The ethics and urgency of identifying domestic minor sex trafficking victims in clinical settings

Abstract

A critical opportunity for identifying children experiencing domestic minor sex trafficking exists in healthcare settings. This quantitative study documented the disconnect between youth seeking help and interventions offered by healthcare providers. Ninety-one sex youth exploited through sex trafficking answered questions detailing their experiences of seeking medical treatment for injuries associated with selling or trading sex. Healthcare providers who were aware that injuries were sustained due to sex trafficking did not always alert legal or mandated reporting authorities. This analysis identified violations of the four pillars of ethical healthcare. This investigation revealed lost opportunities to intervene on behalf of youth suffering trauma and abuse from sex trafficking highlighting the necessity for a formal protocol in healthcare settings to effectively intervene.

Introduction

Prior research has yet to identify the exact number of children who experience domestic minor sex trafficking, which includes involvement in prostitution, exotic dancing, pornography, and other activities. ¹ Research suggests that health services are one of the most common points of access to children and youth exploited through sex trafficking, along with law enforcement and the child welfare system. ² The ways in which these vulnerable youth are perceived and treated by first responders, including healthcare providers, child welfare workers, and other professionals have implications on how willing they are to self-identify as victims and ask for help. Youth experiencing sex trafficking distrust helping professionals because they are often criminalized for prostitution and related charges associated with running away from home, such as truancy, curfew violations, and other illegal activities.^3–6 The purpose of this study is to demonstrate that missed opportunities in healthcare providers interactions with children and youth impacted by sex trafficking constitute failures to meet ethical obligations.

Background

Dr Macias-Konstantopolos ⁷ convincingly argued that healthcare providers have an ethical obligation to improve the treatment of trafficking victims through the principles of autonomy, nonmaleficence, beneficence, and justice. These ethical principles, originally outlined by Beauchamp and Childress, ⁸ need to be reconsidered as they relate to children and youth experiencing sex trafficking. Accordingly, this research presents information on youth who were sex trafficked before the age of 18 years and their experiences within the healthcare system plotted along the four pillars of medical ethical obligations: autonomy, nonmaleficence, beneficence, and justice. In doing so, we document the disconnect between the ethical responsibilities versus the realities of healthcare providers who commonly encounter children and youth experiencing sex trafficking, yet infrequently identify and offer intervention.

Health consequences associated with sex trafficking include a range of physical and sexual/reproductive injuries as well as psychological trauma.^9–11 Evidence shows that children and youth experiencing sex trafficking seek medical care at hospitals, urgent care centers, and other medical clinics throughout the United States.^10,12,13 Therefore, healthcare professionals are in a unique position to aid children and youth exploited through sex trafficking. Identification of exploitation, intervention, and referral for services are all critical steps in caring for sex trafficking-involved youth, as untreated physical and mental injuries can lead to lifelong challenges. ¹² The Center for Disease Control recognizes adverse childhood experiences (ACEs) as a public health crisis due to their lasting negative health consequences into adulthood.^14,15

Evidence suggests that as many as 88% of people exploited through sex trafficking have received medical care during their time of exploitation. ¹⁶ The vast majority of trafficking victims are treated in the emergency department.^16–18 Donahue et al. ¹³ argue that “Hospitalization is one of the few occurrences that intersect the lives of trafficking victims with the general public,” further indicating that healthcare providers have an essential role to play in identifying and assisting these vulnerable youth.

The children and youth victims who are being sex trafficked may not self-identify as needing help. For instance, among 62 children identified as trafficking victims in one pediatric medical facility, less than half self-disclosed a history of involvement in commercial sexual activity. ¹⁰ A majority (82.5%) of those identified had been seen the year prior to their identification visit, with most detailing multiple missed opportunities for early screening. Prior research has highlighted that victims may be reluctant to bring up their exploitation because they are afraid of being judged negatively.^12,19

Healthcare professionals must be aware of sex trafficking red flags and other warning signs. Unfortunately, previous research suggests that anywhere between 63% and 89% of healthcare providers never received training on how to identify children and youth being trafficked or how to effectively intervene if they suspect someone to be a victim.^13,20 Lack of training is reflected in providers who incorrectly answered clinical vignettes regarding the management of patients who have experienced sex trafficking. ²¹ In contrast, when medical providers were educated on trafficking warning signs, they were significantly more likely to describe trafficking as a major local problem, report encountering a trafficking victim in their medical practice, and be more confident in identifying potential victims.^20,22

Healthcare providers’ awareness of human trafficking is not synonymous with knowing how to help or access resources for victims. Research has shown that a significant number of medical professionals do not know whom to call or how to provide assistance to trafficking victims. ²³ Among pediatric clinicians, less than 25% were confident in their ability to identify a child at risk for trafficking, and only 35% felt that they were knowledgeable about their healthcare needs. ²⁴

An additional challenge for healthcare providers is that there are very few screening tools available to aid in identifying children and youth experiencing sex trafficking.^25,26 Development of these screening tools has been relatively recent, and more research is needed on their sensitivity across race, ethnic, and gender groups. ²⁶ Due to the newness and inconsistent use of formal screening tools, victim identification often relies on medical providers’ knowledge of sex trafficking and the ability to recognize risk factors that exacerbate youths’ trajectories into exploitation.

