Interstate Human Trafficking Youth Survivors: Clinical and Forensic Considerations

Abstract

Child trafficking continues to be underreported due to multiple factors including differences in state laws, lack of a centralized database, and overall under-recognition. The care of such youth often entails forensic as well as significant clinical considerations given their traumatization. We report on our experience with a 14-year-old female who presented to an Emergency Department (ED), brought in by law enforcement after her parents filed a missing person report in a different state, with concerns about human trafficking; the patient expressed suicidal ideation in our ED. The patient was placed under involuntary hold, after obtaining collateral from the her parents. During the hospitalization, legal challenges presented barriers to safe discharge and a need to collaborate for providing care between disciplines and across state lines. At the same time, through validation and support in the therapeutic milieu of an adolescent psychiatric unit, she was able to understand that she had just survived sexual assault and began to process the impact of it. Although no medication changes were made, the patient began to develop insight at the time of discharge to the Child Protective Team.

Introduction

Child trafficking continues to be underreported due to multiple factors including differences in state laws, lack of a centralized database, and overall under-recognition. ¹ In a study of trafficked adolescents/young adults, 82.5% were seen at a local children’s hospital within a year before identification. ² These statistics and the following case report highlight healthcare barriers for trafficked persons at the level of clinicians, level of the health system, ³ and level of legal systems.

Case Presentation

A 14-year-old female (pseudonym Sharon) with a history of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), anxiety, and multiple psychiatric hospitalizations in her home state presented involuntarily to an Emergency Department (ED), brought in by law enforcement officers, for concerns of human trafficking after the parents of the child (POC) in the home state filed a missing person report over one month ago. Upon arrival at the ED, Sharon expressed suicidal ideation (SI), and psychiatry consultation was done. At the time, the patient did not report experiencing sexual assault, but did report being given multiple substances including cannabis, molly, and alcohol while staying with an unknown adult male. The patient’s urine drug screen was positive for fentanyl. Psychiatry consultation was done in the ED for the evaluation of involuntary hold upon the medical clearance.

To proceed with a trauma-informed care approach, the psychiatry fellow contacted Sharon’s parents via phone first, in order to get details and further information from the parents rather than having Sharon re-explain and relive the experience. POC expressed that Sharon had been trafficked out of her home state over one month ago with an unknown older male and discussed the pain, frustration, fear, and overall confusion that had ensued since they found out less than 12 hours ago that Sharon was located in a different state. POC had gotten a call from the ED physician informing about involuntary hold due to Sharon expressing SI in the ED. POC reported that they were unsure of the SI reported by Sharon now, since she had “drugged up for days,” possibly high on methamphetamine or other substances when POC last spoke with Sharon via phone. POC stated that Sharon was not herself, but that Sharon had told POC, “I don’t to want to kill myself, I was scared and I said that.”

The child psychiatry fellow expressed concern about Sharon’s low weight and shorter height per the review of documented vital signs and screens for intellectual disability or other medical or developmental issues with her parents. POC expressed that this is the skinniest she has ever seen her (via video in the ED), but that in general, Sharon is “little/short like a lot of people in the family.” In general, POC stated that Sharon had never been underweight in her life. She had no developmental issues or missed milestones/delayed milestones.

POC stated Sharon never had any intellectual delays, adding that Sharon’s grades were average and she was generally very intelligent and “too smart for her own good, always quick as a whip.” They stated that Sharon does have a prior psychiatric history and was previously on fluoxetine 40 mg for depression and hydroxyzine 20 mg BID for anxiety and had recently been prescribed quetiapine 100 mg, which had not yet been started. She had a trauma history including sexual exploitation in the past. POC had concerns that there was a prior incident of human trafficking during that sexual exploitation as the person she was with was an adult male, who was later arrested.

Sharon had expressed SI in the past, but that was in the context of a recent trauma and in the context of bereavement of a family member. Sharon had a close working relationship with her psychiatrist in her home state, with whom she had a good rapport

POC reported they wanted to come to see their daughter right away, but had many barriers to coming to the hospital. For one, they were told by police/authorities to wait to cross state lines because the perpetrator was being processed for jail. The Department of Children and Families (DCF) from their home state wanted POC to cooperate with the internal home state DCF investigation and wanted POC to meet with detectives in the home state. POC were also facing robust financial barriers including flight cost upward of $1200 dollars and ongoing lack of clarity of which state DCF would be able to help fund their travel and possible extended hotel stay. POC were attempting to gather funds on their own including speculating about selling their car or getting a loan to obtain funding quicker. They expressed continued frustration about being 20 hours away by car from their child.

POC requested re-evaluation of involuntary hold given that Sharon may or may not be suicidal based on substances in system or based on circumstances. POC reported that they were supportive of Sharon getting into the psychiatric hospital if it was indicated, but wanted a re-evaluation to determine if that was the appropriate thing to do.

Collateral information was obtained, and based on that, the consults team and attending discussed the best plan of care. Per the chart review, Sharon had already been asked to do a pelvic exam and to re-explain circumstances of admission to multiple providers. It was predetermined by the psychiatry team that the patient should only be asked pertinent, urgent questions given the extended trauma she likely had been through while in hospital by having to explain and re-explain her experience. The team pre-planned to keep the interview brief to respect Sharon’s likely state of fear, overwhelm, and exhaustion.

On initial encounter, Sharon laid on her bed holding a stuffed animal. She was asked if any male members of the team preferred to be excluded from the interview. This was done in order to help Sharon feel comfortable and safe given the trauma she had just experienced. Sharon was screened for any substance withdrawal. She stated that she had experienced withdrawal from using cannabis, molly, and alcohol before and is aware of what symptoms to look for. When asked what psychiatry could help Sharon with, she stated it is hard to remember what psychiatry was doing for her in her home state. When asked if she has had thoughts of SI or self-harm, she answered, “[a] little bit,” and when asked to expand on this, she stated she would rather not. The involuntary hospitalization was explained briefly to her, and that once she got the medical clearance, she would likely be going to the psychiatric hospital, to which she nodded.

