Human Trafficking in the Pediatric ED

Humans can be awful to one another. This is unfortunately very apparent to us who work in the Emergency Department. Violence often surrounds the events that lead to patients needing to seek care. While we spend lots of time focusing on the traumatic injuries that may be the consequence of that violence (of the 550 Ped EM Morsels posted, there are actually 202 references of Trauma currently), we also need to be aware of the other aspects of people being cruel to others. Previously we have spoken about Sexual Assault and Abuse, two terrible presentations that may not be obvious at first. We have learned to be alert for possible clues to these cases (ex, Sentinel Bruising). Another horrific situation that we all need to be vigilant for is Human Trafficking. Let us take minute to remind ourselves of the prevalent problem of Human Trafficking in the Pediatric ED:

Human Trafficking: Misconceptions

  • Human Trafficking only occurs in ‘other cities’.. not mine.”
    • Human Trafficking is a worldwide and prevalent problem. [Becker, 2015; 25651385]
    • Victims have been identified from over 150 countries. [Kaltiso, 2018]
    • Cases have been reported in ALL 50 United States! [Becker, 2015; 25651385]
    • ~27 million men, women, and children are victims of human trafficking worldwide.
    • ~20,000 victims are trafficked into the USA each year!
    • Internationally, human trafficking generates up to 32 billion US dollars (more than the illegal arms trade).
  • Victims are usually undocumented immigrant females.”
    • Human Trafficking victims do not belong only to one group of people. [Becker, 2015; 25651385]
    • Victims of trafficking include:
      • Both males and females
      • Citizens and foreign nationals (documented and undocumented)
        • Human Trafficking Reporting System shows that 85% of sex trafficking victims were US citizens. [Kaltiso, 2018; 30381877]
      • All regions of the socioeconomic spectrum
      • Both children and adults
        • Human Trafficking Reporting System shows that 55% of sex trafficking victims were minors. [Kaltiso, 2018]
    • The diversity of victims makes it challenging to identify them – Only a small fraction of victims are successfully identified.
  • Human trafficking refers to patients being smuggled into a country for prostitution.”
    • The crime of human trafficking is much more expansive – not limited to prostitution / sex exploitation.
    • The United Nations describe Human Trafficking as being composed of 3 elements:
      • The Act:
        • Recruitment, transport, transfer, harboring, or receipt of persons
      • The Means:
        • By threat or use of force, coercion, fraud, deception, abuse of a position of vulnerability, giving payments or benefits, or abduction
      • The Purpose:
        • For exploitation
    • Geographic relocation is not necessary to be a victim of human trafficking. [Becker, 2015; 25651385]
    • Physical force, abuse, or restraint may be involved, but are not necessary characteristics of human trafficking. [Becker, 2015; 25651385]
    • Other examples of human trafficking include:
      • Sexual Exploitation
      • Forced Labor
      • Debt Bondage
      • Domestic Servitude
      • Forced Begging
      • Child Soldiers
      • Forced Marriage
      • Organ Removal
  • “The teenager did not report being forced into prostitution, so it cannot be human trafficking.”
    • Consent of the victim (or even payment received) does not negate the potential for human trafficking.
    • Any person <18 years of age who is involved in prostitution is considered a victim of sex / human trafficking regardless whether force, fraud, or coercion is used (because it is regarded as an abuse of position of the vulnerable).
  • Human trafficking is an issue for the police and lawyers… victims do not show up in the ED.
    • Victims may present with authorities for medical clearance.
    • Victims are also at risk of several health-related problems: [Kaltiso, 2018; 30381877]
      • Physical injuries
      • Sexual Transmitted Infections
      • Dental problems
      • Substance abuse disorders
      • Depression, Anxiety, and Post-traumatic Stress Disorder
      • Suicidality
    • Victims are also know to present with other non-specific physical complaints: [Ottisova, 2016; 27066701]
      • Headaches
      • Abdominal Pain
      • Back Pain
    • One study showed that 81% of victims had been seen by a medical provider during the year prior to being identified. [Goldberg, 2017; 27575407]

Human Trafficking: Red Flags

Risk Factors for Victimization and Human Trafficking [Kaltiso, 2018; 30381877]
  • Prior abuse
  • Substance abuse
  • Prior involvement in the juvenile justice system
  • History of running away from home
  • LBGTQ identification
A Screening Tool to use in the Pediatric ED for Child Sex Trafficking
  • Kaltiso, et al. [2018; 30381877] applied a screening tool to an inner-city Pediatric ED Population who had high-risk complaints and found the screening tool had high sensitivity and high negative predictive value.
  • The screen tool (created by Greebaum et al.) consists of 6 questions:
    • Is there a previous history of drug/alcohol use?
    • Has the patient ever run away from home?
    • Has the patient been involved with law enforcement?
    • Has the patient ever broken a bone, had traumatic loss of consciousness, or sustained a significant wound?
    • Has the patient ever had a Sexual Transmitted Infection?
    • Does the patient have a history of sexual activity with more than 5 partners?
  • Kaltiso, et al. found that having a positive history of sexual activity AND two other positive questions was associated with a Sensitivity of 90.9% and a Specificity of 64.6%.
    • Having any 2 questions be positive had a similar Sensitivity (90.9%), but lower specificity (53.1%).
  • Clearly the screening tool is more effective at excluding Child Sex Trafficking and cannot confirm it nor be used reliably for other forms of human trafficking.
  • If patient screens positive using this tool, additional clarification should be sought (ex, was the episode of running away a low risk event or high risk?) and consult Social Work / Child Protective Services.

Human Trafficking: How to Help

  • If you have suspicion that a patient may be a victim of Human Trafficking, then contact:
    • Social Work (if you have one available)
    • Child Protective Services agency (if patient is < 18 years of age)
    • Local Law Enforcement (if you believe that the patient is in immediate danger)

Moral of the Morsel

  • Human trafficking does not require traffic. It involves a vulnerable person being exploited by another person(s).
  • That seemingly simple complaint may be a sign for a much bigger problem. Stay alert and vigilant for signs and clues for your vulnerable pediatric patients being possible victims of human trafficking.
  • Just because you don’t see it, doesn’t mean that it isn’t happening. Victims of Human Trafficking are likely coming through you ED. Try to help them!

References

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Sean M. Fox
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
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