Evidence Based Strategies: The First Step Toward Safety - Evidence-Based Screening for Child Sex Trafficking and Exploitation

Child sex trafficking (CST) represents a breach of fundamental human rights and a significant public health concern. It occurs when a child or adolescent < 18 years of age exchanges a sexual act for something of perceived value, such as money, food, shelter, safety, drugs or material items. Importantly, CST includes the production of sexual content. Because minors cannot legally provide consent, force, coercion or fraud is not required to meet the definition of CST.^1,2

The incidence of CST is incredibly difficult to confirm. One study of approximately 13,000 U.S. adolescents found that 3.5% had exchanged sex for drugs or money.³ Risk factors for CST include, but are not limited to, history of abuse or neglect, running away from home, homelessness, substance misuse, or involvement with child protective services or the juvenile justice system.^2,4 Those that identify as LGBTQIA+ are also at increased risk. Children and adolescents who are trafficked often endure severe violence and psychological manipulation. These experiences place them at heightened risk for a range of health issues, including physical injuries, infectious diseases, substance use disorders, untreated chronic conditions, pregnancy and unsafe abortions, malnutrition, toxic exposures, suicidality, and mental health disorders such as post-traumatic stress disorder.^1,2

Evidence indicates that victims of CST access health care services across various settings, underscoring the critical need for pediatric medical team members to be equipped to identify and respond to potential cases of trafficking and exploitation.^5,6 One study reported 42.9% of victims presenting to health care in the prior two months.⁴ However, identification of these patients remains a significant challenge due to factors such as fear of traffickers, distrust of authorities, shame, hopelessness, trauma bonds, language barriers and other psychological obstacles that inhibit self-disclosure.^2,7 Additionally, victims may present in the company of their trafficker, who may or may not be their legal guardian.

Screening tools have been developed to improve the identification of CST. In a study appraising the feasibility of six such tools, only two were deemed “highly feasible” in the emergency department (ED) setting.⁸ One of these two was developed by Greenbaum et al. in 2018. In their study, participants were English-speaking and aged 12 to 18 years, presenting to the pediatric ED with concerns of sexual assault, abuse or trafficking. Patients were excluded for extreme developmental delay, intoxication, or if they declined the screen. Eligible participants were interviewed outside the presence of the caregiver. Of the 108 participants, 25 were classified as victims of CST or sexual exploitation, and 83 were classified as victims of sexual assault or abuse without trafficking. Six screening questions were identified via multivariable logistic regression analysis. A positive answer to two or more of the questions was considered a “positive” screen. The screen was able to differentiate CST or sexual exploitation from sexual assault or abuse without trafficking with a sensitivity of 92.3%, specificity of 74.4% and odds ratio of 21.6 (95% confidence interval [CI], 5.9-79.7; P < 0.001).⁹

A subsequent study evaluated the same screening tool in health care settings beyond pediatric EDs, including child advocacy centers and teen clinics.² Participants were English-speaking and 11-18 years of age, but unlike the initial study, did not need to present with sexual concerns. Exclusion criteria were the same. Importantly, the screen was administered in private. Of the 810 participants, 90 (11.1%) were classified as victims of CST. As in the prior study, a positive answer to two or more of the questions was considered a “positive” screen, which had a sensitivity of 84.4% (95% CI: 75.3, 91.2) and specificity of 64.6% (95% CI: 61.0, 68.1).

Recognizing the importance of early identification and intervention, the Children’s Mercy Human Sex Trafficking Clinical Pathway Committee convened to establish recommendations across the health care system. The pathway committee endorsed the use of this screening tool by Greenbaum et al. for patients ≥ 11 years of age with risk factors for being trafficked. The clinical pathway provides risk factors, tips for maintaining patient safety and confidentiality, recommendations for those at risk or who have been trafficked, and educational materials for patients. Additionally, the pathway includes two brief educational videos for medical team members that exemplify how to communicate with patients about confidentiality, the use of the screening tool, and next steps following a positive screen. The clinical pathway can be found at Human Sex Trafficking - Children’s Mercy.

When a victim of CST presents to the pediatric ED, primary care clinic or other care setting, there is a critical opportunity for pediatric clinicians, nurses and social workers to identify potential trafficking and provide essential support. Evidence-based screening is the first step toward a coordinated and trauma-informed response to meet the unique and urgent needs of trafficked children and adolescents.

References:

1. Greenbaum J, Kaplan D, Young J; Council on Child Abuse and Neglect; Council on Immigrant Child and Family Health. Exploitation, labor and sex trafficking of children and adolescents: health care needs of patients. Pediatrics. 2023;151(1):e2022060416. doi:10.1542/peds.2022-060416
2. Greenbaum VJ, Livings MS, Lai BS, et al. Evaluation of a tool to identify child sex trafficking victims in multiple healthcare settings. J Adolesc Health. 2018;63(6):745-752. doi:10.1016/j.jadohealth.2018.06.032
3. 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. doi:10.1136/sti.2006.020693
4. Varma S, Gillespie S, McCracken C, Greenbaum VJ. Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse Negl. 2015;44:98-105. doi:10.1016/j.chiabu.2015.04.004
5. Hornor G, Sherfield J. Commercial sexual exploitation of children: health care use and case characteristics. J Pediatr Health Care. 2018;32(3):250-262. doi:10.1016/j.pedhc.2017.11.004
6. Hornor G, Hollar J, Landers T, Sherfield J. Healthcare use and case characteristics of commercial sexual exploitation of children: teen victims versus high-risk teens. J Forensic Nurs. 2023;19(3):160-169. doi:10.1097/JFN.0000000000000402
7. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36-E49.
8. Armstrong S. Instruments to identify commercially sexually exploited children: feasibility of use in an emergency department setting. Pediatr Emerg Care. 2017;33(12):794-799. doi:10.1097/PEC.0000000000001020
9. Greenbaum VJ, Dodd M, McCracken C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care. 2018;34(1):33-37. doi:10.1097/PEC.0000000000000602