The following is the winning submission from the third annual Section on Pediatric Trainees essay competition. This year’s competition was informed by the 2018–2019 Section on Pediatric Trainees Advocacy Campaign: Advocacy Adventure, which empowered trainees to find their areas of passion, acquire and polish new skills, and organize advocacy efforts collaboratively. We asked writers to share experiences as physician advocates and were impressed with the broad variety of important topics submitted by trainees from around the country. This essay by Drs Panda and Garg highlights a critical issue facing children, human trafficking, and shares their innovative and sustainable survivor-informed training for pediatric trainees. Along with the runner-up submission by Dr Ju, which also appears in this issue, this piece is a wonderfully inspiring reminder that we are all well positioned to advocate for children in our roles as trainees and pediatricians.

The emergency department board flashed red with the arrival of a high-acuity patient: a 17-year-old teenager with suicidal ideation. As I walked toward the patient’s room, I began running through the standard questions about depression and suicide, not realizing I was unprepared for the situation ahead of me. Initially, the patient’s demeanor was guarded and her voice monotonous. She stated her suicide attempt was in response to a video posted on social media without her consent that showed her performing sexual acts with a man. As our conversation began to flow, she readily disclosed more information about her sexual history. “I know that I am pretty, and guys want me,” she said, “I want to feel loved, so I have sex with them. I have had so many partners that I have lost count.” I learned that she had a history of sexual abuse as a child, her mother was barely home, and she was often left unsupervised. As tears glistened in her eyes, I processed the alarms going off in my head. Was my patient being trafficked?

I plunged forward with the questions I knew I needed to ask. “Have you ever been forced to have sex with someone when you did not want to?” “No.” “Have you ever had sex with someone for money or a place to stay?” “No.” “Have you been forced to do things you do not want to do?” “No.” The flow of conversation halted abruptly, her guard was back up, and her answer was no every time. I left the room with an uneasy feeling.

Our team documented the suspicion of human trafficking and discharged the patient to her mother’s care. Two months later, the same patient returned to the emergency department after a sexual assault. After providers reviewed our initial documentation, they had a high suspicion for trafficking before evaluating the patient, allowing for a more extensive interview. This time, she admitted that her boyfriend was selling her for sex to other men.

This teenager was a trafficking victim who easily could have slipped through the cracks unidentified, as many children do. Globally, 25% of trafficking victims are children,1  and in the United States, many domestic victims are trafficked before the age of 18.2  In hindsight, we are thankful a combination of luck and tenacity allowed us to help our patient, but we are sobered by the idea that every day, a seemingly straightforward case may be missed as unrecognized human trafficking.

Almost 90% of sex trafficking victims have contact with the health care system during their exploitation3  and present to various medical settings, from emergency rooms to inpatient floors to primary care offices.4  Physicians, therefore, play a crucial role in identifying and intervening for victims. Despite this, studies show health care providers lack accurate knowledge about human trafficking,5  and few hospitals in the country have a formal protocol for identifying and referring victims.6,7  As this case highlights, a high index of suspicion is crucial in identifying human trafficking. Untrained doctors can miss the most vulnerable children in our communities, who are exploited and subjected to repeated abuse that often leads to complex trauma.8  This dire need for education and advocacy impassioned us to pursue this work as pediatricians.

Our initial challenge was focusing our passion into a project that would fill a need at our children’s hospital and improve outcomes for victims of human trafficking. We learned that there was no formal training for physicians on human trafficking at our institution. Furthermore, although a human trafficking protocol was in place, many providers were unaware of its existence. We partnered with the pediatric sexual assault nurse examiner (our hospital’s expert on human trafficking) and the pediatric emergency medicine fellowship director to embark on our first task: improving the recognition of potential child trafficking victims among resident physicians through education and training.

Our next challenge was to navigate the landscape of trafficking-related resources in our community. We knew that if we wanted our training to be effective and accurate, it was essential to incorporate the input of grassroots organizations engaged in this work. Our initial partners introduced us to the Renee Jones Empowerment Center, a community organization dedicated to the long-term recovery of trafficking victims. Through volunteering at their street outreach events and therapeutic groups, we developed a deeper understanding of the local picture of human trafficking. We were also able to partner with a survivor and advocate for the antitrafficking movement to ensure our training was survivor approved and sensitive. Her role was also to be present at all training sessions to answer questions and provide context with personal experiences at her discretion.

Finally, we needed to ensure that our training was sustainable. To address this, we converted the hospital protocol into a badge-sized card to be worn along with other hospital identification cards. Trainees can easily reference this point-of-care tool to determine next steps regarding the initial screening of a victim, understanding treatment options, and whom to call to refer patients for further assistance.

With support from our partners, advisors, and residency program, we were able to successfully design and implement a survivor-informed training on child trafficking for all pediatric trainees. Each of the residents in the training also received the point-of-care badge card for future reference. We are currently working to integrate the training into our core resident didactic sessions so that it will be sustainable and recur each year.

Although we know it will take time before we see the lasting impact of our intervention, we are beginning to see how important our training was for both the residents and our partners. Our coresidents are now thinking more critically about the patients they see with potential red flags, and a few have contacted us to discuss cases that raised suspicion for human trafficking. Additionally, our survivor leader’s reaction after our first training session has humbled us and is 1 that we will never forget. When we sought her feedback that day, she smiled with genuine happiness and stated, “That feeling was amazing...a room full of educated doctors were looking to me for my input and advice. I felt so proud of the progress I have made and how far I have come.” After being stripped of the right to control her own life for many years, she was taken aback by the respect she received as an expert and was finally able to see the rewards of her years in recovery.

These short-term impacts have empowered us to continue our work. Our hope is that 1 day, all health care providers will understand the impact of human trafficking on the health of children and will be trained to recognize red flags when they are present. As pediatricians, we are all advocates for the children we treat, and we have the unique opportunity to break the cycle of victimization for children who are bought and sold.

Drs Panda and Garg conceptualized, wrote, and revised the initial and final manuscript.

FUNDING: No external funding.

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. 2017 statistics from the national human trafficking hotline and beFree textline.
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. Available at: https://polarisproject.org/2017statistics. Accessed March 2, 2019
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.