Understanding Domestic Minor Sex Trafficking (DMST) and Considerations for Medical Social Workers and Other Healthcare Professionals in Emergency Departments

The importance of being able to identify and care for children and youth from a victim-centered, trauma-informed approach is essential. Human trafficking is one of the most egregious acts of exploitation of children and youth. The identification of this population, as well as the care of their extensive medical and mental health needs, are emerging priorities in healthcare. Becker and Bechtel (2015) highlighted that healthcare practitioners may be the only professionals who come in contact with trafficked children if they present for medical care. Research reports that human trafficking places children and youth at a high level of risk for unwanted or forced pregnancy, forced abortions, HIV/sexually transmitted infection (STI) exposure, physical and sexual assault, substance use and abuse, malnutrition, depression, posttraumatic stress, and suicide. Within human trafficking is sex trafficking of children and youth, and domestic minor sex trafficking (DMST) will be the focus of this column.

The purpose of this column is to feature considerations for a trauma-informed care approach in hospitals, especially in emergency departments, where young people often present. This is especially important, as research indicated that half of survivors encounter medical providers while seeking primary care services, while at the same time being victimized (Chisolm-Straker et al., 2016). Children and youth present for various reasons in emergency departments, including STIs, physical injuries, sexual assault, suicide attempts, and pregnancy complications (American Academy of Pediatrics et al., 2013; Lederer & Wetzel, 2014). Knowing what DMST is and the barriers that victims face is integral to providing critical care.

Defining Sex Trafficking and Barriers to Care for DMST

According to the United Nations (n.d.), human trafficking includes recruitment, harboring, and transportation or receipt of persons for the purpose of exploitation. This is carried out by force, fraud, or coercion and is involuntary in nature. Unlike other forms of human trafficking, no proof of force, fraud, or coercion is needed when the person is under age 18. Child sex trafficking is also referred to as commercial sexual exploitation of youth, teen prostitution, and/or prostitution of children. According to the National Center for Homeless Education (n.d.), child sex trafficking includes minors being engaged in sexual acts in exchange for giving or receiving anything of value such as money, clothing, drugs, food, and shelter. This is also common among homeless minors who may engaged in survival sex to obtain basic necessities for survival. The Victims of Trafficking and Violence Protection Act (2000) broadly defines sexual acts to include street-based and Internet-based sex, survival sex and pornography, as well as other acts in any location. The DMST is for the purposes of commercial sex act of minors (O’Brien, 2018).

The needs of children and youth involved in DMST in the United Sates are multilevel and cut across professional areas of housing, health and mental health, legal services, and basic social service needs such as food and shelter (Kotrla, 2010), and they continue to persist. There are also ongoing barriers to care, one being the inability to identify DMST victims when they present at an emergency department. Contributing to this challenge is the lack of self-disclosure by the young people themselves, which results in treatment prioritizing the apparent health issues, when signs that trafficking caused those issues are not obvious (J. Greenbaum et al., 2015; Lederer & Wetzel, 2014). The lack of self-disclosure may be due in part to the trauma-bond and cycle of abuse that DMST victims are experiencing (Sahl & Knoepke, 2018). Another barrier is that minors are usually presented with adults who might be their traffickers. There are also reasons for not being able to identify victims, on account of the medical providers, including social workers. This is due to lack of knowledge and training and limited validated screening tools (Einbond et al., 2020). This positions healthcare professionals as part of the solution to supporting children and youth involved in DMST. Emergency departments are critical access points (Wallace et al., 2021), to provide safety, support, and services to DMST victims.

Victim Identification Strategies for Integration in Hospital-Based Settings

Trauma-informed screening protocols where victims are likely to be encountered, such as emergency departments, should be considered. The literature suggests several strategies and tools to identify victims of sex trafficking in healthcare facilities (Baldwin et al., 2011; Schwarz et al., 2016) and consider specifically screening for minor sex trafficking in emergency departments (Becker & Bechtel, 2015).

The process usually starts with screening for “red flags” to suspect trafficking. While risk factors make people vulnerable to being trafficked, red flags are signs of being trafficked (Schwarz et al., 2016). Common red flags include untreated STIs; tattoos or branding of ownership; patients who cannot explain the injury; patients who are not aware of their location, the current date, and time; and patients who are not in possession of their identification documents (National Human Trafficking Resource Center, 2019). Additionally, the perpetrators usually accompany victims to the health facility posing as a friend or family member (Becker & Bechtel, 2015; Patel et al., 2010). Traffickers are often well dressed and well spoken and may offer to translate for the victim, speak on behalf of them, and insist on remaining in the examination room. Thus, it is important to separate the victim from the accompanied person for a private physical examination in the emergency department. In cases with non-English speakers, it is important to work with a trained interpreter to avoid retraumatization.

