7


Health and Health Care

Health care providers, such as physicians, nurses, advanced practice nurses, physician assistants, mental health professionals, and dentists, see children and adolescents for prevention and treatment of illness and disease. At any of these encounters, these providers can have an opportunity to identify and assist young people who are victims of commercial sexual exploitation and sex trafficking (Clawson et al., 2009a,b; Irazola et al., 2008; Logan et al., 2009; Macy and Graham, 2012; Williamson et al., 2009). Front-line practice settings in which these providers work and where victims of commercial sexual exploitation and sex trafficking may present for services include, among others, emergency departments, urgent care, primary care clinics, adolescent medicine clinics, school clinics, shelters, specialty clinics (obstetrics/gynecology, psychiatry), community health centers, health department clinics, free-standing Title X clinics, Planned Parenthood, and dental clinics (Cohen, 2005).

Ideally, health care providers would be involved in efforts focused on the prevention of victimization by these crimes and work to identify and provide treatment/referral for victims. Yet despite the potential opportunities for intervention, health care professionals often overlook or fail to identify victimized youth. The result can be missed opportunities for intervention and the continued perpetration of crimes against these youth. The first section of this chapter describes the key barriers to identification of victims among health care professionals. The chapter then describes the current and emerging roles of health care providers in preventing, recognizing, and addressing commercial sexual exploitation and sex trafficking of minors in the United States. Examples of current models of care are



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7 Health and Health Care Health care providers, such as physicians, nurses, advanced practice nurses, physician assistants, mental health professionals, and dentists, see children and adolescents for prevention and treatment of illness and dis- ease. At any of these encounters, these providers can have an opportunity to identify and assist young people who are victims of commercial sexual exploitation and sex trafficking (Clawson et al., 2009a,b; Irazola et al., 2008; Logan et al., 2009; Macy and Graham, 2012; Williamson et al., 2009). Front-line practice settings in which these providers work and where victims of commercial sexual exploitation and sex trafficking may present for services include, among others, emergency departments, urgent care, primary care clinics, adolescent medicine clinics, school clinics, shelters, specialty clinics (obstetrics/gynecology, psychiatry), community health cen- ters, health department clinics, free-standing Title X clinics, Planned Parent- hood, and dental clinics (Cohen, 2005). Ideally, health care providers would be involved in efforts focused on the prevention of victimization by these crimes and work to identify and provide treatment/referral for victims. Yet despite the potential oppor- tunities for intervention, health care professionals often overlook or fail to identify victimized youth. The result can be missed opportunities for intervention and the continued perpetration of crimes against these youth. The first section of this chapter describes the key barriers to identification of victims among health care professionals. The chapter then describes the current and emerging roles of health care providers in preventing, recog- nizing, and addressing commercial sexual exploitation and sex trafficking of minors in the United States. Examples of current models of care are 271

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272 Commercial Sexual Exploitation and Sex Trafficking of Minors discussed, including the potential contributions of using a public health approach to examine and provide services to child and adolescent victims of commercial sexual exploitation and sex trafficking. Public health pro- gram models are described as examples of how health care providers and communities have taken such an approach. The chapter concludes with the committee’s findings and conclusions regarding the roles of health care providers in addressing commercial sexual exploitation and sex trafficking of minors in the United States. Victims and survivors of commercial sexual exploitation and sex traf- ficking of minors may experience a variety of physical and mental health illnesses and injuries. Thus, they might be expected to present for treat- ment at some point during their victimization. If each of these encounters is viewed as a potential opportunity to assist victims, it would follow that health care providers must be prepared to identify victims and provide this assistance. Yet little is known about how often these opportunities arise and how health care providers can fulfill this role. To date, only two published studies have examined how often victims of human trafficking were taken to health care providers during their victimization. Both of these study samples included victims of all ages, of both domestic and international trafficking, and of all forms of human trafficking (including labor and sex trafficking). One study entailed interviews with 21 victims of trafficking aged 12-53 (FVPF, 2005). The authors found that 28 percent of victims had seen a health care provider at least once during their victimization. In the second study, a qualitative study of women aged 22-63, 6 of the 12 victims of sex trafficking interviewed reported a visit to some type of health care provider, including a curandera or traditional Latina healer (Baldwin et al., 2011), for treatment of sexually transmitted infections, testing for pregnancy, and abortion services. The findings of these two small, qualita- tive studies suggest that human trafficking victims may seek treatment by health care providers, but they reveal little about the role of the health care providers visited in identifying and assisting victims. Both studies also have limitations that underscore some of the inherent challenges entailed in research on vulnerable populations such as victims of human trafficking. First, the sample sizes were small, which is not unexpected when one is try- ing to recruit and study victims who may be unwilling to self-identify and volunteer. Also, it is reasonable to question whether youth who are victims of domestic sex trafficking would report different patterns of interaction with the health sector and providers from those of adults who are trafficked for other purposes, even though some factors associated with age and le- gal status might make accessing health care more difficult for them. Still, despite the lack of scientific data with which to fully appreciate the role of health care providers in identifying and assisting victims of commercial sexual exploitation and sex trafficking, there are lessons to be drawn from

