CHAPTER 143
Commercially Exploited Children and Human Trafficking
Jordan Greenbaum, MD
CASE STUDY
At age 17 years, Joe ran away from home to escape family violence and maternal substance use. He had no money or resources while living on the street, so he exchanged sex acts for money, food, shelter, clothes, and drugs. Many of the other homeless youth were doing the same, and they provided support to each other. None of the youth was operating under the control of a “pimp.” Joe continued to engage in “survival sex” until age 19 years, at which time he met a man who promised to get him more clients and money. Joe agreed to the arrangement and stayed with this man for 1 year, giving him 30% of what he earned. Eventually Joe made the decision to stop this work, but when he announced this to his “friend,” the man beat him and told Joe he could not quit and must continue selling sex to “earn his keep.” Further, the man threatened to tell Joe’s family that he was selling sex unless Joe agreed to deliver drugs to a dealer in another city. Joe’s involvement in commercial sex and the drug trade continued for 6 months. Today, Joe arrives at your clinic and requests testing for HIV and sexually transmitted infections.
Questions
1. What are some of the risk factors associated with a trafficked individual?
2. What is the typical sequence of events that precede becoming trafficked?
3. In a patient, what are possible indicators of human trafficking?
4. What is the best means of approaching a patient who may be experiencing sex or labor trafficking?
5. Is Joe, the patient in the scenario, being trafficked? Why or why not?
Epidemiology of Child Trafficking
According to United States federal law, child sex trafficking occurs when an individual engages a minor (younger than 18 years of age) in a commercial sex act (ie, any sexual act that involves an exchange of something of value); no force, fraud, or coercion is necessary. Thus, children or adolescents exchanging sex for food or money to purchase luxury items are trafficked persons, as are those who are engaged in the production of child sexual exploitation images (formerly referred to as “child pornography”) and those working in strip clubs. Neither involvement of a third party in the sexual transaction nor transportation of the individual from 1 place to another is necessary to constitute child sex trafficking. However, once the youth turns 18 years of age, the adult definition of sex trafficking applies, which requires the demonstration of force, fraud, or coercion as a means of exploitation. Thus, Joe, the patient presented in the case study, was being sex trafficked while he was a minor (ie, exchanging sex to fill critical survival needs), but once he turned 18, the survival sex was no longer considered “trafficking” because no obvious force, fraud, or coercion was involved. When Joe is working for the “friend” and that person assaults him when Joe wants to leave commercial sex work, Joe becomes a victim of adult sex trafficking because force has been used; Joe’s previous “consent” in the commercial sexual activity becomes irrelevant.
Throughout this chapter, the term “victim” is used in its objective, legal sense as indicating a person who has been harmed as a result of some event or action or who has suffered as the result of someone else’s actions. The term does not refer to how the individual may feel or perceive himself or herself as a result of the event or events and is not intended to be used to label that individual.
Both child labor trafficking and adult labor trafficking involve recruiting, harboring, transporting, providing, or obtaining an individual for labor using force, fraud, or coercion. This may involve either use of physical or psychologic tactics or abuse of the legal system in an effort to force an individual to work (ie, involuntary servitude). It may also involve charging an individual an exorbitant amount and forcing the individual to work off the debt (ie, debt bondage). Children and adults may be trafficked in a wide variety of industries, both legal and illegal. Some of the more common industries include domestic servitude (eg, nanny, live-in maid), construction, agriculture, nail salons, sales crews, the hospitality industry, restaurants, and peddling or begging. Individuals may be trafficked in criminal activities, such as drug dealing or theft. In some cases, especially among females, both labor and sex trafficking occur. Joe is experiencing both labor and sex trafficking: he is coerced (via threats) to engage in illegal drug activity and is being forced to engage in commercial sex work.
Reliable prevalence rates for labor and sex trafficking are elusive, given the criminal nature of the activity, the reluctance of trafficked persons to report the crime, the lack of a centralized database and consistently used definitions, and the fact that many individuals do not realize they are being exploited. Statistics of identified trafficked persons suggest that girls are more vulnerable to sex trafficking than boys, although reporting bias, under-recognition, and reluctance to report likely contribute to the lack of identified males. Both males and females are vulnerable to labor trafficking, especially in the adolescent age group. Risk factors for child trafficking are described in Table 143.1. Research consistently demonstrates very high rates of prior abuse and neglect, as well as runaway/homeless status and involvement with child protective services and/or juvenile justice systems among sex-trafficked youth; these factors are very likely relevant to labor trafficking as well, although less research is available on this type of exploitation. Poverty, natural disasters, forced migration, and dysfunctional family situations may drive a child into a labor or sex trafficking situation. Exploitation may occur at any age, although adolescents age 13 to 17 years tend to be overrepresented. Limited research suggests that intrafamilial trafficking may involve younger children, on average, than trafficking involving non-family members, and may involve children in a wider age range. Trafficking occurs among children of all races, ethnicities, religions, cultures, and socioeconomic statuses.
