According to the U.S Department of State, human trafficking is the subjugation of an individual “through force, fraud, or coercion…to involuntary servitude, forced labor, or commercial sex”1. Out of the estimated 40.3 million victims of human trafficking worldwide, approximately 25% are children 2. In the United States, it is suspected that hundreds of thousands of victims, both adults, and children, are currently involved in human trafficking, with the number of reported cases increasing annually 2.
Trafficking affects children of all races, ethnicities, and socioeconomic backgrounds, but children from some of the most vulnerable circumstances are often at higher risk. Runaways, youth in foster care, and children with prior abuse are particularly at risk for human trafficking 3,4. Due to the increased risk of homelessness, LGBTQ+ youth are also at higher risk 4. One study based in New York City estimated that over 1 in 4 LGBTQ+ youth experiencing homelessness are victims of human trafficking 5.
Children who have been trafficked have both short and long term health problems while trafficked and as survivors. These can include mental health consequences such as suicidal ideation and PTSD, physical health consequences such as malnutrition and fractures, and substance abuse and addiction6. Trained pediatricians have the opportunity to recognize and intervene for victims and facilitate their road to survivorship. Survivors of child trafficking have significant health needs, and medical providers who are knowledgeable about human trafficking can provide compassionate, trauma-informed care to help meet their needs. Although statistics on how many trafficking victims encounter the healthcare system can be challenging to estimate, in a study of 98 survivors by Lederer et al., it was as high as 87.8%7. While the most common places victims encountered the healthcare system were emergency departments and walked in clinics, victims presented to a variety of medical settings, including primary care offices 7. Another study of 12 human trafficking victims in Los Angeles found medical visits primarily focused on testing and treating sexually transmitted infections, pregnancy testing, and medical abortions 8. Some barriers for accessing healthcare identified by victims included their trafficker accompanying them to the appointment, feelings of guilt and shame, and difficulty establishing trust with the healthcare provider 8. In a Southern California study, additional barriers identified by victims included: generalized fear and anxiety, wanting to protect their confidentiality, limited knowledge of resources, and believing the healthcare to be of poor quality 9.
Given that a significant proportion of human trafficking victims encounter the medical system before and after survivorship, but experience significant barriers, education on recognition and intervention has been proven to increase provider index of suspicion. One study in Central Pennsylvania surveying 4,925 healthcare providers and medical students found 57.06% of respondents felt they are likely to interact with a human trafficking victim in the healthcare setting, but 47.51% felt they were not confident in their abilities to identify potential victims 10. This study highlights the critical need for education on this topic across all levels of training. Another example of a promising intervention was an education presentation on human trafficking given to healthcare providers in fourteen emergency departments in San Francisco 11. A statistically significant difference in pre and post-intervention test scores was observed in identifying victims of human trafficking and recognizing supportive community resources 11.
Pediatric Trainees at Rainbow Babies and Children’s Hospital in Cleveland, Ohio, have started to educate their cohort on the identification and assistance of victims of child trafficking seen at their institution. With the development of badge-sized cards containing an algorithm for use at the bedside for cases of suspected trafficking and the survivor-approved education materials, they hope their sessions will have a more significant impact on victim assistance. Their preliminary survey results show that their intervention correlates with an increase in confidence in recognizing victims in the clinical setting. While further research quantifying the effectiveness of such interventions is needed, we believe that every program should be trained on the recognition and intervention of potential trafficking survivors with the ultimate goal of creating a safer medical system for survivors and victims with long term trauma centered care.
In addition to victim identification, providing training on the long-term healthcare needs of human trafficking survivors, and risk factors that make a person more susceptible to becoming a victim, are both areas of healthcare provider education that can be strengthened 12. An example of a valuable resource is the SOAR (Stop; Observe;Ask; Respond) training, which was developed for healthcare professionals by the U.S. Department of Health and Human Services (HHS) Office on Trafficking in Persons (OTIP). It is evidence-based and uses standards from a study of survivors and experts to develop guidelines and objectives 13.
Ultimately, child human trafficking is an issue that affects thousands of children across North America with significant long term health consequences for survivors. A significant proportion of victims come into contact with the healthcare system but cannot access help due to a host of barriers. We hope that pediatric training will continue to be strengthened in victim identification, reporting, and supporting survivors. We hope that pediatric trainees will be inspired to work with their educational institutions to improve teaching on this topic and contribute to the development of a new curriculum. Future work focusing on the development of educational tools such as the work featured by trainees in Cleveland, Ohio, in this paper are required along with research studies analyzing their effectiveness. Medical students and residents will be vital to this cause.
Contributing Medical Trainees: Karishma Manji, Anjali Garg, Preeti Panda, and Paul Slodovonick
- Major Forms of Trafficking in Persons. U.S. Department of State. https://2009-2017.state.gov/j/tip/rls/tiprpt/2008/105377.htm. Published 2008.
- The Facts. Polaris. https://polarisproject.org/human-trafficking/facts. Published 2017.
- Harper E, Kruger A, Varjas K, Meyers J. An Organizational Consultation Framework for School-Based Prevention of Commercial Sexual Exploitation of Children. Journal of Educational and Psychological Consultation. 2018:1-22. doi:10.1080/10474412.2018.1552155
- Lockwood W. Human Trafficking. Rn.org. http://www.rn.org/courses/coursematerial-10024.pdf. Published 2018.
- Child Sex Trafficking Statistics. Thorn. https://www.thorn.org/child-trafficking-statistics/. Published 2019.
- Zimmerman C, Hossain M, Watts C. Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science & Medicine. 2011;73(2):327-335. doi:10.1016/j.socscimed.2011.05.028
- Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Health Law. 2014;23(61). https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.
- Baldwin S, Eisenman D, Sayles J, Ryan G, Chuang K. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):e36-49. https://www.jstor.org/stable/pdf/healhumarigh.13.1.36.pdf?seq=1#page_scan_tab_contents.
- Ijadi-Maghsoodi R, Bath E, Cook M, Textor L, Barnert E. Commercially sexually exploited youths’ health care experiences, barriers, and recommendations: A qualitative analysis. Child Abuse Negl. 2018;76:334-341. doi:10.1016/j.chiabu.2017.11.002
- Sinha R, Tashakor E, Pinto C. Identifying Victims of Human Trafficking in Central Pennsylvania: A Survey of Health-Care Professionals and Students. J Hum Traffick. 2018;5(2):165-175. doi:10.1080/23322705.2018.1448956
- Grace A, Lippert S, Collins K et al. Educating Health Care Professionals on Human Trafficking. Pediatr Emerg Care. 2014;30(12):856-861. doi:10.1097/pec.0000000000000287
- Stoklosa H, Grace A, Littenberg N. Medical Education on Human Trafficking. The AMA Journal of Ethic. 2015;17(10):914-921. doi:10.1001/journalofethics.2015.17.10.medu1-1510
- SOAR Works!. Substance Abuse and Mental Health Services Administration. https://soarworks.prainc.com/topics/soar-online-course.