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Health and Health Care 273 the little research that has been done and from reports of clinicians in the field. Barriers to Identification of Victims Although no currently available studies specifically examine the unique challenges faced by health care providers, a number of reports describe a range of factors that contribute to a failure to recognize and identify victims of commercial sexual exploitation and sex trafficking of minors (Clawson and Dutch, 2008a; Crane and Moreno, 2011; Lillywhite and Skidmore, 2006; Smith et al., 2009). Several of these factors are similar to those found to contribute to a failure to identify victims of child abuse (IOM, 2002). These factors include, but are not limited to, a lack of understanding of commercial sexual exploitation and sex trafficking of minors (by both professionals and victims), a lack of disclosure by victims, potential and perceived complications related to mandated reporting, and a lack of poli- cies and protocols related to these crimes to assist health care providers in assessing and treating victims. Lack of Understanding of Commercial Sexual Exploitation and Sex Trafficking of Minors The need for education and training of health care providers on the topic of commercial sexual exploitation and sex trafficking of minors has been identified as a barrier faced by these professionals in identifying and providing services to victims (Clawson and Goldblatt Grace, 2007; Fong and Berger Cardoso, 2010; Okech et al., 2011). Health care providers not only need to be aware of the issue of commercial sexual exploitation and sex trafficking of minors but also need to have the knowledge and skills necessary to provide care to victims. In a survey of 159 service providers across the United States, including health care providers, who work with victims and survivors of human trafficking, the lack of adequate training was identified as a key barrier to providing services (Clawson et al., 2013). The survey identified a number of specific training needs, including training in confidentiality issues, in gaining victims’ trust, in victim identification, in collaboration and networking, in outreach methods, in medical and mental health issues, in cultural and religious issues, and in staffing challenges. Three recent studies examine knowledge, attitudes, and beliefs regard- ing human trafficking among health care providers. The first, a survey of 262 Canadian medical students, assesses awareness of and attitudes toward human trafficking (Wong, 2011). In this study, 48.5 percent (n = 127) of respondents reported not being knowledgeable about human trafficking, 45.4 percent (n = 119) said they were somewhat knowledgeable, and only

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274 Commercial Sexual Exploitation and Sex Trafficking of Minors 5.7 percent (n = 15) reported being knowledgeable. When asked when they first learned about human trafficking, the majority of the medical students (69.8 percent, n = 183) said it was before they entered medical school. Al- though no students reported learning about human trafficking within the medical school curriculum, 76 percent (n = 199) said they perceived human trafficking as an important community health issue (Wong, 2011). The second study was cross-sectional with a two-part design (Chisolm- Straker et al., 2012). The first part was a survey designed to assess the knowledge and comfort level of emergency department providers in iden- tifying and treating victims of human trafficking; the second part entailed development and testing of an intervention designed to train providers in the emergency department in identifying and treating victims. The sample for part one consisted of 180 health care providers from four different hospitals, including attending physicians (20.6 percent), emergency medi- cine residents (27.2 percent), physician assistants (2.8 percent), registered nurses (13.9 percent), social workers (14.4 percent), and medical students (13.9 percent). The majority of participants in part one (79.4 percent) reported knowing what human trafficking is, yet very few (2.2. percent) had received any formal training in identifying victims, and few (5 percent) had knowingly treated victims (Chisolm-Straker et al., 2012). Among the participants, confidence in their abilities to identify and treat victims of traf- ficking was very low. Only 4.8 percent reported feeling confident in their ability to identify victims and 7.7 percent in their ability to treat victims. Immediately following the educational intervention, 90.3 percent (n = 164) of the participants reported being very confident/confident in their abilities to identify and treat victims of trafficking (Chisolm-Straker et al., 2012). The third study focused on the topic of domestic sex trafficking of mi- nors, examining physicians’ knowledge, attitudes, and training (Reinhard et al., 2012). The authors surveyed physicians practicing in Kansas via an online questionnaire. Unfortunately, the response rate was very low (4 percent); however, findings from the 69 participants are consistent with those of the two studies discussed above. The majority of the physicians (86 percent, n = 59) identified domestic sex trafficking of minors as a prob- lem in the United States, yet 76.8 percent (n = 53) said they did not feel comfortable with identifying victims in their own practice. Screening and identification of possible or suspected cases of domestic sex trafficking of minors presented challenges to this group of respondents. Only 8 of the 69 reported screening patients for victimization by this crime, and while 42 (61 percent) reported encountering patients with possible signs of victimization, very few reported suspecting domestic sex trafficking of minors (Reinhard et al., 2012). Five of the respondents had encountered a total of 24 victims of do- mestic sex trafficking of minors in their practice setting and reported 22