Finally, despite healthcare professionals being mandated reporters of child abuse in all US states, research among mandated reporters, including some healthcare workers, has shown a reluctance to report due to a lack of faith in the utility of interventions. ²⁷ These researchers also found that 25% of the mandated reporters surveyed did not believe that trafficking was prevalent in their communities, and 21% believed that victims were likely to be from countries other than the United States. This prior research reveals gaps in education, training, and medical protocols that need to be addressed in order to provide an adequate level of care.

Ethical principles for intervening with trafficked children and youth

The first principle advocated by Beauchamp and Childress ⁸ is respect for autonomy. Autonomy is defined as “personal rule of the self that is free from both controlling interference by others and from personal limitations that prevent meaningful choice.” ⁸ Liberty (independence from controlling influences) and agency (capacity for intentional action) are both necessary for autonomy. When evaluating children and youth experiencing sex trafficking, liberty and agency are often compromised; victims face controlling influences, both from their traffickers and extreme environmental stress.^12,28

For typical pediatric procedures, medical ethics decisions are usually made by the parents. However, the situation may be different with children impacted by sex trafficking. Family members who accompany the exploited children may be ill-equipped to advocate for them due to high levels of psychosocial challenges (e.g. child welfare involvement, parental mental health, substance abuse, or other family disruption issues). ¹⁰ Autonomy is reduced for youth who have a history of abuse amidst the frequent failures of systems designed to protect them; children and youth experiencing trafficking begin their medical interactions with a diminished sense of agency.

In many cases, healthcare professionals inadvertently restrict autonomy of children experiencing sex trafficking by not dedicating one-to-one discussions with the patients. Allowing adolescents to meet alone with healthcare providers is a best practice in pediatrics for disclosure and autonomy. ²⁹ It is critically important for healthcare professionals to understand the chilling effects of having a trafficker in the exam room with a victim during a possible intervention opportunity. If traffickers are profiting off of the children's sexual exploitation or are wary of legal ramifications, they may encourage them to hide their victimization. Children and youth experiencing sex trafficking likely fear repercussions from their traffickers if they reveal their exploitation. ¹² Children may be directed by their exploiters to lie to medical providers about their injuries, and traffickers may actively work to dissuade medical professionals from reporting the victimization. ²⁸

The second medical ethical principle, nonmaleficence, asserts that one must not inflict harm upon others. ⁸ As mentioned by Macias-Konstantopolos, ⁷ clinicians must be careful not to retraumatize patients by prying for information when working with children experiencing sex trafficking. This does not mean, however, that the solution is to not ask questions. Interactions should be guided by trauma-informed care that is sensitive to previous or current trauma. ³⁰ Trafficked youth may have already experienced negative healthcare encounters during which they felt judged.^12,19 With youth experiencing sex trafficking, there can be added complexities when asking questions (e.g., possible mandated reporting requirements, not asking leading questions that taint disclosure, negative first responses causing children to change their disclosures, etc.).

Beneficence, the third ethical principle, is the moral obligation of contributing to others’ welfare. ⁸ For children and youth experiencing sex trafficking, this goes beyond identifying and reporting; clinicians should seek to understand the patient's unique situations and goals in order to make a satisfactory plan of care. Beneficence for trafficked patients involves building a bridge and making them feel safe to disclose their victimization or ask for help.

