Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States: A Guide for the Health Care Sector (2014)

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Barriers to Identification of Victims and Survivors

“In contrast with intimate partner violence and child abuse, few health care settings have established screening practices, policies, and protocols related to commercial sexual exploitation and sex trafficking of minors.”

Victims and survivors of commercial sexual exploitation and sex trafficking of minors may experience a variety of physical and mental health illnesses and injuries. Thus, they might be expected to present for treatment at some point during their exploitation. If each of these encounters is viewed as a potential opportunity to offer needed assistance, it would follow that health care professionals must be prepared to identify these youth and provide this assistance.

Yet a number of factors contribute to a failure to recognize and identify victims and survivors of these crimes among professionals not just in health care, but in all the various sectors that provide services to youth [9, 10, 11, 12]. Several of these factors are similar to those found to contribute to a failure to identify victims of child abuse and neglect [13]. These factors include, among others, a lack of understanding of commercial sexual exploitation and sex trafficking of minors (by both professionals and victims/survivors), a lack of disclosure by victims, potential and perceived complications related to mandated reporting, and a lack of policies and protocols related to these crimes to assist health care professionals in assessing and treating victims and survivors.

LACK OF UNDERSTANDING

Health care professionals need education and training to overcome a widespread lack of understanding of commercial sexual exploitation and sex trafficking of minors, which may prevent them from identifying and providing services to victims and survivors [14, 15, 16]. They need not only to be aware of the issue but also to have the knowledge and skills to identify and provide assistance to victims, survivors, and those at risk for exploitation, including reporting and referrals to other service providers. Among specific needs are training in confidentiality issues, identifying and gaining the trust of victims and survivors, collaboration and networking, outreach methods, medical and mental health issues, cultural and religious issues, and staffing challenges [17]. Yet a number of barriers to the training of health care professionals in these areas exist:

• Stereotypes and misperceptions—Two persistent stereotypes in particular may inhibit the identification of victims and survivors [4, 18, 19]: (1) the notion that the victims of these crimes are young, adolescent girls from foreign countries who are brought to the United States and coerced into prostitution [18], whereas in fact they include girls, boys, and transgender youth of different races/ethnicities and both domestic and international backgrounds; and (2) the tendency to label victims of these crimes who are minors as “child prostitutes” or to view them as being willingly engaged in criminal behavior [4, 19].
• Lack of training opportunities—Health care professionals may find it difficult to identify appropriate, well-designed training and education offered by individuals qualified to facilitate or provide it. Given that similar issues arise with domestic violence and child abuse and with commercial sexual exploitation and sex trafficking of minors, the current training of health care professionals 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 awareness through continuing medical education and sponsored training and meetings. Section 4 of this guide describes some current education and training programs that may meet this need but require further evaluation.
• Funding constraints—As in other areas of health care, limited funding is available with which to develop, provide, and evaluate training and curricula on commercial sexual exploitation and sex trafficking of minors for health care professionals [20, 21, 22].

• Competing priorities—Health care professionals are often 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

An additional barrier to identifying victims and survivors is their lack of disclosure of being commercially sexually exploited or trafficked. This lack of disclosure may be due to a fear or distrust of professionals and the systems within which they operate [20, 23]. Victimized youth also may fear how their exploiter will respond to their disclosure [10, 12, 24, 25, 26]. These youth may be coached by their exploiter in how to answer questions from authority figures or health care professionals so as not to draw attention to their exploitation. Moreover, they may not perceive themselves as victims or may believe that they are responsible for their exploitation [4, 8, 10, 12]. Box 4 describes one potential approach to overcoming this barrier.

POTENTIAL AND PERCEIVED COMPLICATIONS RELATED TO MANDATED REPORTING¹

In all 50 states and the District of Columbia, health care professionals are mandated reporters, required to report all cases of suspected child abuse. In a significant number of states, however, mandatory reporting applies only when the suspected abuser is a family member or caregiver. Yet the perpetrators of commercial sexual exploitation and sex trafficking of minors are not always family members, and the victims are often not living at home. In those states, therefore, most commercial sexual exploitation and sex trafficking of minors does not fall within the mandatory reporting requirements.

Several states have passed legislation that makes commercial sexual exploitation and sex trafficking of minors by non-family members reportable forms of child abuse. Yet such mandated reporting could undermine health care professionals’ willingness to screen for these crimes or respond to victims’ voluntary disclosure [8, 27, 28, 29]. Clinicians may worry that reporting could make it more difficult 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 exploiters. Thus, to avoid the unintended consequences of being compelled to notify child protective services and/or other authorities, health care professionals may decide not to ask specific questions related to possible exploitation or trafficking [8, 27, 28, 29]. Clinicians’ reservations about mandatory reporting are clear from published data showing that mandated reporting of child abuse and intimate partner violence makes health care professionals more reluctant to screen and intervene in these areas [30, 31, 32, 33, 34, 35]. Likewise, victims may not disclose their exploitation if they know or suspect that a health care professional will report it to the authorities.

LACK OF POLICIES AND PROTOCOLS

The kinds of established screening practices, policies, and protocols used for intimate partner violence and child abuse in health care settings do not exist for commercial sexual exploitation and sex trafficking of minors. Ideally, such policies and protocols should be evidence-based and evaluated for their effectiveness in assisting providers with identification, treatment, and referral for services.

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¹The IOM/NRC report [1, pp. 26-27] includes a detailed explanation of the complexities of mandatory reporting of commercial sexual exploitation and sex trafficking of minors in the United States in the context of the current practices of the legal, health care, and support service sectors. Available online: www.iom.edu/sextraffickingminors.