“Regardless of how they are identified, it is essential that health care professionals 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.”
The health care response to commercial sexual exploitation and sex trafficking of minors and research on the strengths and weaknesses of specific health care practices in this area are much less well developed than is the case for other health domains. However, the IOM/NRC report highlights a number of current practices and opportunities described by a variety of sources that show promise as ways of preventing commercial sexual exploitation and sex trafficking of minors and providing victims and survivors with the help they need. As emphasized in the IOM/NRC report, additional research is needed to evaluate these approaches for their efficacy in preventing or responding to these crimes (see the recommended strategies in Section 6).
Health care professionals lack evidence-based models to use in identifying and assisting victims of commercial sexual exploitation and sex trafficking of minors. However, the challenges they face in seeking to help these youth
are similar to those encountered with intimate partner violence, child maltreatment, sexual assault services, and public health. Some agencies have therefore adapted models used in these fields to provide health care services to victims and survivors of commercial sexual exploitation and sex trafficking.
Many health care professionals have been trained to recognize victims of intimate partner violence and child abuse, and these skills could potentially be adapted for use in identifying victims of commercial sexual exploitation and sex trafficking of minors [29, 36]. Models of care for intimate partner violence and child maltreatment also may be applicable to commercial sexual exploitation and sex trafficking of minors given the similar risks, signs, symptoms, and emotional and social consequences shared by victims and survivors [20, 29, 36, 37, 38].
Many victims of commercial sexual exploitation and sex trafficking have a history of childhood sexual assault and are sexually abused repeatedly as part of their exploitation. Therefore, intervention programs for victims and survivors of these crimes could potentially use the SANE program as a model.
SANE providers evaluate cases referred by their local jurisdiction using forensic interviews and forensic medical exams as part of a sexual assault investigation. The SANE examiners are already working in a system of care that is victim centered and collaborates with many of the same agencies likely to be encountered by a victim of commercial sexual exploitation or sex trafficking of minors (such as child protective services, law enforcement, and prosecutors). Thus, they could potentially provide the same kind of care to victims and survivors of these crimes [8, 29].
Some agencies have integrated services and resources for victims and survivors of commercial sexual exploitation and sex trafficking into established child abuse and/or intimate partner violence programs. Two examples are described in Box 5.
Victims and survivors of commercial sexual exploitation and sex trafficking have multiple needs that cut across a number of different disciplines. Child advocacy centers (CACs) and sexual assault response teams (SARTs) both offer
Examples of Integrated Services
The Sexual Assault and Violence Intervention (SAVI) program at Mount Sinai Hospital in New York City has begun serving trafficking victims identified through the court system; referrals from other clients; and disclosure from a sexual assault evaluation, including such an evaluation in the health care setting . These victims of commercial sexual exploitation and sex trafficking are provided free and confidential services, including case management, medical care, crisis shelter, legal assistance, and trauma therapy services, all of which are already provided to other sexual assault victims.
FOR MORE INFORMATION:
Sexual Assault and Violence Intervention Program.
Asian Health Services in Oakland, California, has modified its screening tool for interpersonal violence for use in identifying victims of commercial sexual exploitation. It also has worked with those who deal with victims of interpersonal violence, including police investigators and health and mental health care professionals, to serve victims of commercial sexual exploitation as well as domestic violence victims .
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Asian Health Services.
multidisciplinary services, and are therefore a potential model for identification, assessment, and management of victims and survivors of these crimes [29, 39]. The SAVI program described in Box 5 demonstrates the expansion of services provided to sexual assault victims by a SART center to include victims of these crimes. This approach may offer important advantages, particularly in those jurisdictions that lack specialized services for victims and survivors of commercial sexual exploitations and sex trafficking. At the same time, however, care must be taken to ensure that the services thus provided meet the special needs of these youth, which may exceed or differ from those of other youth served by CACs and SARTs.
Commercial sexual exploitation and sex trafficking of minors are associated with several public health issues of concern to local communities, including
domestic violence, child abuse and neglect, HIV and other sexually transmitted infections, unwanted pregnancies, basic unmet primary preventive health care needs among adolescents (e.g., immunizations, tuberculosis screening), drug and alcohol abuse and addiction, and numerous other often unmet medical and mental health needs [8, 40, 41]. Accordingly, some health care professionals and local communities have developed integrated programs to prevent and respond to these crimes through a public health model of care.
Asian Health Services in Oakland, California, for example, developed several such programs. These programs focus community efforts on (1) early primary prevention (e.g., education on healthy relationships for the younger adolescent population); (2) secondary prevention (identification of those at high risk for commercial sexual exploitation and sex trafficking and their referral to local service provider Banteay Srei , which provides resources to prevent them from becoming victims); and (3) tertiary prevention (e.g., a program to help those identified as victims and provide services to assist them in transitioning out of their victimization) . Others have described a public health model for basing primary, secondary, and tertiary levels of prevention on the stage of trafficking of victims [10, 40].