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Health and Health Care 275 of those cases (Reinhard et al., 2012). Barriers to reporting identified by respondents included being unsure whether the patient was a victim (73.9 percent, n = 51), not knowing how to report (30.4 percent, n = 21), victims not acting like they needed help (4.3 percent, n = 3), and not having time to report (2.9 percent, n = 2). As in the other two studies, very few of the physicians participating in this study had received training in domestic sex trafficking of minors (5.8 percent, n = 4), but the majority said they would like to receive such training (66.7 percent, n = 46). These three studies highlight that, although many health care providers have some cognizance of human trafficking and domestic sex trafficking of minors in particular, they lack confidence in their abilities to identify and assist victims. In addition, the intervention study of Chisolm-Straker and colleagues (2012) demonstrated that their educational intervention was successful in increasing the knowledge and confidence of emergency department providers not only in identifying but also in treating victims of trafficking. There is a clear need for training for health care providers on the topic of human trafficking, including domestic sex trafficking of minors; victim identification; and assistance to victims, including reporting and referrals to other agencies. These findings are consistent with reports and testimony of health care providers during the committee’s site visits and public workshops. Yet a number of barriers to the training of health care providers in these areas exist, including stereotypes and mispercep- tions about commercial sexual exploitation and sex trafficking of minors, limited availability of evidence-based training/educational programs, fund- ing constraints, and competing priorities for health professionals’ time and educational efforts. Stereotypes and Misperceptions Stereotypes and misperceptions surrounding commercial sexual exploi- tation and sex trafficking of minors may contribute to health care providers’ inability to identify and assist victims effectively. A recent report describes two persistent stereotypes, in particular, that may inhibit victim identifica- tion (Clawson and Dutch, 2008b; Clawson et al., 2009b; Farley and Kelly, 2000). An exploratory study by the Department of Health and Human Services found that some health care providers stereotypically view victims of commercial sexual exploitation and sex trafficking as young, adolescent girls from foreign countries who are brought to the United States and co- erced into prostitution (Clawson and Dutch, 2008b). This stereotype may prevent health care providers from recognizing as victims other youth in their care, including those who are U.S. citizens or who are male or trans- gender. In addition, victims of commercial sexual exploitation and sex trafficking of minors often are labeled as “child prostitutes” or perceived

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276 Commercial Sexual Exploitation and Sex Trafficking of Minors as being willingly engaged in criminal behavior. This misperception may prevent health care providers from recognizing these youth as victims of sex crimes rather than criminals (an issue addressed in detail in Chapter 5) (Clawson et al., 2009b; Farley and Kelly, 2000). Contrary to these stereotypes, victims of commercial sexual exploita- tion and sex trafficking of minors include a broad range of individuals, in- cluding girls, boys, and transgender youth of different races and ethnicities and from both domestic and international backgrounds (Eastman, 2012; Kotrla and Wommack, 2011; Lillywhite and Skidmore, 2006; Miller et al., 2007; Ring, 2012; Smith et al., 2009). Therefore, it is important to deter- mine what if any stereotypes and misperceptions health care providers hold regarding victims of these crimes, how widely held those beliefs are among these professionals, to what extent those beliefs influence health care pro- viders’ behaviors, and how they can be overcome (Williamson et al., 2009). Lack of Training Opportunities Health care providers may face challenges in identifying appropriate, well-designed training/education offered by individuals qualified to facilitate or provide it. As previously noted, data are lacking with which to evaluate the effectiveness of current educational efforts in enhancing providers’ abil- ity to identify and assist victims. Although limited research has examined how health care providers receive training in domestic violence and child abuse, these fields of study entail issues that are similar to or overlap with those encountered with commercial sexual exploitation and sex trafficking of minors (see Chapter 3). Therefore, the training of health care providers in the former fields in medical and nursing schools, in residency, and during fellowships may provide an opportunity for improving training in the latter. Furthermore, many national health care organizations can help promote provider awareness through continuing medical education and sponsored training and meetings designed to educate those whose disciplines make them most likely to encounter victims of commercial sexual exploitation and sex trafficking of minors. Further research is needed to help determine the most effective means of educating health care providers in how best to identify and assist victims of these crimes. Funding Constraints As in other areas of health care, limited funding is available with which to develop, provide, and evaluate curricula and training on commercial sexual exploitation and sex trafficking of minors for providers in the health care sector. The committee heard from agency representatives and front-line health care providers who described health care budgets that are already