Lastly, the ethical principle of justice embodies the fair distribution of benefits, risks, and costs. ⁸ Modern treatment of children and youth experiencing sex trafficking presents an unjust distribution of resources and reduced access to care. ⁷ Injured children rely on adult healthcare providers to understand the complex physical, psychological, and developmental challenges. ²⁴ Youth experiencing sex trafficking should not be the ones to educate providers about their needs for trauma-sensitive care. Sex trafficking victims have complained about having intimate treatment modalities (e.g. pelvic examinations) conducted by male providers despite histories of rape and molestation. ¹²

The failure to have victimization identified or a lack of trauma-informed care may be due to a lack of trafficking education among emergency room staff. ³¹ Even with an awareness of the issue, identification and referrals may not be occurring due to a lack of screening tools, protocols, or confidence among healthcare professionals on how to act.^20,22

Method

The data collected for this study were part of a larger, mixed-methods project surveying youth exploited through sex trafficking and their experiences while trading or selling sex. ³² Recruitment occurred at nonprofit agencies providing services to children and youth impacted by sex trafficking in Nevada. Participants were eligible if they were 18 and 24 years old and were first screened to confirm that they had been trafficked before the age of 18. Screenings were completed by a survivor of domestic minor sex trafficking who had a graduate degree in mental health. Once screened, participants completed an online survey questionnaire and were given a $25 gift card for their time. Study procedures were approved by the authors’ institutional review boards as well as the federal human subjects protection office. Both closed and open-ended questions were included and the frequencies of responses are reported in this article.

Our sample included 91 female-identifying and 5 male-identifying youth exploited through sex trafficking between the ages of 18 and 24 years(average = 20.3). The sample was diverse (30.9% Latinx, 35.1% African American (including Latinx), 19.1% White, 9.6% Mixed, and 5.3% Other). The median age of starting in commercial sexual activity was 16, and more than a quarter (28%, n = 27) were still involved in selling or trading sex at the time of the survey. The majority of the sample reported seeking medical treatment for an injury sustained while trading or selling sex (91.2%, 83 of the 91 answering questions about injuries). The descriptive analyses included in this article were frequencies generated using SPSS (version 27).

Results

In the Results section, we document the shortcomings in meeting the four medical ethics principles outlined by Beauchamp and Childress ⁸ and present evidence of how healthcare providers can better support children and youth using survey findings.

Autonomy

Violations of autonomy were reported with clear limitations in liberty and agency. The majority of the youth experiencing sex trafficking reported that the person who brought them for medical treatment remained present when they were speaking to a nurse or doctor (51.2%, n = 41 of 80 respondents). When asked if the nurse or doctor instructed the person to leave the room during the examination, only 30.8% (n = 24 of 78) reported that such a request had been made. This did not meet the best practice of having healthcare professionals meet alone with adolescents to promote disclosure. ²⁹

In our study, nearly a quarter of our youth exploited through sex trafficking reported that their traffickers were the ones who accompanied them to see medical professionals. When asked who most commonly took them for healthcare for injuries related to their trafficking, 24% (n = 23 out of 82 respondents) reported it was their traffickers, 8% reported their parents or guardians, 7% reported a friend or advocate, and 6% reported a boyfriend or girlfriend. Nearly 40% (n = 38 of 91 respondents) reported seeking help independently most of the time. One person reported that they were taken to the hospital by a random person who found her unconscious on the side of the road. Either alone or accompanied by a trafficker, these minors seeking healthcare treatment rarely fit the traditional model of having a caring adult advocate assisting in making the best healthcare choices on behalf of the child.

Nonmaleficence and beneficence

The principles of nonmaleficence (not inflicting harm) and beneficence (contributing to others’ welfare) were violated in some instances as well. Surprisingly, the youth seeking treatment reported that only 70% of medical providers asked how they sustained their injury (57 of 83). Less than a third 29.6% (24 of 83) reported that the medical staff knew that the injury was due to trading or selling sex so staff had an incomplete picture of the circumstances of the harm and future risk.

Medical professionals treating injured minors are usually mandated reporters of child abuse, but only 13.8% (n = 11) of youth being exploited said that staff reported their abuse to police, probation, or other legal entity. Similarly, only 12.5% (n = 10) were reported to child protective services despite being a minor specifically seeking treatment for injuries related to their abuse. Among the 24 who specified that medical staff were aware the injury was from being sex trafficked, only 3 youth reported that the staff contacted law enforcement or child protective services with that knowledge and only 7 were encouraged to stop their high-risk behavior. Treating an injury caused by trading or selling sex is the opportune time to start a conversation about risk reduction. If medical staff are uncomfortable about their education on identifying and intervening with children and youth experiencing sex trafficking, they may hesitate in having that conversation.^13,24

Justice

Meeting the principle of justice requires fair access to resources and care, including trauma-sensitive care. The lack of screening and interventions reported above by youth who experienced sex trafficking suggests that the healthcare providers that they saw were lacking in training on or comfort with strategies for meeting the needs of youth.

