick D.
      • Howard L.M.
      • Stanley N.
      • Oram S.
      Responding to the health needs of survivors of human trafficking: A systematic review.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). Sexually transmitted infections, including hepatitis B or C and HIV, are among the most common sexual health issues reported (
      • Cannon A.C.
      • Arcara J.
      • Graham L.M.
      • Macy R.J.
      Trafficking and health: A systematic review of research methods.
      ;
      • Oram S.
      • Abas M.
      • Bick D.
      • Boyle A.
      • French R.
      • Jakobowitz S.
      • Zimmerman C.
      Human trafficking and health: A survey of male and female survivors in England.
      ;
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). 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 (
      • Cannon A.C.
      • Arcara J.
      • Graham L.M.
      • Macy R.J.
      Trafficking and health: A systematic review of research methods.
      ;
      • Cannon A.C.
      • Arcara J.
      • Graham L.M.
      • Macy R.J.
      Trafficking and health: A systematic review of research methods.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). 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 (
      • Cannon A.C.
      • Arcara J.
      • Graham L.M.
      • Macy R.J.
      Trafficking and health: A systematic review of research methods.
      ) and injury (e.g., limb amputations). Child victims often live in overcrowded, unclean conditions where they are further exposed to communicable diseases (
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). Sexual abuse may occur during labor trafficking (
      • Cannon A.C.
      • Arcara J.
      • Graham L.M.
      • Macy R.J.
      Trafficking and health: A systematic review of research methods.
      ).
      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 (
      • Hemmings S.
      • Jakobowitz S.
      • Abas M.
      • Bick D.
      • Howard L.M.
      • Stanley N.
      • Oram S.
      Responding to the health needs of survivors of human trafficking: A systematic review.
      ;
      • Oram S.
      • Abas M.
      • Bick D.
      • Boyle A.
      • French R.
      • Jakobowitz S.
      • Zimmerman C.
      Human trafficking and health: A survey of male and female survivors in England.
      ;
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ;
      • Richards T.A.
      Health implications of trafficking.
      ;
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ). In addition, substance abuse or misuse may occur because of forced or coerced use of substances (
      • Zimmerman C.
      • Hossain M.
      • Watts C.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ).

      PRESENTATION OF VICTIMS IN THE CLINICAL SETTING

      It is estimated that 88% of victims access health care services sometime during their exploitation (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;
      • Reid J.A.
      • Baglivio M.T.
      • Piquero A.R.
      • Greenwald M.A.
      • Epps N.
      No youth left behind to human trafficking: Exploring profiles of risk.
      ). Since 2016, 14 states have enacted legislation addressing health professional education about HT (
      • Atkinson H.G.
      • Curnin K.J.
      • Hanson N.C.
      U.S. state laws addressing human trafficking: Education of and mandatory reporting by health care providers and other professionals.
      ). 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 (
      • Fedina L.
      • Williamson C.
      • Perdue T.
      Risk factors for domestic child sex trafficking in the United States.
      ). 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 (

      Dignity Health (n.d.). Taking a stand against human trafficking. Retrieved from https://www.dignityhealth.org/hello-humankindness/human-trafficking

      ).
      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 (
      • Noll J.G.
      • Trickett P.K.
      • Long J.D.
      • Negriff S.
      • Susman E.J.
      • Shalev I.
      • Putnam F.W.
      Childhood sexual abuse and early timing of puberty.
      ). 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” (
      • Fang S.
      • Coverdale J.
      • Nguyen P.
      • Gordon M.
      Tattoo recognition in screening for victims of human trafficking.
      ;

      NAPNAP Partners. (2019). Tattoos of human trafficking victims. Retrieved fromhttps://www.napnappartners.org/tattoos-human-trafficking-victims

      ).

      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 (

      US Department of Health and Human Services [USDHHS]. (2014). Substance abuse and mental health services administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884.html

      ). 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 (

      US Department of Health and Human Services [USDHHS]. (2014). Substance abuse and mental health services administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884.html

      ;

      Dignity Health (n.d.). Taking a stand against human trafficking. Retrieved from https://www.dignityhealth.org/hello-humankindness/human-trafficking

      ). 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 (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;

      Dignity Health (n.d.). Taking a stand against human trafficking. Retrieved from https://www.dignityhealth.org/hello-humankindness/human-trafficking

      ). The trauma-informed approach assists HCPs in identifying subtle indicators of trauma while creating a safer space for self-disclosure of victimization (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ;
      • Peck J.L.
      • Meadows-Oliver M.
      Human trafficking of children. Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part one.
      ).
      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 (

      Polaris. (2018b). Healthcare providers play a crucial role in victim identification. Retrieved fromhttps://polarisproject.org/blog/2016/11/03/healthcare-providers-play-crucial-role-victim-identification

      ;
      • Sprang G.
      • Cole J.
      Familial sex trafficking of minors: Trafficking conditions, clinical presentation, and system involvement.
      ). 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 (

      US Department of Health and Human Services [USDHHS]. (2014). Substance abuse and mental health services administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884.html

      ;

      United States Department of State. (2019). United States Advisory Council on Human Trafficking: Annual Report 2019. Retrieved fromhttps://www.state.gov/wp-content/uploads/2019/05/US-Advisory-Council-2019-Report.pdf

      ). 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 (

      National Child Traumatic Stress Network (NCTSN). (n.d.). Understanding and addressing trauma and child sex trafficking. Policy Brief. Retrieved fromhttps://www.nctsn.org/resources/understanding-and-addressing-trauma-and-child-sex-trafficking-policy-brief

      ; ).
      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 (

      National Child Traumatic Stress Network (NCTSN). (n.d.). Understanding and addressing trauma and child sex trafficking. Policy Brief. Retrieved fromhttps://www.nctsn.org/resources/understanding-and-addressing-trauma-and-child-sex-trafficking-policy-brief