Clinical Presentation
Research suggests that a large proportion of identified trafficked persons, especially those who are involved in sex trafficking, seek health care during or shortly before their period of exploitation. In 1 study of adolescent/young adult trafficked persons, 82.5% were seen at the local children’s hospital within the year prior to identification. In another study of sex-trafficked adolescent females, 42.9% had received health care within the 2 months prior to identification. Numerous studies from around the globe have documented a wide array of adverse physical and mental health effects associated with trafficking, including physical injury (from work-related accidents, to physical or sexual assault); HIV and other sexually transmitted infections (STIs); non-sexually transmitted infections, such as tuberculosis; malnutrition and dehydration; unplanned pregnancy and complications thereof; substance misuse; chronic pain; posttraumatic stress disorder; depression and suicidality; somatic symptoms; and behavioral problems.
| Table 143.1. Risk/Vulnerability Factors for Child Trafficking: Socioecological Model | |
Level | Description |
Individual | History of sexual violence; physical abuse and/or neglect Homeless, runaway, or throwaway status a Involvement with juvenile justice system and/or child protection services Substance misuse Untreated mental health and/or behavioral problems LGBTQ+b status Migration (especially unaccompanied minors) Lack of official documents (eg, immigration document, card, or visa, birth certificate) |
Relationship | Intimate partner violence Family poverty and/or unemployment Family dysfunction Limited education Parent/guardian and/or peers involved in commercial sex work or purchasing sex Intolerance of LGBTQ+ status Forced migration |
Community | Tolerance of sexual exploitation Lack of community resources High crime rate (especially organized crime) Tourism and/or transient populations in area Lack of awareness about child trafficking Adult sex work in area Gang activity |
Societal | Gender-based violence and discrimination Cultural attitudes and/or beliefs Natural disasters Political and/or social upheaval, military conflict Law enforcement and/or political corruption Lack of acknowledgment of child rights |
a Throwaway status: child told to leave home or told not to return home.
b Lesbian, gay, bisexual, transgender, queer/questioning, or other sexual minority (see Chapter 57).
Given the plethora of adverse health consequences, trafficked children and youth may present with any of a wide variety of chief concerns. Such individuals may present for evaluation of sexual or physical assault (often with a false history provided), requests for STI or pregnancy testing, other genitourinary symptoms, behavioral issues, attempted suicide, drug intoxication, or sexual abuse. They may present with chronic medical conditions that are unrelated or only indirectly related to their exploitation (eg, asthma exacerbation from lack of access to the patient’s medications). Evidence of adverse health effects may be noted incidentally, such as a finding of scarring from cigarette burns on physical examination.
Care may be sought in a variety of health care settings. Although studies show a large proportion of trafficked persons seeking care in emergency departments and reproductive care clinics (especially Planned Parenthood), trafficked persons may also attend clinics for teenagers, community health centers, school clinics, private pediatrician practices, specialty clinics, mental health clinics, psychiatric hospitals, dental practices, or surgical practices. Trafficked children and adolescents may present to a health care facility alone or with peers (who may be traffickers, other survivors, or friends unaware of the exploitation). They may be accompanied by a parent or other relative (who may or may not be a true relative and who may or may not be involved with the trafficking), an employer, or some other adult.
Trafficked persons may be very reluctant to disclose their exploitative situation to health professionals. This may be secondary to distrust of authority, language barriers, shame, guilt, fear of retaliation by a trafficker, fear of arrest or deportation, fear of being sent back to foster care, or a desire to protect the trafficker, whom the trafficked person feels is looking out for his, her, or their best interest. In the latter case, a patient may have developed strong “trauma bonds” with the trafficker related to the highly stressful, manipula-tive character of the relationship. These bonds may prevent the trafficked person from realizing the exploited status and result in the trafficked person actively defending the trafficker. In other cases, a patient may not perceive the situation to be exploitative because it has been normalized or because the individual is unaware of his or her human and legal rights.
If spontaneous disclosure by a patient is unlikely, presenting symptoms may be varied, and a patient may or may not be accompanied by a trafficker, how does a health professional recognize a trafficked child or youth, or one who is at high risk for exploitation? The health professional should be aware of risk factors for trafficking and some of the potential indicators that may be present at the time of the health visit (Table 143.2). It is important to note that the indicators are nonspecific and may be absent in a given case.