Another missed opportunity to meet the principles of justice is having access to regular medical homes. Prior research has shown that exploited youth feel disconnected from communities and use emergency rooms for non-emergent situations. ¹² Only 9.2% of youth experiencing sex trafficking reported seeking treatment at primary care facilities. Much more frequently, they went to walk-in clinics (46.1%), urgent care (31.6%), and ERs (36.8%). While some of the visits may have been to an emergency room because of the severity of the injury, the low number of children and youth impacted by sex trafficking who reported going to a primary care physician mirrors research detailing how children in the welfare system often have unmet medical needs as well as low rates in service utilization. ³³ In addition to their injuries, abused youth who do not seek treatment for mental health issues show higher nonpsychiatric healthcare costs in the future. ³⁴

Another concern related to justice and fair access to healthcare involved the selection of the healthcare provider. A quarter of the youth (19 out of 76) reported that their healthcare provider was personally connected to the trafficker or buyer. This specific question has not been addressed in prior research and underscores that children and youth exploited through sex trafficking already feel marginalized and disempowered within healthcare settings. ¹²

Discussion

Evidence shows that children and youth exploited through sex trafficking frequently seek medical care from hospital emergency rooms, urgent care centers, and other medical clinics. This research highlighted that healthcare providers have an ethical responsibility to identify and intervene in suspected cases of trafficking. While over 90% of participants reported seeking medical care, only a small proportion of providers followed ethical principles by identifying, assisting, and reporting suspected trafficking to law enforcement, child welfare, or the victims’ families. There is a disconnect between healthcare providers’ ethical responsibilities and their interventions with children being exploited through sex trafficking.

Several policy recommendations can be derived from this study. First, medical providers should screen children potentially experiencing sex trafficking alone since many accompanying individuals are frequently involved with the youth's exploitation. Understanding the unique dynamics and experiences of sex trafficking-impacted youth is essential to providing trauma-informed care. Allowing the patient to make their own healthcare choices cultivates the patient's sense of self and agency.

Second, medical providers should use trauma-informed approaches and evidence-based protocols to avoid re-traumatizing trafficked youth. Some of the questions asked during a medical visit might be unnecessarily triggering; for instance, after learning that a patient has been sex trafficked, asking for the number of sexual partners can be perceived as harmful or shaming. Instead of asking “are you a prostitute?” a more appropriate question is “have you ever been asked to trade sex for a place to stay or money?”

Third, after identifying the trafficking situation, healthcare providers have a moral obligation to not only intervene but also report the situation to the appropriate agencies. Unfortunately, there remains a significant percentage of identified children and youth exploited through sex trafficking victims whose cases were not reported to the appropriate agencies—failure to assist results in them returning to abusive situations. If there are no child or youth sex trafficking protocols in place, child abuse treatment guidelines should be used.

Finally, more resources and training should be allocated to those who are most likely to encounter sex trafficking children and youth exploited through sex trafficking such as healthcare providers at clinics, hospital emergency rooms, and urgent care. Medical staff have an ethical obligation to understand the dynamics of trafficking, intervene during a potential sexual exploitation situation, and follow appropriate reporting protocols. Many exploited children do not attend school, do not receive regular medical care, and live outside the regulated societal infrastructure designed to oversee and protect youth; their emergency care interaction is a critical opportunity for adults to intervene. ¹² When medical professionals fail to intervene, sex trafficked youth believe help is unattainable or that their victimization is unconcerning. ²⁸

Findings should be considered in light of several limitations. First, this was a descriptive study that relied on retrospective self-report, so causal relationships could be determined. Second, the study only focused on the perspective of youth, so healthcare providers could not provide their personal justification for not intervening. Finally, the study relied on a sample of youth from one area in the United States and may not be generalizable to all exploited youth or healthcare providers.

The American Academy of Family Physicians provides trauma-informed guidelines for treating a patient who has been sex trafficked. ³⁵ Notably, clinicians should focus on creating an environment where the patient is comfortable disclosing trauma. This can be done by ensuring confidentiality and protection of the patient. Responses to disclosures should be empathetic and adequately address the patient's mentioned concerns. Clinicians should understand that patients who have experienced sexual violence may decline some triggering procedures such as pap smears, colonoscopies, or dental care. Minimally invasive alternatives should be suggested, when possible, in addition to offering another person in the room as a source of support during the procedure. The ultimate goal of creating a comfortable environment for the patient is not necessarily for the divulgence of the patient's entire traumatic history but rather to promote the physician-patient relationship and to increase the likelihood for the patient to return for care.

Finally, all health settings should be adopting screening tools to bolster provider confidence in identifying children and youth exploited through sex trafficking. ²⁵ More healthcare providers should be encouraged to become Alliance for Children in Trafficking (ACT) advocates. ²⁴