Identification of victims of sex trafficking follows by asking questions to screen for specific indicators. Although there are several screening tools, Hainaut et al. (2022) in their scoping review determined only six validated tools to identify or screen for victims of human trafficking in healthcare settings. The following tools specifically targeted victims of child trafficking: Screening Tool for Victims of Human Trafficking (Egyud et al., 2017); Short Screen for Child Sex Trafficking (V. J. Greenbaum, Dodd, & McCracken, 2018); Short Screen for Child Sex Trafficking (2016, six questions); Short Screen for Child Sex Trafficking (V. J. Greenbaum, Livings, et al., 2018); and SEXual health Identification Tool (Hammarström et al., 2019). Most of these tools have requirements such as the presence of red flags that would then prompt the screening process. The Short Screen for Child Sex Trafficking (V. J. Greenbaum, Dodd, & McCracken, 2018) is the only tool that has been evaluated in several studies and stated that answering “yes” to just two of those questions properly identified child sex-trafficked victims, with a sensitivity of 92 percent, specificity of 73 percent, positive predictive value (PPV) of 51 percent, and a non-PPV of 97 percent.

Despite healthcare professionals using validated tools, many victims do not disclose their trafficking status because of a lack of trust, fear of the trafficker, guilt and shame, or lack of awareness that they are being trafficked (Armstrong, 2017). Also, many existing tools include questions about victims’ recent traumatization, which are potentially triggering. In addition, some of the instructions do not let the potential victim know they are being asked questions that could disclose victimization and may require a mandated report. Thus, training for healthcare professionals, including medical social workers in emergency departments, needs to focus on implementing a trauma-informed approach in the identification of victims of DMST.

Considerations for Social Workers and Multidisciplinary Hospital-Based Teams

The opportunity to learn, reflect, and share strategies on the topic of human trafficking would ultimately enhance services across network of groups in the training of healthcare professionals. It is important to consider Bronfenbrenner’s (1976, 1977) ecological framework, which includes the individual, relational, social, and environmental aspects of a person, when dealing with human trafficking (Barner et al., 2018). This perspective centers children and youth while taking into account their historical and current environments that place them in states of multiple vulnerabilities. A culturally competent understanding for social workers requires understanding of the impact of the legal, medical, and social system on the victim. For example, victims repeatedly retelling their stories to various members of their care teams or subsequent community members (police, outside social workers) may retraumatize victims (Mullin, 2020).

There is a growing amount of literature that focuses on developing the practice of delivering aftercare services in the provision of care (Macy & Graham, 2012). While children and youth are presenting at emergency departments, it is critical to be intentional about the continuum of care including aftercare services. Macy and Graham (2012) recommend that providers identify referrals and resources for victims (in this case DMST) before implementing screening strategies. This would involve strengthening work and collaboration with community-based organizations and other youth service organizations in the community.

The ecological framework goes on to expand and further illustrate the risk factors of DMST related to individual risk factors such as history of child abuse, LGBT identity, and history of being systems-involved, as well as relationship risk factors that include familial dysfunction and disruption, as children and youth may be exposed to and experience domestic violence. Then there is the level of community risk factors that may include underresourced schools, neighborhoods, and communities, along with gang involvement. Next is the level of societal risk factors that may include sexualization of children and lack of awareness of sexual exploitation (Goldberg & Moore, 2018). Utilizing this framework, understanding the difference between children and youth who have experienced DMST and those who have experienced child sexual abuse will also be important for healthcare professionals in emergency departments, as the distinction help with follow-up care and treatment, with the initial importance of being able to identify the victim of DMST.

There are also clinical considerations for medical social workers skilled in trauma-focused cognitive–behavioral therapy, dialectical behavioral therapy, and eye movement desensitization and reprocessing as these types of interventions are evidenced as effective for people who experience trauma (Clawson & Goldblatt Crace, 2007). Incorporating these trauma-informed strategies into practice would strengthen not only healthcare professionals’ ability to identify victims, but also the nurturing of an environment where victims are likely to disclose. Victims face psychological impacts of sex trafficking such as complex trauma and experience a worldview that is altered and inhibits the ability to escape and leave their situation (Hardy et al., 2013; Lloyd, 2011).

The lived experiences and intersectional identities of victims are critical to research and practice approaches and should continue to be prioritized, given that multiple oppressed identities are taken into account, including gender identities, as part of community-based participatory research. Moss et al. (2020) highlighted the importance of treatment algorithms and the need to recognize behavioral challenges among children and youth emphasizing that de-escalation strategies are a necessary protocol in the identification process. Egyud et al. (2017) found that education and treatment algorithms were effective in improving recognition of victims and the need for screening in emergency departments, nationwide.

The authors would like to thank Lisa Tuchman, MD, MPH, and Katherine Deye, MD, who served as principal investigators on a Children’s National Health System demonstration project that was federally funded by the U.S. Department of Justice, Office of Victims of Crime. The authors appreciate Drs. Tuchman and Deye and their team for their commitment and expertise on adolescent health and medicine. The Moss et al. (2020) report was based on evaluation work related to this project.

References