“Sam” sat before me, inappropriately dressed for the cold weather, dismissive, hurting, and guarded. At age 15, with divorced parents and shuffling back and forth between homes, Sam had been on her own, at least mentally, for a number of years already. She recently had run away from home but was found by her father and brought in for abdominal pain. I soon asked Sam’s concerned father to leave the room, which he did, and after explaining the rules of confidentiality and mandated reporting I dived into the “teenager questions,” what I call questions about “sex, drugs, rock and roll”—reproductive health, illicit substance use, and abuse.
Because I knew the warning signs, and because Sam answered that she is sexually active “but only when drunk,” I asked Sam a question I’ve never asked before: “Do you ever trade sex for money or shelter or stuff?” Her answer: “Yeah, sure, sometimes.”
We continued our interview and I contacted our social worker, who continued the visit with Sam and her dad.
The commercial sexual exploitation of children is a domestic problem that affects 100,000 American children in the United States each year, according to the most reliable estimates.1 In what has been termed “modern day slavery” by President Obama and “child sex trafficking” by others, children as young as 7 years old are being bought and sold for purposes of sexual exploitation, including prostitution and Internet pornography. Ten percent of US children living in shelters and 28% of US children living on the streets report exchanging sex for drugs or money.2 Social workers, police officers, teachers, and physicians all may interact with these children regularly and unknowingly. Because the average age of a child entering “the life” is just 13 years old, pediatricians have a unique opportunity to help.1
However, pediatricians are not recognizing these children because we are under the mistaken notion that these children never make it to our care. A recent study found that 28% of European trafficking victims had seen a healthcare professional while still in captivity.3 Even when health professionals acknowledged that trafficked victims appeared in their emergency departments, most healthcare providers lacked confidence that they would be able to identify these victims, and almost all had received no training in recognizing the signs of trafficked victims.4 Preliminary survey data support this (Titchen, Chin, Sharif, unpublished data, 2013), showing that most medical students, residents, and physicians agree that it is important to know about human trafficking while a minority understand the scope of the problem and know what to do when they encounter a trafficked child.
Although trafficked children can be male or female, straight or gay, and of any race or ethnic background, they tend to have a few common characteristics. They may be from the foster care system, broken homes, or they may be runaways. Many are taught by their abusers to avoid eye contact, thus appearing “defiant” to healthcare practitioners. Many are dressed inappropriately for the weather or time of year. Some will present with signs of physical abuse, particularly dental or head injuries, or repeated sexually transmitted diseases. Chronic abdominal pain is a common complaint of sexually violated girls. Some will be “branded” with a tattoo bearing their pimp’s name. Occasionally, a controlling adult who speaks for the child or refuses to leave the exam room will accompany the child.5-9
In caring for these children, it is important to treat them as you would any other patient: Attend to physical needs; establish rapport and trust by inquiring about the child’s immediate comfort and well-being; establish a private and confidential environment; and inquire sensitively yet directly about the patient’s safety, nutrition, and autonomy, including the ability to come and go freely. Understand that you as the physician are one of many stepping-stones in this patient’s journey back to health. Avoid the rescue fantasy, especially with older teens; one visit is unlikely to fix everything. Be up front about mandated reporting and confidentiality.10
Above all, give the patient a reason to return. Schedule a follow-up appointment for them; get them plugged into social work resources; and provide written instructions about their needed follow-up. This may be the patient’s only legitimate excuse to ever meet with a healthcare practitioner again.10 Do not give written information about abuse hotlines and other resources because these can endanger the patient. Do provide the easily memorized 888-3737-888 national human trafficking hotline phone number or the text address “BeFree” (233733) to patients verbally. If possible, provide your pager or work phone number to the patient for his or her cell phone.
I cannot say with certainty that Sam was trafficked, but she was certainly at risk. Sam was fortunate that she had at least one parent who was appropriately concerned and involved in her life. For many others, their physician may be the only adult concerned enough to intervene, but intervention hinges on the physician recognizing the warning signs.
US Department of Justice. The National Strategy for Child Exploitation Prevention and Interdiction: A Report to Congress, August 2010. http://www.justice.gov/psc/docs/natstrategyreport.pdf. Accessed February 24, 2014.
Edwards JM, Iritani BJ, Hallfors DD. Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States. Sex Transm Infect. 2006;82(5):354-358.
Family Violence Prevention Fund, World Childhood Foundation. Turning Pain into Power: Trafficking Survivors’ Perspectives on Early Intervention Strategies. San Francisco, CA: Family Violence Prevention Fund; 2005.
Chisolm-Straker M, Richardson L. Assessment of emergency department (ED) provider knowledge about human trafficking victims in the ED (Abstract 336). Acad Emerg Med. 2007;14(suppl 1):S134.
Barrows J, Finger R. Human trafficking and the healthcare professional. South Med J. 2008;101(5):521-524.
Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health. 2010;55(5):462-467.
O’Callaghan MG. The health care professional as a modern abolitionist. Perm J. 2012;16(2):67-69.
Newby A, McGuinness TM. Human trafficking: what psychiatric nurses should know to help children and adolescents. J Psychosoc Nurs Ment Health Serv. 2012;50(4):21-24.
Sabella D. The role of the nurse in combating human trafficking. Am J Nurs. 2011;111(2):28-37.
Lloyd R, Orman A.Training Manual on the Commercial Sexual Exploitation of Children (CSEC). New York: Girls Educational Mentoring Services (GEMS); 2009.