Evaluation
A traumatized patient, such as a patient who has experienced sex or labor trafficking, needs a trauma-informed approach to health care. According to the Substance Abuse and Mental Health Services Administration, the trauma-informed approach incorporates a real-ization that traumatic experiences may profoundly affect the individual, family, group, organization, and community. Trafficked children and youth often have experienced repeated severe trauma, both before and during their period of exploitation. Their feelings, attitudes, and behaviors are shaped by these experiences; they interpret the world around them, including the words and behaviors of others, through a trauma lens. Stress reactions and behaviors developed to survive in a dangerous situation may lead traumatized patients to behave in ways that, to a health professional, appear maladaptive. A trauma-informed physician can recognize signs of trauma and trauma-related stress and respond in a supportive, nonjudgmental, and empathic manner. Such physicians demonstrate openness, respect, and cultural sensitivity. They take steps to increase the patient’s sense of safety (physical and psychological), trust, and resilience. Additionally, these health professionals make every effort to minimize re-traumatization associated with the health visit. They use a victim-centered approach, in which the best interest of the patient drives all questions, discussions, plans, and activities. Key concepts of a trauma-informed approach to care are presented in Table 143.3.
| Table 143.2. Potential Indicators of Child Trafficking | |
Evaluation | Indicator |
Initial presentation | Patient presents either alone or with multiple peers requesting treatment Patient or companion gives inconsistent or implausible history Patient appears depressed, fearful, or quite anxious Patient is unfamiliar with the city or town, cannot give address where staying Patient’s companion is: Domineering and apparently intimidating to the patient Speaking for the patient or trying to insist on translating for the patient Reluctant to answer health professional’s questions, impatient for discharge Reluctant to leave patient alone with the health professional Is not the patient’s guardian |
History | Sexual, emotional, or physical abuse or neglect Runaway, homeless, or throwaway status a Involvement with child protective services or juvenile justice system LGBTQ+ Behavior problems and/or mental health history >5 sex partners Multiple prior sexually transmitted infections Pregnancy (or fathering a child) Forced migration Patient is an immigrant and not in control of official documents Relatives and/or peers participate in commercial sex work, whether selling or buying |
Physical examination | Flat affect; withdrawn or hostile/aggressive Signs of posttraumatic stress disorder (eg, dissociation, hypervigilance, triggered anxiety responses) Patterned injuries or injuries in protected areas (neck, ears, torso, upper arms, thighs) Evidence of anogenital trauma or infection Signs of substance use/misuse Signs of malnutrition, dehydration Certain types of tattoo (eg, sexual inuendo, street name, gang insignia) Patient inappropriately dressed for weather Patient with large amount of cash, a few expensive items, multiple cell phones |
a Throwaway status: Child or youth is told to leave home or told not to return home. Abbreviation: LGBTQ+, lesbian, gay, bisexual, transgender, queer/questioning, or other sexual minority.
Effectively working with trafficked individuals involves respect for fundamental human rights, including respect for the patient’s race/ethnicity, sex, gender, sexuality, religion, social status, and cultural beliefs, without demonstrating bias or discrimination. It involves respecting a patient’s right to information that is provided in an understandable manner and the patient’s right, as developmentally appropriate, to actively participate in the patient’s own care. Additionally, it involves respecting the patient’s rights to privacy and confidentiality.
