There are several chronic medical and psychiatric health sequelae or presentations of victims of DMST (Table 25.2). One retrospective cohort study of adolescents presenting to a health center for specific evaluation of DMST concerns found that the most common chief complaints of previous medical visits included psychiatric issues (28%), abdominal or back pain (13%), physical injury (9%), gynecologic complaint (8%), and sexual abuse/assault (8%) [28]. Like Maria, victims of physical or sexual abuse may present with chronic pelvic pain (CPP), defined as at least 3–6 months of noncyclic pain at or below the umbilicus and interfering with daily activities [29]. The differential diagnosis for CPP in the adolescent female is broad including infectious, such as pelvic inflammatory disease; gynecologic, including dysmenorrhea and endometriosis; and functional abdominal pain (Table 25.3). Depression and anxiety are associated with CPP, and these may be either a cause or result. Finally, the physician should have a high index of suspicion for CPP as sequelae of chronic or acute PID, especially given that adolescents are at increased risk for PID because of cervical ectopy and increased behavioral risk taking [30]. Maria’s history included two episodes of PID , which sets her up for CPP.

A 2015 American Academy of Pediatrics clinical report on child sex trafficking recommends asking three pointed questions when the patient exhibits several signs of DMST victimization: (1) Has anyone ever asked you to have sex in exchange for something you wanted or needed (money, food, shelter, or other items)? (2) Has anyone ever asked you to have sex with another person? (3) Has anyone ever taken sexual pictures of you or posted such pictures on the internet? [31] It would have been prudent for the physician to ask Maria if she had ever traded anything for sex and to follow up on Maria’s statement that she sometimes would “work something out” on the street to obtain opioid medication: a positive response could alert providers to the possibility that Maria was a victim of DMST. Furthermore, as homelessness is a major risk factor for DMST, Greenbaum and colleagues encourage asking, “Have you ever run away from home? How many times in the last year?” [32], when the clinician has clinical suspicion for DMST. These questions are likely to have been met with positive responses by Maria.

Because sexual abuse may cause or contribute to CPP, it is imperative that the physician obtains a confidential history from the patient without interference by a parent, guardian, or individual accompanying the patient to her appointment, as was done in Maria’s case [33]. In addition, it is a good idea to preface questions involving abuse with reassurance that such questions are routine and standard and do not reflect judgmentalism. This is especially relevant when asking about the number of sexual partners: a victim of DMST who discloses his or her situation may report hundreds of sexual encounters. And like Maria, victims of DMST are less likely to have used a condom at last sexual encounter, putting them at high risk for STIs and HIV infection [31].

If an acute history of sexual assault is elicited, a sexual assault evidence kit may be offered within 3–4 days of the trauma as well as pregnancy, STI, HIV, HEP B and C, and syphilis testing. Physicians may refer to CDC guidelines of STI testing in cases of assault [34].

Forced tattoos may also represent physical assault, and many victims of trafficking are branded with symbols that represent a certain pimp or trafficker , or they may be tattooed with dollar signs or profanity [10, 27, 32] (Fig. 25.1). Questions about tattoos may include the open-ended “Tell me about your tattoo,” as well as inquiry about use of clean needles and tattoo placement of the patient’s own volition versus forced tattooing or branding [35].

Because direct questioning about signs specific to trafficking may elicit anxiety and distress from the patient, a trauma-informed approach is needed. This requires the establishment of rapport and trust by inquiring about the patient’s immediate needs, establishing a private and confidential setting, and using sensitive language, with avoidance of terms that confer judgment, such as “prostitute” and “hooker” [10]. Prior to any questioning, limits of confidentiality should be reviewed, and disclosure of trafficking should not be forced [10]. Instead, autonomy should be restored to the patient, and it should be emphasized to the patient that she or he is not required to provide answers to questions and that all questions are being asked for the sole purpose of providing better risk assessment and patient care [36].

Unfortunately, in a survey of physicians at all stages of training, researchers found that although a majority of physicians acknowledge the importance of awareness of human sex trafficking, only 40% stated that they knew whom to call if they encountered a DMST victim , and most are not familiar with existing resources [37]. To help guide clinical encounters, the National Human Trafficking Resource Center (NHTRC) created an algorithm to help identify, triage, and refer victims [38]. (Fig. 25.2).

The NHTRC (phone number 888-3737-888) can provide the physician and health-care professional with resources for patients on a state and even local level. The phone number is easily memorized and should be given to patients verbally and privately in the health-care setting. In addition, patients may text “BeFree” if they are in immediate danger. In each case, a volunteer at the NHTRC will return their communication in a safe, private manner and with an ability to provide resources such as housing, medical, and legal help to the patient. For the protection of the patient, no information regarding resources for human trafficking should be printed for the patient in the event that the patient’s trafficker finds such materials and is enraged.