Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department (Human Trafficking CME and Ethics CME)

Table of Contents

 

About This Issue

Human trafficking impacts pediatric patients of all ages and genders, and a majority of trafficking survivors report having been cared for in a healthcare setting during their trafficking experience. Both labor and sex trafficking have been shown to have significant mental and physical health consequences for survivors. In this issue, you will learn:

The types of trafficking that may impact children and adolescents

The indicators of trafficking that may be identified during the history and physical examination

Considerations for patient privacy, confidentiality, and mandated reporting

The role and availability of screening tools to help identify patients who are in a trafficking situation

The importance of a trauma-informed care approach with patients who are being trafficked and/or exploited

Why it is important that clinicians not approach trafficked patients with a “rescue” mentality

How to access antitrafficking resources for patients and clinicians

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Definitions
6. Critical Appraisal of the Literature
7. Core Competencies
8. Etiology and Pathophysiology
9. Differential Diagnosis
10. Prehospital Care
11. Emergency Department Evaluation
    1. Privacy and Confidentiality
    2. History
    3. Physical Examination
    4. Documentation
12. Diagnostic Studies
    1. Imaging Studies
    2. Laboratory Studies
    3. Screening Tools
    4. Trauma-Informed Care
13. Treatment
    1. Sexually Transmitted Infections
    2. Emergency Contraception
    3. Connection to Services
       1. Mandated Reporting
14. Special Populations
15. Controversies and Cutting Edge
    1. Diagnostic Coding and Documentation
    2. Additional Screening Tools
16. Disposition
17. 5 Things That Will Change Your Practice
18. Summary
19. Time- and Cost-Effective Strategies
20. Risk Management Pitfalls for Management of Potentially Trafficked Pediatric Patients
21. Case Conclusions
22. Tables and Figures
23. References

Abstract

Labor and sex trafficking impact children of all ages, genders, and nationalities. Trafficked patients present to the emergency department for illnesses and injuries both related and unrelated to their trafficking experiences. Emergency clinicians are not meant to be experts in labor and sex trafficking, but they must know enough to be able to identify patients at risk for trafficking and ensure that these patients have the opportunity to be connected to relevant services and support. This issue reviews the ways in which youth are trafficked, the indicators of trafficking, and the evidence-based and best-practice recommendations for addressing suspected or confirmed trafficking in the pediatric and adolescent patient populations.

Case Presentations

A 15-year-old boy presents to the ED with an injury to his right eye...

• He is accompanied by a coworker who speaks for him because the patient speaks only Mam, a Mayan language.
• The coworker reports that the patient was cutting tile with a handheld saw when a piece of tile flew into his right eye. The patient looks uncomfortable and anxious.
• Your initial examination of the eye is suggestive of an open globe injury, so you call for an ophthalmology consult and place an eye shield over the affected eye.
• As you offer the patient pain medication, it occurs to you that it is late morning on a weekday. You wonder why this young man is not in school...

A 13-year-old girl arrives in the ED complaining of dysuria and abdominal pain...

• She says she has been experiencing these symptoms for the past week.
• You see in her chart that she has a history of depression and post-traumatic stress disorder, with multiple inpatient psychiatric hospitalizations.
• The chart also indicates that this patient tested positive for chlamydia and genital herpes in the past year, and a prior chart note says she has been in foster care and had run away from a group home.
• You assess her pain score for pain relief, set up for a pelvic exam, and order lab work. As you address her medical needs, you consider whether and how you should address the multiple indicators that this patient may be experiencing trafficking…

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Risk Management Pitfalls for Management of Potentially Trafficked Pediatric Patients

2. “He’s here with his stepfather, who is a distinguished-looking gentleman. The ED is busy and it will take a while to do a one-on-one history. It’s only really necessary when the situation seems suspect.” Do not assume that a patient presenting in what appears to be a socially acceptable relationship is in a safe or healthy situation. Always speak with a patient privately at some point during their evaluation.

5. “Now that I know the indicators of a trafficking situation, I will be able to intervene and keep my patient safe. It feels good to rescue victims from scary situations.” Do not plan to “rescue” patients from a situation. The goal is to empower them to use their own agency to promote their health and wellbeing. If the patient is a minor and a mandated report is indicated, this should be done in a collaborative and trauma-informed manner.

8. “I want to avoid conflict, so I’m going to make this report to child welfare and not tell the patient.” Always inform a patient you are a mandated reporter before you gather sensitive information. If you see concerning indicators, make the mandated report in collaboration with the impacted youth, letting the patient know that you are a mandated reporter and that you are hoping to leverage helpful support for them. Do not make clandestine reports.

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Institute of Medicine; National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States: A Guide for Providers of Victim and Support Services. National Academies Press; 2014. (Organizational report)

2. * Greenbaum J, Bodrick N, Committee on Child Abuse and Neglect: Section on International Child Health. Global human trafficking and child victimization. Pediatrics. 2017;140(6):e20173138. (Policy statement) DOI: 10.1542/peds.2017-3138

7. * Chisolm-Straker M, Baldwin S, Gaïgbé-Togbé B, et al. Health care and human trafficking: we are seeing the unseen. J Health Care Poor Underserved. 2016;27(3):1220-1233. (Retrospective survey; 173 participants) DOI: 10.1353/hpu.2016.0131

40. * Macias-Konstantopoulos W, Zhou B. Physical health of human trafficking survivors: unmet essentials. In: Chisolm-Straker M, Stoklosa H, eds. Human Trafficking is a Public Health Issue: A Paradigm Expansion in the United States. Springer; 2017:185-210. (Textbook chapter)

52. * Shandro J, Chisolm-Straker M, Duber HC, et al. Human trafficking: a guide to identification and approach for the emergency physician. Ann Emerg Med. 2016;68(4):501-508.e501. (Review article) DOI: 10.1016/j.annemergmed.2016.03.049

72. * Greenbaum J, McClure RC, Stare S, et al. Documenting ICD Codes and Other Sensitive Information in Electronic Health Records. HEAL Trafficking; January 2021. Accessed June 1, 2022. (Documentation guidelines)

74. * CommonSpirit, HEAL Trafficking, Pacific Survivor Center. PEARR Tool: Trauma-Informed Approach to Victim Assistance in Health Care Settings. HEAL Trafficking; 2019. Accessed June 1, 2022. (Practice guideline)

98. * Macias-Konstantopoulos WL. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA J Ethics. 2017;19(1):80-90. (Review article) DOI: 10.1001/journalofethics.2017.19.1.msoc2-1701

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Keywords: human trafficking, trafficking children, trafficking adolescents, trafficking teens, sex trafficking, labor trafficking, trauma-informed care, PEARR tool, CSE-IT, HEADS-ED, STIs, emergency contraception, consent, mandated reporting, trafficking response protocol