| Table 143.3. Concepts of a Trauma-Informed Approach to Care | |
Concept | Attitudes and Behaviors |
Screen for trauma (ie, human trafficking) | The physician is aware of risk factors and potential indicators of human trafficking and asks questions to assess the level of risk for exploitation. The goal is not necessarily to obtain a disclosure but to assess risk so as to be able to respond appropriately and offer resources. If the health professional is a mandated reporter, the professional’s response to a patient deemed to be at high risk for exploitation is the same as for a patient who is known to be trafficked; that is, report to authorities and offer resources/referrals and anticipatory guidance. Having certainty about exploitation is not required, and pushing a patient to disclose is not appropriate. |
Safety | The health professional takes steps to increase the patient’s physical comfort (eg, uses private, youth-friendly room; inquires about the patient’s basic physical needs) and decrease stress and anxiety. The health professional ensures the physical safety of the patient and staff and interviews the patient with the companion(s) out of the room. |
Trust | The health professional takes time to build rapport; maintains nonjudgmental, empathic attitude; actively listens to the patient; demonstrates interest in learning about the patient’s situation; and avoids making assumptions. |
Respect | The health professional demonstrates respect by explaining what the professional wants to do and why (eg, reasons for asking questions, conducting examination, ordering tests), seeks permission (truly informed consent) for every step of the health visit, and accepts the patient’s perspective and decisions without argument or applying pressure to change the patient’s mind.a The health professional listens more than talks. |
Transparency | The health professional explains limits of confidentiality early in the medical interview, uses simple language when explaining the process of the visit and suggestions for treatment, and thoroughly explains the process of reporting to authorities (as applicable). |
Strengths-based approach | The health professional seeks to identify patient strengths (ie, resilience), facilitates patient awareness and appreciation of the patient’s own strengths, and acknowledges that the patient is the expert on himself or herself. |
Patient engagement and empowerment | The health professional actively encourages patient questions, discussion and suggestions for care; asks the patient questions about the patient’s own view of the situation and what might help improve it; solicits feedback on the health professional’s ideas for treatment and referral; and offers the patient choices and control whenever possible throughout the health care visit. |
Cultural sensitivity | To the extent possible, the health professional is aware of and sensitive to cultural differences between the professional and the patient; and the health professional takes steps to understand the patient’s cultural perspective and to respect cultural preferences when possible. The health professional asks questions about how the patient perceives relevant problems and solutions as well as the patient’s views on health care and on the patient’s current life situation. |
Emphasis on minimizing re-traumatization | The health professional asks only the questions necessary to guide the examination, evaluation, anticipatory guidance, treatment, and referrals and to assess safety; monitors the patient for verbal and nonverbal signs of distress during the medical interview and examination; takes steps to reassure and support the patient; and has a plan in place to manage major psychological distress. |
Available resources/referrals | The health professional or a designee creates a list of community, regional, and national resources to provide to the patient; establishes relationships with community victim service agencies and knows their services and eligibility requirements; and arranges a “warm hand-off”b to the referral agency when possible. |
a Respecting a patient’s decision about evaluation and treatment assumes the absence of life-threatening health issues that require emergent care, such as uncontrolled bleeding.
b In the “warm hand-off,” the health professional directly contacts the victim service agency to discuss and arrange the referral or assists the patient with making contact while in the health facility (eg, allowing patient to use the telephone in a private room, providing the agency number, offering assistance as needed).
If a patient presents with risk factors for, potential indicators of, or other concerns for possible trafficking, the health professional will need to ask additional questions to assess risk (with the patient’s assent). Questions to consider are shown in Box 143.1.
If the patient is willing, it is helpful to include in the medical history a detailed reproductive history, including information such as gender identity and sexual orientation, number of sexual partners, age at first sexual intercourse, and use of condoms. Addressing these issues opens the door for anticipatory guidance, helps indicate what resources or referrals may be necessary, and assists the health professional in gauging risk for sexual exploitation. Because of the very high rates of posttraumatic stress disorder and depression among victims of sex and labor trafficking, a brief mental health screening is appropriate to determine whether emergency psychiatric intervention is necessary. Screening for substance misuse is also indicated.
With patient consent, a thorough head-to-toe physical examination will allow assessment of nutrition, hydration, and any evidence of chronic disease. The trauma-informed approach extends to the physical examination, and it is important that the health professional explain each aspect of the examination and proceed slowly, being mindful of any sign of distress from the patient. Thorough documentation of extragenital and genital injury is important; this is best done with photographic documentation and a thorough written description of injuries. A chaperone (not the individual[s] accompanying the patient) must be present for the examination to monitor the patient for signs of distress. It is common for sex-trafficked youth to experience anxiety and distress with the anogenital examination, and if episodes of the patient’s victimization have been recorded in the past, the use of cameras or videorecorders during the examination may trigger additional stress. For suspected sex trafficking and cases of labor trafficking that might also involve sexual exploitation and/ or assault, an anogenital examination should be offered to the patient. If the health professional is not confident in conducting a detailed anogenital examination, it is appropriate to contact a specialist, such as a sexual assault nurse examiner or a child abuse pediatrician.
Box 143.1. Sample Questions for Assessing Risk for Trafficking
•I see many kids who live on the streets or run away from home, and most of them have a very hard time obtaining the money they need to survive. Many have to resort to exchanging sex to get food, shelter, money, drugs, or other things. Do you know anyone who has had to do that? Have you ever felt like you were in that position? Can you tell me about that?
•Has anyone ever offered to pay you to have sex? If so, do you feel comfortable telling me about that?
•Can you tell me a bit about your job? Maybe take me through a typical day for you?
•Are the working arrangements you have now at your job what you expected they would be? If not, can you tell me a bit about that? How are they different from what you expected?
•Has there ever been a time when someone asked you to do or forced you to do something that made you feel uncomfortable? Do you feel comfortable telling me about it?
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