Telehealth has been used successfully to deliver care for sexually abused children in rural, underserved areas [43, 44], for adolescents and children needing psychiatric services [45, 46], and for victims of domestic violence and sexual assault in rural communities . Similarly, health care professionals who may lack the resources for evaluation, referral, and/or assistance for victims and survivors of commercial sexual exploitation and sex trafficking within their own communities may be able to use telehealth to access those resources.
As discussed in Section 3, a lack of training is a significant barrier to the ability of health care professionals to identify victims and survivors of commercial sexual exploitation and sex trafficking. To help overcome this barrier, a growing number of organizations providing services to victimized or at-risk youth are offering education and training programs for health care professionals [26, 48, 49]. However, the vast majority of training developed for health care professionals focuses on the broader topic of human trafficking, and although content on commercial sexual exploitation and sex trafficking of minors may be included, programs specific to these issues are lacking.
Programs identified in the IOM/NRC report were designed to help health care professionals recognize the signs and symptoms of commercial sexual
exploitation and sex trafficking, provide tools for screening, and highlight reporting requirements and how/when to refer victims and survivors for additional services [20, 21, 26, 27, 48, 49, 50, 51, 52]. Three examples are described in Box 6.
Examples of Education and Training Programs
The Houston Rescue and Restore Coalition (HRRC) is a nonprofit organization in Houston, Texas, focused on raising awareness of human trafficking. In collaboration with the University of Texas School of Public Health, it developed a curriculum titled “Health Professionals and Human Trafficking: Look Beneath the Surface, H.E.A.R.a Your Patient” for front-line health care professionals and health care organizations . The intent is to provide health care professionals with not only the information and knowledge but also the skills necessary to identify and refer trafficking victims.
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Houston Rescue and Restore Coalition.
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 commercial 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 .
FOR MORE INFORMATION:
Children’s Health Care of Atlanta. Child Sex Trafficking Webinar Series.
Polaris Project offers free, online training and webinars that provide education and training on various topics related to human trafficking and sex trafficking in particular.
FOR MORE INFORMATION:
Polaris Project. Online Training.
a H.E.A.R. is an acronym for H: Human Trafficking and Health Professionals, E: Examine History, Examine Body, Examine Emotion, A: Ask specific questions, and R: Review options, Refer, Report.
Box 7 describes a variety of tools, instruments, and lists of questions designed to assist health care professionals in identifying victims and survivors of commercial sexual exploitation and sex trafficking. Again, none of these tools have as yet been evaluated for their ability to correctly identify these youth.
The agencies and providers that developed these screening tools emphasize the need for health care professionals to be aware of the unique experiences of victims and survivors of these crimes (such as repeat and/or chronic sexual victimization, potential stigma and shame associated with victimization, and possible negative interactions with authority figures and support systems). Specifically, it is recommended that the tools be used by
Examples of Tools for Identifying Victims and Survivors of Commercial Sexual Exploitation and Sex Trafficking
The following tools have been developed to assist health care professionals in identifying victims and survivors of commercial sexual exploitation and sex trafficking:
- Rapid Screening Tool for Child Trafficking and Comprehensive Screening 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 .
- Commercial Sexually Exploited Children (CSEC) Screening Procedure Guideline: A screening tool developed and used by health care professionals at Asian Health Services in Oakland, California, that is used with patients aged 11-18 exhibiting high risk factors for sexual exploitation .
- Rescue and Restore: A screening tool developed by the U.S. Department of Health and Human Services and used by health care professionals, social workers, and law enforcement to determine potential victims of human trafficking .
- Comprehensive Human Trafficking Assessment: A screening tool developed 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 .
- Home, Education/employment, peer group Activities, Drugs, Sexuality, Suicide/depression (HEADSS) : A screening tool developed for assessing an adolescent’s psychosocial development. Mount Sinai Adolescent Health Center has adopted HEADSS, integrating specific questions into its regular assessment to screen for the potential of commercial sexual exploitation among patients seen in the clinic .
providers who are trained in or understand the nature of the trauma these particular victims and survivors suffer. The emphasis is on the importance of being trauma-aware when screening for commercial sexual exploitation and working with identified victims and survivors [8, 29, 12, 59, 60, 61].
Regardless of how they are identified, minors who are victims or survivors of commercial sexual exploitation and sex trafficking have myriad acute and chronic physical and mental health needs. It is essential that health care professionals recognize and respond to these complex needs, which include not only basic primary preventive care services but also specialized services such as substance abuse treatment, chronic illness management (e.g., HIV, hepatitis B/C, diabetes, asthma, depression, anxiety), ongoing assessment and refilling of essential prescriptions, and overall and specific dental care [27, 62, 63]. Moreover, health care professionals who identify victims and survivors of commercial sexual exploitation and sex trafficking of minors likely will need to refer patients to other specialists, including mental health professionals and local nongovernmental organizations/agencies that can meet the specific mental health needs of these youth. They should be active in the development and implementation of the kinds of multisector approaches discussed below.
