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Human trafficking, or modern day slavery, is a heinous violation of human rights, and it is a hidden crime that has infiltrated communities around the world.1,2 According to the Victims of Trafficking and Violence Protection Act of 2000 and its 2003, 2005, 2008, and 2013 reauthorizations, human trafficking occurs if a person is induced through the use of force, fraud, or coercion to perform labor or a commercial sex act.3 Human trafficking does not require that a person or persons be transported across geographical borders and can include cases in which victims are exploited within their own community.1 Victims may be forced or coerced by physical or psychological means; in fact, the profound impact of psychological coercion and control is often overlooked.4
Sex trafficking may encompass such activities as prostitution, escort services, working in brothels, stripping, and pornography.5 The legal definition specifically refers to the “recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act,” or a sex act in which something of value was given or received by any person.3 Domestic minor sex trafficking (DMST), or child sex trafficking, explicitly refers to a situation in which the individual engaging in a commercial sex act is younger than 18 years of age.3
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The purpose of this article is to provide information for primary care providers that they can use to assess, identify, and intervene with adolescent patients who are being trafficked for sex, so that missed clinical opportunities can be prevented.
Domestic minor sex trafficking
Because of the sensitive nature of the crime and underreporting, current statistics on DMST within the United States are limited. However, the US Department of Health & Human Services estimates that between 100,000 and 325,000 American youth are at risk for sexual exploitation.1
DMST transcends racial, ethnic, gender, and educational barriers and can potentially affect any youth.6 Age is one of the primary factors related to being trafficked, and young people are considered the most vulnerable group in the United States for exploitation as victims of sex trafficking.5 Youth are often more susceptible to the psychological tactics used by traffickers, including manipulation, deception, and romantic advances.7 The average age of girls at entry as female juvenile prostitutes is 12 to 14 years.7
Additionally, a number of secondary factors have been linked to a higher risk for DMST. For instance, environmental factors such as family situation (ie, domestic violence, abuse, neglect, parental substance abuse, single-parent homes), frequent encounters with child welfare services, poverty, and homelessness appear to be significant risk factors for DMST.6,7 Childhood sexual abuse has also been demonstrated to be a significant risk factor.6 Runaway or throwaway children are also at high risk for becoming victims of child sex trafficking. Current estimates are that 1 in 6 runaways are likely to be victims of child sex trafficking.9 These youth are often recruited into sex trafficking within days of running away and frequently become involved as a means to procure basic necessities such as food, water, and shelter, a situation termed survival sex.7
It is important to recognize that despite the lack of clarity on prevalence rates, the sexual exploitation of American youth would not be so widespread or lucrative were it not for the demand.5 In American society, the demand for sex and sexuality is high, and the media have made terms such as prostitution, pimps, and johns part of everyday vocabulary. With an estimated $150 billion in yearly profits,10 human trafficking has been cited as the third largest source of revenue (behind narcotics and arms sales) and the fastest-growing criminal industry in the world.11
Missed clinical opportunities
Identifying victims of human trafficking within the clinical setting is an onerous task. Victims are often reluctant to disclose their situation, and they generally do not present with glaring risk factors to indicate their predicament. However, failure to identify victims of sex trafficking within the clinical setting can lead to missed opportunities and potentially devastating outcomes.
A missed opportunity is often described in everyday conversation as a missed chance, lost opportunity, or failure to do something. Within the clinical setting, a missed opportunity may encompass failure to provide patient education, health promotion, preventative care, or referrals to resources. As the health care system continues to evolve with technological advances, new methods of patient–provider interaction (telephone, urgent care, e-mail), and increased access to over-the-counter treatment options, the potential for losing opportunities to provide comprehensive care increases.
These lost opportunities to provide care can be reflected in decreased patient satisfaction, patient safety, and comprehensive care and in increased cost. The increased cost related to DMST can be represented in terms of the actual financial expense and of the loss of care that should be offered to a disempowered group such as adolescent victims of sex trafficking. Furthermore, from the perspective of a clinician, missed opportunities in health care are just as important as successful patient encounters.
As mentioned earlier, this article offers information that can be used in the primary care setting to assess, identify, and intervene with adolescent patients who are being trafficked for sex. The following is a description of a clinical scenario that represents a missed clinical opportunity.
Case study: Anna
While staying in a short-term shelter for runaway and homeless youth, Anna (name has been changed), age 17, presented to the medical clinic for mandatory history and physical examination. She completed a comprehensive history form, which was reviewed by the nurse practitioner, and underwent a physical examination.
Anna lived with her family in a suburb of a large metropolitan city. She was the oldest of 3 children, with 2 siblings younger than 10 years of age. Anna said she had come to the shelter because of a stressful relationship and disagreements with her parents.
Anna’s medical history was negative for any chronic disease or acute illnesses, daily medication, or current complaints. Her social history revealed no cigarette smoking and no alcohol or drug use. However, a review of her sexual history indicated that Anna had had multiple sexual partners (more than 50 in the prior 3 months). Further questioning revealed that she was having sex for money.