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Health and Health Care 277 stretched thin and could not support such efforts (Chang, 2012; Goldblatt Grace et al., 2012; Siffermann, 2012). A number of these individuals de- scribed how they have developed education and training for a variety of service providers and community members but lack the expertise, time, and/ or personnel to evaluate their programs. Competing Priorities Agencies and providers in the health care sector may face challenges in implementing training because of competing priorities. Health care provid- ers often are overburdened with mandatory training and education within their practice environments. It is important to note that simply adding another required educational topic, whether through in-person training or computer-based module, may not result in a more informed provider; education and training must be thoughtfully designed. Lack of Disclosure As discussed in earlier chapters, an additional challenge to identifying victims is their lack of disclosure of being commercial sexually exploited or sex trafficked. The committee learned from both service providers and health care providers that lack of disclosure may be due to victims’ fear or distrust of professionals and the systems with which they interface (Chang, 2012; Nguyen, 2012). Victimized youth also may be fearful of the consequences of disclosure from their exploiter (Crane and Moreno, 2011; Holzman, 2012; Miller et al., 2007; Ring, 2012; Smith et al., 2009). They may be coached by their exploiter in how to answer questions from authority figures or health care providers so as not to draw attention to their victimization. For those victims of commercial sexual exploitation and sex trafficking who are living in the United States and are not fluent in English, language barriers are confounded by a lack of ready access to culturally competent interpreters. Another potential explanation for a lack of disclosure from victimized youth is that they may not perceive themselves as victims or may believe that they are responsible for their victimization and so feel that there is nothing to disclose (Clawson et al., 2009b; Crane and Moreno, 2011; Smith et al., 2009; Williamson et al., 2009). Although no studies have examined to what extent lack of disclosure contributes to nonidentification of victims, it is of interest that some or- ganizations have begun to address this potential barrier through use of a model screening protocol for domestic violence, adapted to help victims of commercial sexual exploitation and sex trafficking. For example, rep- resentatives of Asian Health Services in Oakland, California, described to the committee how they ensure that all patients are interviewed alone

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278 Commercial Sexual Exploitation and Sex Trafficking of Minors and use interpreters of patients’ native language to interview them instead of interviewing family members who may speak English (Chang, 2012). Given the similar issues of nondisclosure faced by victims of commercial sexual exploitation and sex trafficking and domestic violence, the use of strategies for addressing domestic violence would appear to hold promise for overcoming lack of disclosure as a barrier to identification of victims of commercial sexual exploitation and sex trafficking of minors. Potential and Perceived Complications Related to Mandated Reporting As noted in Chapter 1, mandatory reporting of commercial sexual ex- ploitation and sex trafficking of minors is complicated and presents several challenges. For providers who are mandatory reporters of child maltreat- ment, the added complexities of commercial sexual exploitation and sex trafficking of minors can present unique challenges to victim identification and referral for services. In all 50 states and the District of Columbia, health care providers are mandated reporters and therefore are required to report all cases of suspected child abuse. Yet in a significant number of states, child abuse is subject to mandatory reporting only when the sus- pected abuser is a family member or caregiver. In those states, therefore, most commercial sexual exploitation and sex trafficking of minors does not fall within the mandatory reporting requirements. Moreover, the child welfare system typically addresses child victims whose perpetrators are family members, assessing the victims’ living envi- ronment to determine whether they need to be removed and placed in foster care. In contrast, the perpetrators of commercial sexual exploitation and sex trafficking of minors are not always family members, and the victims often are not living at home; in fact, many have left their home because of a history of neglect and abuse there. For this reason, several states, including Florida, Georgia, and Massachusetts, have passed legislation that includes commercial sexual exploitation and sex trafficking of minors by non-family members as reportable forms of child abuse. However, the solution to identifying and assisting victims of commer- cial sexual exploitation and sex trafficking of minors may not be as simple as mandatory reporting. Mandating reporting of extrafamilial child abuse such as commercial sexual exploitation and sex trafficking of minors may place further strain on the child welfare system. In addition, as discussed in Chapters 1 and 6, the child welfare system may not be adequately pre- pared to provide the unique services required by victims of these crimes. Therefore, two states that now mandate reporting of these crimes, Georgia and Massachusetts, have developed systems to handle the unique challenges entailed in reporting and providing services to these victims. In addition to the potential extra burden placed on the child welfare

