Child Sex Trafficking in the U.S. is Real — and a New Tool can Help Doctors Identify Victims

At least one in every 10 minors visiting emergency departments, child advocacy centers and teen clinics for sexual trauma or assault are victims of child sex trafficking, according to a recent study in the Journal of Adolescent Health. That number is likely even higher, however, since children seen in study locations who were excluded from the study (those who were intoxicated, extremely agitated, mentally incapable of providing consent or unwilling to participate) represent a high-risk group that may be more likely than average to have experienced sex trafficking.

According to federal law, child sex trafficking (CST) occurs when anyone younger than 18 engages in any commercialized sexual activity (including producing pornography, prostitution, or performing in a sex-related business) in exchange for something of perceived value, such as shelter, food, drugs, money or luxury items. Activities don’t have to be forced or coerced, since minors cannot legally consent.

“Everybody says we have a human trafficking problem in the United States, but nobody actually knows what the prevalence is. Our aims for the study were to find an objective measure of the prevalence and to determine the validity of a screening tool across different health care settings,” says Mary Jo Bowman, MD, attending physician in emergency medicine at Nationwide Children’s Hospital and the principal investigator of the multicenter study for its two Nationwide Children’s locations. “We were surprised at how high the prevalence was, even though these types of health care settings are the ones most likely to see victims of sex trafficking.”

The study included data from 16 facilities: five pediatric emergency departments, six child advocacy centers and five teen clinics, all of which were located in urban areas. The research team collected data and responses to a short CST screening tool from 811 participants. Health care providers also asked follow-up questions as needed and recorded their opinion about the child’s CST status, which was used as the “gold standard” to validate the tool.

Ninety children (11.1 percent) were classified as CST victims. The screening tool had an overall sensitivity of 84 percent and a specificity of 57.5 percent, which improved to 65.6 percent after a poorly associated question was removed from the tool. The final tool was effective at identifying children who were not likely victims (97.1 percent negative predictive value), and the study authors believe that even with sensitivity missing up to 17 percent of victims, the tool represents an enormous gain over current CST identification standards, which are largely nonexistent.

“We want to be able to screen and educate providers. We want to have people looking for these victims,” says Dr. Bowman, who conducts nurse and clinician education on human trafficking at Nationwide Children’s and volunteers with multiple antitrafficking organizations in her free time. “Having a fast, simple tool as a prompt can help remind health care providers to keep that concern top of mind.”

The emergency departments and The Center for Family Safety and Healing at Nationwide Children’s have continued using the screening tool for victims of sexual assault since the study’s completion. The screening is now part of the patient history process and is provided using a digital tablet. Dr. Bowman is working on getting the screening’s results directly linked with the hospital’s medical record system to simplify data collection and record management for affected youths. She has additional CST-related research in progress and submitted for publication.

“It’s important to know that child sex trafficking actually happens,” says Dr. Bowman. Historical research indicates that many patients do not volunteer or even consider their sex trafficking status despite interaction with the health care system, placing the onus on medical personnel to identify victims.

“These patients were seen and not identifying or even thinking about it. And it’s not just one or two people that it happens to — it’s a significant number of people,” says Dr. Bowman. “And now we have a screening tool to help these people find the resources they need to get out of the activity or not get into it in the first place.”

When a victim is identified, Dr. Bowman says, obtaining as much information as possible from the victim and the person who brought them in for evaluation — one at a time — can give health care providers enough detail to identify the victim and enable follow-up from authorities or social workers when it is safe for clinicians and the child. Dr. Bowman suggests that physicians interested in obtaining additional education and guidance on sex trafficking protocols and resources for affected youths reach out to the National Human Trafficking Hotline.

“We’re at a great starting point for better identifying vulnerable children,” says Dr. Bowman, who hopes to expand use of the tool beyond emergency departments and specialty child and teen centers. “We see so many children in behavioral and mental health services who have anxiety or post-traumatic stress disorder or aggression. If we take advantage of the tool for that population as well, we may find many of our patients with mental health disorders are trafficking victims as well.”

Reference:

Greenbaum VJ, Livings MS, Lai BS, Edinburgh L, Bailie P, Grant SR, Kondis J, Petska HW, Bowman MJ, Legano L, Kas-Osoka O, Self-Brown S. Evaluation of a tool to identify child sex trafficking victims in multiple healthcare settings. Journal of Adolescent Health. 2018 Oct 4. [Epub ahead of print.]