Eve is a 15-year-female who does well in school and is active in sports. One day, she meets a 35-year-old man online. He tells her she is beautiful, listens to her problems and nurtures a romantic relationship. Her parents are unaware of the situation and think Eve is dating a school mate. The man convinces Eve to have sex with other men, as a sign of her love and devotion to him and to obtain money for their future life together.
William is a 16-year-old gay male who runs away from home to escape family violence. Once he is living on the streets, he joins a group of four boys who agree to help him make money: They show him how to sell sex. William engages in “survival sex” a few times per week to get money for food, clothing and occasional drugs. The boys protect and support each other.
These are two examples of child sex trafficking, which occurs when a person engages a minor (younger than 18 years) in a commercial sex act, even if there is no apparent force, fraud or coercion. The act may involve a child exchanging sex for money, food, shelter or other item of necessity or desire, or a person using a child to create pornography, prostituting a child to buyers or engaging the child in a sex-oriented business such as exotic dancing.
General pediatricians and specialists may encounter victims of sex trafficking since these youths typically seek medical attention at some point during their period of exploitation. They may seek care at private practices or public clinics, urgent care centers or emergency departments.
Victims tend to be adolescents, but some are younger than 10 years of age. They may be of any gender, race or ethnicity. They may or may not have known risk factors such as a history of abuse/neglect, foster care, substance misuse, running away from home or behavioral issues. Those who identify themselves as gay, lesbian, bisexual, transgender or other sexual minority (LGBTQ) are at particular risk, as they may be rejected by family and peers and forced to engage in risky behavior to survive or to find others who will accept them.
It is important to consider the possibility of sex trafficking and exploitation when providing care to any adolescent, but especially one with known risk factors.
Victims may seek care for chronic conditions such as diabetes or asthma; acute injury from physical or sexual assault; sexually transmitted infections (STIs), including HIV/AIDS; pregnancy; or for emotional problems such as anxiety, depression, suicidality or post-traumatic stress disorder. They may be accompanied by a parent who is unaware of the victim’s exploitation, by the trafficker (who may be a family member or posing as one) or by a person working with the trafficker.
Possible indicators of victimization include the following:
- unusual behavior (e.g., very submissive, withdrawn, fearful, intoxicated, or aggressive and hostile);
- being accompanied by a person who insists on speaking for the patient and may be eager to leave;
- presenting for STI testing, pregnancy testing or care, suicide attempt, injury that may be inflicted, substance misuse, foster care clearance exam or sexual assault;
- old or recent injuries suspicious for being inflicted (located in protected places, accompanied by inconsistent history of event); and
- history of one or more STIs or pregnancy.
Given that victims have experienced extensive trauma and stress, it is critical for the pediatrician to remain open, nonjudgmental and sensitive when speaking with potential victims. Tips for a successful interaction include:
- building rapport and treating the patient with respect;
- speaking with the child outside the presence of an accompanying person;
- taking steps to ensure physical and emotional safety of patient and staff;
- discussing limits of confidentiality early in the visit;
- explaining the reasons for the detailed interview and all aspects of the evaluation, and asking permission at each step;
- having a chaperone in the room to protect the pediatrician and to monitor patient for signs of stress during exam;
- following state mandatory reporting laws; and
- offering resources to the patient (LGBTQ resources, local shelters, teen clinic, substance use treatment centers, behavioral health referrals).
Dr. Greenbaum is an affiliate member of the AAP Section on Child Abuse and Neglect.