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Health and Health Care 279 system if health care providers are required to report commercial sexual exploitation and sex trafficking as a form of child abuse, there is reason to believe that mandated reporting could undermine health care providers’ willingness to screen for these crimes or to respond to victims’ voluntary disclosure (Dovydaitis, 2010; Durborow et al., 2010; Williamson et al., 2009, 2010b). The committee heard from health care providers that man- datory reporting is a concern and a potential barrier to victim identification (Steever, 2012). Clinicians may worry that reporting could impede their ability to create trust with and obtain sensitive information from their patient. They also may worry that reporting may place victims at greater risk from their traffickers, especially if the response from the child welfare system fails to provide adequate protection. Moreover, mandatory report- ing laws can be a deterrent for victims, who may not disclose their victim- ization if they know or suspect that a health care provider will report it to the authorities. That clinicians have reservations about mandatory report- ing is supported by published data demonstrating that mandated reporting of child abuse and intimate partner violence makes health care providers more reluctant to screen and intervene in these areas (Davidov et al., 2012; Flaherty and Sege, 2005; Flaherty et al., 2006, 2008; Vulliamy and Sullivan, 2000; Warner and Hansen, 1994). As with child abuse and intimate partner violence, the perceived bar- rier for health care providers regarding mandated reporting of commercial sexual exploitation and sex trafficking of minors arises when a provider must balance the protection of a patient’s confidential information, often necessary to facilitate disclosure of sensitive information, with the obliga- tion to report abuse knowing that in some cases, doing so could put victims at greater risk for harm, particularly from their exploiters and traffickers. Providers may decide not to ask specific questions related to possible ex- ploitation or trafficking because they want to avoid the unintended conse- quences of being compelled to notify child protective services and/or other authorities (Dovydaitis, 2010; Durborow et al., 2010; Williamson et al., 2009, 2010b). Lack of Policies and Protocols No rigorous, evidence-based studies examining the most effective poli- cies for helping health care providers identify and assist victims of com- mercial sexual exploitation and sex trafficking of minors are currently available. In contrast with intimate partner violence and child abuse, more- over, few health care settings have established screening practices, policies, and protocols related to commercial sexual exploitation and sex trafficking of minors. Screening for any health condition or behavior presents challenges to

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280 Commercial Sexual Exploitation and Sex Trafficking of Minors health care providers (e.g., the time required to screen effectively for a con- dition or behavior; the level of experience, training, or comfort a provider has with respect to a condition or behavior; the need to understand what to do about positive responses). For example, engaging in broader and better identification of commercial sexual exploitation and sex trafficking of mi- nors entails the risk that identification of victims and survivors will outpace the availability of services to assist them. Moreover, conducting assessments or screening in the absence of established policies or protocols could be detrimental to children and adolescents in need of assistance. This challenge is not unique to commercial sexual exploitation and sex trafficking of mi- nors. Similar challenges exist in screening for depression, substance abuse, and cancer, for example. Thus, training programs for health care providers and other professionals responsible for assessing children and adolescents for risk of or current exploitation need to include guidance on developing plans for referrals and treatment. One example of a protocol developed for the education sector is included in Chapter 8. In addition, given the early stages of work on commercial sexual exploitation and sex trafficking of minors, there will be some degree of overlap between the development of tools for identification of victims and the implementation of interventions. Under these circumstances, health care and other professionals may have to rely on national-level resources for guidance and referrals until additional local-level resources are established. Despite the inherent challenges related to screening, experts and provid- ers have advocated for health care agencies to establish clear policies and protocols on commercial sexual exploitation and sex trafficking of minors to assist in the identification of and response to victims (Asian Health Services and Banteay Srei, 2012a; Crane and Moreno, 2011; Dovydaitis, 2010; Goldblatt Grace et al., 2012; Isaac et al., 2011; McClain and Garrity, 2011; Todres, 2011; Williamson et al., 2009, 2010a). Doing so, it is ar- gued, would help health care providers recognize risk factors, signs, and symptoms and provide treatment/referrals for victims (Crane and Moreno, 2011; Dovydaitis, 2010; Hossain et al., 2010; McClain and Garrity, 2011; Zimmerman et al., 2008). Ideally, policies and protocols should be evi- denced based and evaluated for their effectiveness in assisting providers with identification and treatment. Some experts and professionals working in the field have suggested that screening for commercial sexual exploitation and sex trafficking of minors should be similar to that for intimate partner violence (Pearce, 2006; Williamson et al., 2010b). In fact, during its San Francisco site visit, the committee learned about one agency’s development of its own screening protocol for commercial sexual exploitation and sex trafficking of minors that was modeled after its domestic violence screening protocol (Chang, 2012).