Mental Status Exam had pertinent findings of disheveled appearance, limited eye contact, thought content of SI without expressed plan or intent, and speech low in volume, hesitant, and hypo-verbal. Some memory deficits were noted, and affect was guarded and constricted.

On Day 2, late in the night, Sharon was transferred to psychiatric hospitalization. The case was followed by the consult fellow; in reviewing the chart it was noted in nursing documentation that Sharon expressed not wanting to be in the hospital upon arrival. Sharon initially did not report any sexual assault by the older male, both in the medical hospital and again at the time of psychiatric hospital admission. Although group therapy was encouraged, Sharon was given agency to decline participation. In her daily interactions with staff and physicians, she was treated with supportive psychotherapy. The inpatient staff adhered to the hospital’s Trauma-Informed Care Model, in which Sharon did not need to repeat and relive the events of her trauma. The inpatient physicians, nurses, therapists, and staff were able to facilitate an environment of minimal pressure to allow her time to process what had occurred.

Multiple legal challenges and disposition challenges arose while Sharon was in the psychiatric hospital. On the morning of Day 3, neither Sharon nor POC wanted to start medications because the plan was to return to her home state and proceed with treatment by a home psychiatrist. Social work, case management, physician, home state DCF, and presenting state DCF had to coordinate care and have multiple meetings. The case was referred to hospital administration to determine safe and legal disposition planning. At the time of discharge on Day 5, Sharon reportedly began to develop insight about having experienced trauma. She was able to state to the treatment team that she had been sexually abused. Sharon was discharged to the Child Protective Team with her parents, who were finally able to fly over to participate in care for their daughter.

Discussion

This case highlights the multiple barriers that arise for patients and families when navigating the healthcare system. It also emphasizes the ethical dilemma that came up regarding continuing Sharon’s involuntary hospitalization and determining if more prolonged psychiatric hospitalization would be indicated. An assessment and treatment plan was designed after thoughtful consideration. Given the information of her prior history of sexual exploitation, Sharon appeared to be at a high risk to be trafficked again due to high level of vulnerability and recent trauma. Yet, if held involuntary, she would be subject to staying in a locked facility after being in a confined space for the past month. This would be a restrictive treatment for someone who had just stayed in a restrictive and abusive environment away from home already.

There was also concern that Sharon could be further traumatized at a psychiatric hospital, where she would be exposed to people with more severe psychiatric conditions. The team carefully discussed the implications of psychiatric hospitalization on the patient’s ability to have agency after this experience.

However, Sharon’s expressed suicidality with little to no detail provided left a level of concern from both primary team and psychiatric team that could not be ignored. In such circumstances, some time away from the stressors allowed her to begin to reflect in a therapeutic environment about the events that had occurred. Despite challenges on the unit, she was in a safe space until next steps could be determined. She was able to be in a therapeutic milieu. With each interview and interaction on the unit, she was being exposed to the concerns from doctors, nurses, and therapists. This likely helped to validate that what she went through was traumatic. She presented as denying what had occurred; this numbing may have been a guarded defense for survival to mitigate experiencing traumatic stress. Hearing people’s concern and support may have helped her drop her defenses and start to process the impact of what had happened.

Conclusion

This case may be able to help other children impacted by human trafficking by drawing attention to the rising rates of human trafficking in the United States and other nations and by presenting readers with helpful information about the dynamics of child trafficking. It is important that people understand how entrapment occurs so that victimization can be prevented through increasing awareness. As written by Louise Shelley, author of Human Trafficking: A Global Perspective, human trafficking does not circumscribe to a particular nation or culture. She states, “Everywhere in the world, the consequences of human trafficking are devastating for its victims and for its larger community… all of society suffers from such victimization. Other casualties include the principles of a democratic society, the rule of law, and respect for human rights.” ⁴

Multiple people can be involved in the organization and maintenance of trafficking, and they do this by exercising psychological manipulation and control over vulnerable populations. ⁵ It is important to note that recruitment techniques of human traffickers often involve preying on people who are already struggling with psychiatric histories of depression, trauma, or social stress, ¹ so that they may entrap vulnerable children. They often give false promises of a better life, romance, financial assistance, and fraudulent job opportunities ⁶ and exercise control through deceptive tactics of offering “free” help, then capitalizing on the victim’s helplessness in a new location with new laws. This unfamiliarity of a new situation allows the trafficker to give the victim intentional misinformation and often leads children to not even recognize that their situation is exploitative. ⁷ In this case, the patient had risk factors of psychiatric history and prior trafficking. The promise of romance and a better life were used as tactics to recruit, and having her in an unfamiliar state was used as a method of control and manipulation.

This case discussion hopes to elicit understanding of what the patient and family go through, and all of the barriers that come along the way. The case report hopes to spark further discussion about what we can do at the ground level in our day-to-day life to help patients experiencing this and also to inspire physicians to advocate for legislative changes and funding to be allocated for prevention of such crimes.

Furthermore, this case displays the value of a therapeutic holding environment in helping youth trafficking victims to process traumatic experiences in a low-pressured safe space. Supportive psychotherapeutic techniques provide validation, support, and encouragement; all three of these things are much needed for a trauma survivor. A psychiatric unit can provide this support, but a similar environment could be replicated in a structure such as a youth shelter or a group home setting. The survivor would then have access to clinical or near-clinical expertise while processing the trauma.