      ;

      Polaris. (2018b). Healthcare providers play a crucial role in victim identification. Retrieved fromhttps://polarisproject.org/blog/2016/11/03/healthcare-providers-play-crucial-role-victim-identification

      ). Some factors compelling nondisclosure include fear, distrust of authority, shame, hopelessness, and trauma bonds (
      • Greenbaum V.J.
      • Dodd M.
      • McCracken C.
      A short screening tool to identify victims of child sex trafficking in the healthcare setting.
      ). 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 (

      National Child Traumatic Stress Network (NCTSN). (n.d.). Understanding and addressing trauma and child sex trafficking. Policy Brief. Retrieved fromhttps://www.nctsn.org/resources/understanding-and-addressing-trauma-and-child-sex-trafficking-policy-brief

      ; ), 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
      Source:
      • Peck J.L.
      Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part two.
      .
      ResponseAction items
      Evidence-BasedPractice 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-InformedSafety-

      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-ResponsiveIdentify 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
      Note. CT, child trafficking.
      FIGURE 1
      FIGURE 1National Human Trafficking Hotline. Source:

      National Human Trafficking Hotline. (2019). National human trafficking hotline. Retrieved from https://humantraffickinghotline.org/

      .
      (This figure appears in color online at www.jpedhc.org.)
      TABLE 3Open-ended conversation approaches
      Source:

      National Human Trafficking Resource Center. (2019). Comprehensive human trafficking assessment. Retrieved from https://humantraffickinghotline.org/resources/comprehensive-human-trafficking-assessment-tool

      .
      Concern for labor traffickingConcern for sex trafficking
      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.

      RECOMMENDATIONS FOR CALLS TO ACTION

      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 (
      • Gordon M.
      • Fang S.
      • Coverdale J.
      • Nguyen P.
      Failure to identify a human trafficking victim.
      ). Pediatric HCPs should not conduct forensic interviews if not properly trained to do so.
      TABLE 4Recommended calls to action
      Evidence-Based, Trauma-Informed, Survivor-Informed, Culturally-Responsive
      EntityAction items
      Individual HCPsSeek 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 EnvironmentsEstablish 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 InstitutionsImplement 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
      TABLE 5Resources for individual HCPs, health care organizations, and academic institutions
      OrganizationResourceWebsite
      ACT, National Association of Pediatric Nurse Practitioners Partners for Vulnerable YouthACT Advocates Train the Trainer program for healthcare professionals and speaker's bureauhttps://www.napnappartners.org/act-advocates-program
      Dignity HealthShared Learnings Manualhttps://www.dignityhealth.org/hello-humankindness/human-trafficking
      Dignity Health in partnership with HEAL Trafficking and Pacific Survivor CenterPEARR Tool (A Trauma-Informed Approach to Victim Assistance in Health Care Settings)https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool
      HEAL TraffickingProtocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings

      Recent Publications and Reports

      Webinars
      https://healtrafficking.org/protocol-toolkit-for-developing-a-response-to-victims-of-human-trafficking-in-health-care-settings/

      https://healtrafficking.org/publications-and-reports/

      https://healtrafficking.org/webinars/
      PolarisNational Human Trafficking Hotlinehttps://humantraffickinghotline.org/
      Shared Hope InternationalState Report Cards for Sex Trafficking Lawshttps://sharedhope.org/what-we-do/bring-justice/reportcards/2018-reportcards/
      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 HealthSOAR 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
      https://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training/soar-online
      U.S. Department of Homeland SecurityBlue Campaign- A national public awareness campaign designed to educate the public, law enforcement and other industry partners to recognize and respond to human traffickinghttps://www.dhs.gov/blue-campaign
      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 (
      • Richards T.A.
      Health implications of trafficking.
      ). Health care professionals should contribute to critical efforts to identify situations CLT in addition to situations of CST (
      • Ronda-Perez E.
      • Moen B.E.
      Labour trafficking: Challenges and opportunities from an occupational health perspective.
      ). 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 (

      Dignity Health (n.d.). Taking a stand against human trafficking. Retrieved from https://www.dignityhealth.org/hello-humankindness/human-trafficking

      ). 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 (
      • Barnert E.
      • Iqbal Z.
      • Bruce J.
      • Anoshiravani A.
      • Kolhatkar G.
      • Greenbaum J.
      Commercial sexual exploitation and sex trafficking of children and adolescents: A narrative review.
      ). 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 (). Organizations should ensure that employees know how to contact the

      National Human Trafficking Hotline. (2019). National human trafficking hotline. Retrieved from https://humantraffickinghotline.org/

      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 (
      • Peck J.L.
      Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part two.
      ). Care should be taken to construct tools with a strong scientific approach and implement rigorous efforts to assess reliability and validity.
      FIGURE 2
      FIGURE 2International Classification of Diseases, 10th Revision, Clinical Modification codes for trafficking. Source:

      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 (
      • Le P.D.
      Human trafficking and health research: Progress and future directions.
      ).

      CONCLUSIONS

      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 (
      • Peck J.L.
      Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part two.
      ). 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.

      Appendix. SUPPLEMENTARY MATERIALS

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      Biography

      Jessica L. Peck, Clinical Professor of Nursing, Louise Herrington School of Nursing, Baylor University, Friendswood, TX.
      Mikki Meadows-Oliver, Associate Professor of Nursing, Quinnipiac University, Hamden, CT.
      Stacia M. Hays, Clinical Assistant Professor, University of Florida, Gainesville, FL.
      Dawn Garzon Maaks, Clinical Professor, University of Portland, Portland, OR.