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Health and Health Care 281 Current Practices and Opportunities The health care response to commercial sexual exploitation and sex trafficking of minors in the United States and research on specific health care practices are considerably underdeveloped compared with work in other health domains. It is therefore difficult to assess the strengths and limitations of current practices. The committee had little more to consider than the experience and testimony of health care and other service provid- ers. However, certain themes and current practices emerged from those sources that warrant discussion and further examination. Models of Care Given the lack of evidence-based models for use by health providers in identifying and assisting victims of commercial sexual exploitation and sex trafficking of minors, the committee examined other models of care, includ- ing those for intimate partner violence, child maltreatment, sexual assault services, and public health, which face similar challenges and barriers to the identification and management of victims. The committee heard testimony from representatives of several agencies that have adapted and modified these models in their efforts to provide health care services to victims of commercial sexual exploitation and sex trafficking of minors. Intimate Partner Violence and Child Maltreatment Some reports suggest that health care approaches to commercial sexual exploitation and sex trafficking of minors could benefit from the use of well-established models of care for intimate partner violence and child maltreatment (Chang, 2012; Lalor and McElvaney, 2010; Latimer, 2012; Pearce, 2006; Williamson et al., 2010b). These models of care may be espe- cially relevant given that victims of commercial sexual exploitation and sex trafficking and of intimate partner violence share similar risks, signs, and symptoms, as well as emotional and social consequences of their victimiza- tion. Because some health care providers have been trained to recognize victims of intimate partner violence and child abuse, these skills could potentially be adapted to address commercial sexual exploitation and sex trafficking of minors (Pearce, 2006; Williamson et al., 2010b). Sexual Assault Nurse Examiner (SANE) Since many victims of commercial sexual exploitation and sex traffick- ing have a history of childhood sexual assault and are repeatedly sexually abused as part of their exploitation, intervention programs for victims

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286 Commercial Sexual Exploitation and Sex Trafficking of Minors worthy education/training practices and activities. It should be noted that this discussion is not intended to imply that the committee is endorsing any specific program or approach. Additional research is needed to evaluate the effectiveness of these and future education and training programs and approaches. The Houston Rescue and Restore Coalition is a nonprofit organization in Houston, Texas, focused on raising awareness of the broader topic of human trafficking. In collaboration with the University of Texas School of Public Health, it developed a curriculum on human trafficking for front-line health care providers and health care organizations (Isaac et al., 2011). An evidence-informed strategy was used to provide health care professionals with not only the information and knowledge but also the skills neces- sary to identify and refer victims of human trafficking. The curriculum, Health Professionals and Human Trafficking: “Look Beneath the Surface, H.E.A.R. Your Patient” consists of two main components. Component A is an in-person 1-day training session for health care providers and hospital/ clinic administrators. The content of this training is focused on the topic of human trafficking and the steps required to identify and assist victims. H.E.A.R. is the acronym used to help providers in the patient care setting assess and assist (H = Human trafficking and health professionals; E = Ex- amine history, examine body, examine emotion; A = Ask specific questions; R = Review options, refer, report). Component B includes a newsletter that is sent out to hospital/clinic administrators, as well as follow-up technical support. The program is in the pilot phase, and as of this writing, no out- come data have been published. In another example, Children’s Health Care of Atlanta, along with the Georgia Governor’s Office for Children and Families, developed and provided training for medical professionals via a webinar/computer-based training series. The five-session series provides an overview of commer- cial sexual exploitation of minors, the medical evaluation of suspected victims, extended medical history, special related topics, and a victim/ survivor-centered approach to working with these youth. The program has had 260 participants to date, and outcome data have yet to be published (Greenbaum, 2012). Finally, Polaris Project offers free online training and online webi- nars that provide education and training on various topics related to hu- man trafficking and sex trafficking in particular (see http://www.polaris project.org/what-we-do/national-human-trafficking-hotline/access-training/ online-training [accessed April 11, 2013]).

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Health and Health Care 287 Tools for Identification of Victims A search of the Internet and the published literature produces a variety of tools, instruments, or lists of questions designed to assist health care professionals in identifying victims of commercial sexual exploitation and sex trafficking (see Box 7-1). However, it is important to note that those tools were developed based not on empirical data but on the experiences of providers and experts working in the field. In addition, none of the screen- ing tools, instruments, or questions have been evaluated to date for their ability to correctly identify victims of trafficking. BOX 7-1 Examples of Tools for Identifying Victims/Survivors of Commercial Sexual Exploitation or Sex Trafficking The following tools have been developed to assist health care providers in identifying victims of commercial sexual exploitation and sex trafficking: •  apid Screening Tool for Child Trafficking and Comprehensive Screening R and Safety Tool for Child Trafficking: Two screening tools developed by the International Organization for Adolescents for use as a guide in identifying minors that are potentially being trafficked (Walts et al., 2011). •  ommercial Sexually Exploited Children Screening Procedure Guideline: C A screening tool developed and used by health care providers at Asian Health Services in San Francisco that is used with patients aged 11-18 exhibiting high risk factors for sexual exploitation (Asian Health Services and Banteay Srei, 2012a). •  escue and Restore: A screening tool developed by the Department of R Health and Human Services and used by health care providers, social workers, and law enforcement to determine potential victims of human trafficking (Administration for Children and Families, Office of Refugee Resettlement, 2012). •  omprehensive Human Trafficking Assessment: A screening tool devel- C oped by the National Human Trafficking Resource Center and adapted by Polaris Project and its partners for assessing potential signs of a client’s having been a victim of human trafficking (Polaris Project, 2012). •  ome, Education/employment, peer group Activities, Drugs, Sexuality, H Suicide/depression (HEADSS) (Goldenring and Cohen, 1988): A screen- ing tool developed for assessing an adolescent’s psychosocial develop- ment. Mount Sinai Adolescent Clinic has adopted HEADSS, integrating specific questions into its regular assessment to screen for the poten- tial of commercial sexual exploitation among patients seen in the clinic (Steever, 2012).