Each of the sectors involved in responding to commercial sexual exploitation and sex trafficking of minors—victim and support services, health care, education, the legal sector, and the commercial sector—has specific roles to play. However, an adequate response to these crimes requires collaboration and coordination among all of these sectors, as well as at all levels—federal, state, and local. Yet the efforts of individuals, groups, and organizations in different sectors and with different areas of expertise tend to be disconnected. The IOM/NRC report highlights a number of examples of initiatives that have overcome this barrier to a comprehensive response.
Multisector and interagency efforts to address commercial sexual exploitation and sex trafficking of minors at the federal level include task forces and other partnerships, such as those mandated by the 2013 reauthorization of the Trafficking Victims Protection Act [54, 64, 65, 66].
FOR MORE INFORMATION:
BJA (Bureau of Justice Assistance). 2013. Anti-Human Trafficking Task Force Initiative.
Cook County Human Trafficking Task Force.
OVC (Office for Victims of Crime). 2013. OVC-Funded Grantee Programs to Help Victims of Trafficking.
OVC and BJA. 2011. Anti-Human Trafficking Task Force Strategy and Operations E-guide.
OVC and BJA. 2013. Enhanced Collaborative Model to Combat Human Trafficking FY 2013 Competitive Grant Announcement.
President’s Interagency Task Force to Monitor and Combat Trafficking in Persons. 2013. Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States 2013-2017.
U.S. Attorney’s Office for the District of Columbia. 2013. The D.C. Human Trafficking Task Force.
U.S. Department of State. 2012. Annual Meeting of the President’s Interagency Task Force to Monitor and Combat Trafficking in Persons.
Examples of state and local efforts include the following:
- Washington State—Washington state’s Model Protocol for Commercially Sexually Exploited Children for responding to cases of commercial sexual exploitation and sex trafficking of minors is focused on fostering collaboration and coordination among agencies, improving identification of these crimes, providing services to victims and survivors, holding exploiters accountable, and working toward ending
these crimes in the state . The protocol calls for use of a victim-centered approach by law enforcement, the courts, victim advocacy organizations, youth service agencies, and other youth-serving professionals to ensure that victims of these crimes are treated as such rather than as criminals. The protocol encourages multisector collaboration through state, regional, and local efforts. For example, it calls for the use of multidisciplinary teams to provide immediate consultation on cases of commercial sexual exploitation and sex trafficking of minors as they arise and to participate in meetings to share information and collaborate in the management of each ongoing case.
FOR MORE INFORMATION:
Washington State’s Model Protocol for Commercially Sexually Exploited Children.
- Multnomah County, Oregon—In 2008, Multnomah County initiated a coordinated multisector response to commercial sexual exploitation and sex trafficking of minors. Specific work groups focus on legislation, assistance for victims and survivors, law enforcement practices (e.g., arrests, investigation, and prosecution of exploiters and traffickers), and physical and mental health care. Steering committee members include law enforcement; the district attorney’s office; the Departments of Health, Community Justice, and Human Services; survivors; and nongovernmental service providers. Several strategies are used to ensure collaboration across agencies and among various systems. For example, the county created a special unit within the state child welfare agency for victims and survivors of these crimes [68, 69].
FOR MORE INFORMATION:
Multnomah County Community Response to Commercial Sexual Exploitation of Children.
- Suffolk County, Massachusetts—In Suffolk County, more than 35 public and private agencies participate in the Support to End Exploitation Now (SEEN) Coalition. SEEN’s multisector, coordinated approach to identifying and serving high-risk and sexually exploited
minors includes three components: (1) cross-system collaboration, (2) a trauma-informed continuum of care (see Section 4), and (3) training for professionals who work with children and adolescents. To facilitate collaboration and communication among coalition members, SEEN established formal relationships and protocols, including a steering committee and advisory group, multidisciplinary teams of professionals, and a case coordinator who serves as the central point of contact for all reported victims of commercial sexual exploitation and sex trafficking .
FOR MORE INFORMATION:
Support to End Exploitation Now (SEEN) Coalition.
- Alameda County, California—H.E.A.T. (Human Exploitation and Trafficking) Watch is a multidisciplinary, multisystem program that brings together individuals and agencies from law enforcement, health care, advocacy, victim and support services, the courts, probation agencies, the commercial sector, and the community to (1) ensure the safety of victims and survivors and (2) pursue accountability for exploiters and traffickers. Strategies employed by H.E.A.T. Watch include, among others, stimulating community engagement, coordinating training and information sharing, and coordinating the delivery of victim and support services. The program uses a multisector approach to coordinate the delivery of support services. For example, multidisciplinary case review (modeled on the multidisciplinary team approach) is used to create emergency and long-term safety plans. Referrals for case review are made by law enforcement, prosecutors, probation officials, and social service organizations that have come into contact with these youth. This approach enables members of the multidisciplinary team to share confidential information with agencies that can assist youth in need of services and support.
FOR MORE INFORMATION:
Alameda County District Attorney’s Office. 2012. H.E.A.T. Watch Program Blueprint.