Child Trafficking

Human trafficking is a public health crisis that disproportionately affects children, with estimates that one-third of victims globally are <18 years of age. Generally, child trafficking refers to the exchanging of something of value for sex with a child or if a minor is compelled to perform forced labor. Closely related terms include:

• commercial sexual exploitation of children (CSEC): the involvement of a minor in any sexual act in exchange for something of perceived value or for the financial benefit of another

• survival sex: sexual activity exchanged for basic needs (e.g., food or shelter); most frequently seen in unhoused or runaway youth

Regardless of the form of child trafficking, these children often experience force, fraud, or coercion — although some victims may not view themselves as being exploited — and these elements need not be demonstrated to consider a child a victim of trafficking.

Risk Factors

Children who are victims of trafficking are typically peri-adolescent or adolescent when they are first exploited. Children all along the gender spectrum may be trafficked, although female-identifying victims are most frequently discussed in the literature. Ultimately, a child’s vulnerability for exploitation is reflective of a complex interplay of individual, relational, community, and societal risk factors. Risk factors for child trafficking include the following:

• maltreatment

• homelessness

• substance misuse

• undocumented immigration status

• involvement in juvenile justice system

• multiple adverse childhood experiences

• mental illness

Medical providers may encounter victims of child trafficking in a variety of settings including emergency departments, family planning clinics, crisis response centers, and primary care offices. Potential risk factors on physical exam include the following:

• malnutrition

• untreated chronic disease

• untreated injury

• suspicious signs of assault (acute or healed)

• tattoos (sexual or gang-related)

• flat affect

• hostility

• suspicious attitude

• anxiety

Screening

Screening tools for child trafficking are limited, although they comprise an expanding area of research. The goal of child-trafficking screening tools is to identify high-risk individuals who may benefit from targeted support rather than to elicit a definitive disclosure.

• Short Screen for Child Sex Trafficking prompts children to answer questions regarding risk factors (e.g., number of sex partners, involvement with law enforcement) with follow-up questions as needed to stratify level of risk and needs.

Health Needs

Children who experience trafficking are at risk for developing a plethora of physical and mental health conditions. Victims of child trafficking may present for care with acute medical conditions requiring emergency intervention given barriers to accessing care. In such circumstances, a strong effort should be made to connect children to a medical home for trauma-informed, comprehensive care. Regardless of the setting, the following factors should be considered in the evaluation of a patient at risk for child trafficking:

• Medical history: Obtain a thorough history of acute and chronic health conditions that may require ongoing care (e.g., prescription refills and medical referrals).

• Mental health: Obtain a through history of acute and chronic mental health needs with special attention to screening for acute psychiatric emergencies.

• Physical examination: Complete a thorough head-to-toe physical examination, including an anogenital examination if patient assents. Take special note of the following:

  • growth and development

  • dental health

  • acute or chronic injuries (genital and extragenital)

  • tattoos (patients may have invisible ink tattoos only visible with a Wood lamp)

• Laboratory evaluation to consider:

  • testing for pregnancy and sexually transmitted infections (STIs) including gonorrhea, chlamydia, trichomoniasis, HIV, syphilis, hepatitis B, and hepatitis C; consider repeat testing of HIV, syphilis, hepatitis B, and hepatitis C at 4-6 weeks and 12 weeks given high-risk clinical scenarios

  • screening for substance use

  • testing for nutritional deficiencies (iron, folate, vitamin B₁₂, vitamin C, etc.)

  • testing for communicable diseases (tuberculosis, Covid-19, etc.)

• Medication

  • Offer empiric STI treatment for gonorrhea, chlamydia, and trichomoniasis. Although first-line treatment for chlamydia is doxycycline and for trichomoniasis is metronidazole, patients may benefit from single-dose azithromycin and tinidazole, respectively.

  • Offer HIV preexposure or postexposure prophylaxis as appropriate.

  • Offer pregnancy prophylaxis.

  • Offer immunization as needed, including against human papillomavirus (HPV) and hepatitis B.

• Forensic evidence: Offer forensic evidence collection per your institution’s policies for sexual assault response if there is a concern for acute sexual assault (typically within 72 hours). Be mindful of informing patients that forensic evidence collection is an investigative tool that triggers the involvement of law enforcement so that patients can make an informed decision regarding consenting to this procedure.

• Multidisciplinary care: Children and adolescent victims of trafficking often need assistance with housing, food, job training, immigration, and crisis interventions and likely will require referrals to community resources. Ideally a social worker or case manager can coordinate care within the child’s medical home to address barriers that arise and ensure long-term follow-up.

Reporting

Federal and state policies have been amended to recognize child trafficking as a form of child maltreatment. Therefore, medical providers must adhere to their duty as mandatory reporters, clearly explain to patients the need to file a report, and be certain investigators understand that the child is a victim, and not a perpetrator, of a crime. Ensuring a safe disposition for the child following a report is essential.