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288 Commercial Sexual Exploitation and Sex Trafficking of Minors The agencies and providers that work with victims of commercial sexual exploitation and sex trafficking and have developed these screening tools emphasize the need for health care providers to be aware of the unique experiences of victims of these crimes (e.g., repeat and/or chronic sexual victimization, potential stigma and shame associated with victimization, possible negative interactions with authority figures and support systems), as these often are chronic and ongoing traumatic experiences. Specifically, it is recommended that screening tools be used by providers who are trained in or who understand the nature of the trauma these particular victims suffer, with an emphasis on the importance of being trauma-aware when working with identified victims and screening for commercial sexual ex- ploitation (Clawson et al., 2008; Hossain et al., 2010; Lebloch and King, 2006; Smith et al., 2009; Williamson et al., 2009, 2010b). For instance, a victim may have developed trauma bonds with his/her exploiter or may experience some form of Stockholm Syndrome, a condition in which a victim feels bonded to his/her abuser, similar to what has been described in sexually abused children who continue to bond with their offenders (Julich, 2005; Smith et al., 2009). Several reports highlight that being trauma-aware or providing trauma-informed care (discussed earlier in this chapter) may be particularly useful when working with victims of commercial sexual exploitation, particularly because, as noted earlier, they may not see them- selves as victims and may refuse assistance when it is offered (Clawson and Goldblatt Grace, 2007; Crane and Moreno, 2011; Holzman, 2012; Ring, 2012; Smith et al., 2009). Health Care of Victims: Management and Treatment Regardless of how victims are identified, it is essential that health care providers recognize and treat the myriad acute and chronic medical and mental health needs of minors who are victims or survivors of commercial sexual exploitation and sex trafficking. Unfortunately, little research has fo- cused on how the medical and mental health needs of victims and survivors of these crimes, particularly those who are minors, are being met. As noted in Chapter 3, a few studies have examined the health and mental health consequences for adult victims of sexual exploitation and sex trafficking and the types of health services they receive. For example, an international study examined the physical and psychological health status of 192 women receiving posttrafficking services (Zimmerman et al., 2008). That study found that 63 percent of the women reported at least 10 concurrent physi- cal health problems, and 39 percent reported suicidal thoughts within the past 7 days. Participants also reported significantly higher rates of depres- sion and anxiety symptoms compared with the general U.S. population (Zimmerman et al., 2008).

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Health and Health Care 289 Another international study examined the global health consequences of child prostitution by estimating the potential global morbidity and mor- tality associated with commercial sexual exploitation and sex trafficking. The authors calculated global estimates for associated medical conditions including sexually transmitted diseases (HIV, hepatitis B and C, and human papilloma virus), as well as rates of pregnancy and its associated compli- cations (e.g., maternal death, spontaneous abortions) (Willis and Levy, 2002). Estimates also were derived for mental health conditions including posttraumatic stress disorder; suicidality; substance abuse; and other effects of violence, including homicide. Although this study did not examine U.S. minors specifically, the authors emphasize the need for health care providers not only to provide direct service to victims, but also to collaborate with local organizations to assist victims with these complex health conditions (Willis and Levy, 2002). Another study, conducted in Bristol, England, examined access to health care services by 71 female “sex workers,” some of whom were as young as 16 years old. The researchers found that, although 83 percent had seen a general practitioner, a majority (62 percent) had not disclosed their involvement in sex work. Only 46 percent had been screened for sexually transmitted infections during the previous year, 24 percent had been vac- cinated for hepatitis B, and only 38 percent had undergone cervical cancer screening according to national guidelines (Jeal and Salisbury, 2004). A more recent small study (n = 38), conducted in the United States, examined health outcomes among adult women trafficked for sex both domestically and internationally. The researchers found that the domestic trafficking victims had poorer health outcomes than the international vic- tims (Muftic and Finn, 2013). Although more work has been done on the mental health needs than on the physical health needs of victims, including the U.S. Department of Health and Human Services’ brief on Evidence-based Mental Health Treat- ment for Victims of Human Trafficking, the authors of this brief recognize the limitations of attempting to address the specific needs of child victims of sex trafficking given the lack of available evidence (Williamson et al., 2010a). This brief does, however, emphasize the need to provide trauma-in- formed services to victims of human trafficking, including children who are victims of sex trafficking, given the high levels of trauma they have endured. These services need to address, among others, the following mental health conditions: posttraumatic stress disorder, anxiety disorder, panic disorder, obsessive-compulsive disorder, dissociative disorder, major depressive disor- der, and substance abuse disorder (Williamson et al., 2010a). The authors acknowledge the limitations of available research on effective mental health treatments for victims of commercial sexual exploitation, and encourage mental health practitioners to base their current treatment options on “ex-

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290 Commercial Sexual Exploitation and Sex Trafficking of Minors isting research and interventions found to be successful with other similarly victimized populations” (Williamson et al., 2010a, p. 9). In addition, during many of its site visits with service providers currently caring for survivors of commercial sexual exploitation and sex trafficking, the committee heard about the need for long-term mental health services for victims, particu- larly given issues of reintegration into mainstream life and the need to help those who may have reentered “the life” of commercial sexual exploitation (Latimer, 2012; Phillips, 2012; Ring, 2012; Steever, 2012). As noted, victims’ physical health and mental health needs are complex and include not only basic primary preventive care services but also special- ized services such as substance abuse treatment, chronic illness manage- ment (e.g., HIV, hepatitis B and C, diabetes, asthma, depression, anxiety), ongoing assessment and refilling of essential prescriptions, and overall and specific dental care (Dovydaitis, 2010; Sabella, 2011; Zimmerman et al., 2008). Health care providers who identify victims of commercial sexual exploitation and sex trafficking of minors will likely need to refer patients to other specialists, including mental health providers and local nongovern- mental organizations/agencies that can meet the specific mental health needs of these victims, and should be active in the development and implementa- tion of multisector approaches (as discussed in Chapter 10). FINDINGS AND CONCLUSIONS The challenges of identifying victims of commercial sexual exploita- tion and sex trafficking of minors and connecting them with timely and appropriate services may seem overwhelming to communities and to indi- vidual providers. Consistent themes across the limited health care research on commercial sexual exploitation and sex trafficking of minors and the testimony to the committee of health care and service providers are a lack of awareness (at both the community and provider levels); a lack of clarity on how often commercial sexual exploitation and sex trafficking of minors occur, on characteristics of exploited youth, and on how to identify victims of these crimes; and a lack of appropriate, evidence-based services for these youth. As demonstrated in Chapter 3, the needs of minors who are victims of commercial sexual exploitation and sex trafficking are highly complex, necessitating comprehensive health services and treatment that span a con- tinuum of care from emergency to short-term to longer-term assistance. Current efforts to address commercial sexual exploitation and sex traffick- ing of minors suggest that the duration and types of services needed may vary greatly among victims. The committee’s review of current practices in the health care sector underscores the need for greater awareness and for additional training

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Health and Health Care 291 among health care providers. In addition, the committee noted a lack of evidence-based or evaluated screening and assessment tools for health care providers, few policies and protocols for responding to commercial sexual exploitation and sex trafficking of minors, and an extremely limited number of service providers to whom health care providers can refer the victims they encounter. This chapter also has highlighted noteworthy and emerging efforts and approaches in the health care sector. The committee reminds readers that the need to evaluate these and future programs for addressing commercial sexual exploitation and sex trafficking of minors is great. In addition, the committee formulated the following findings and conclusions: 7-1 Future research needs to focus on the roles of the health sector and health care providers in both prevention of and treatment for victims of commercial sexual exploitation and sex trafficking of minors. 7-2 Education and training programs for health care providers need to be evidence-based and have outcome data to support their effectiveness. 7-3 Assessment and screening tools and intervention programs for use by health care providers in identifying and assisting victims of commercial sexual exploitation and sex trafficking of minors in the United States need to be developed and evaluated. 7-4 Professionals and researchers can look to lessons learned and potential best practices from the health sector’s response to similar and overlapping public health issues, such as domestic violence and child abuse, as examples of the health care pro- vider’s role in addressing and responding to commercial sexual exploitation and sex trafficking of minors in the United States. References Administration for Children and Families, Office of Refugee Resettlement. 2012. Rescue & Restore Campaign Tool Kits. http://www.acf.hhs.gov/programs/orr/resource/rescue- restore-campaign-tool-kits (accessed April 11, 2013). Asian Health Services and Banteay Srei. 2012a. Asian Health Services and Banteay Srei CSEC Screening Protocol. http://www.asianhealthservices.org/docs/CSEC_Protocol.pdf (accessed April 11, 2013). Asian Health Services and Banteay Srei. 2012b. Programs. http://banteaysrei.org (accessed April 16, 2013). Baldwin, S. B., D. P. Eisenman, J. N. Sayles, G. Ryan, and K. Chuang. 2011. Identification of human trafficking victims in health care settings. Health and Human Rights 13(1):36-49.

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