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Youth survivor perspectives on healthcare and sex trafficking

Open AccessPublished:June 09, 2022DOI:https://doi.org/10.1016/j.pedn.2022.05.020

      Highlights

      • Youth survivors reported multiple barriers to healthcare.
      • Accurate education and training are essential to identification and response.
      • Survivors recommended a non-judgmental approach and assurance of safety.
      • Survivors emphasized the need for more questioning about their experiences.
      • Access to mental health resources is needed both during and after exploitation.

      Abstract

      Purpose

      This study aimed to assess the perspectives of youth survivors of sex trafficking on healthcare to improve care for this vulnerable and often unrecognized population.

      Design and methods

      Semi-structured focus groups were conducted with eight survivors in Southern California who interacted with the healthcare system while being sex trafficked. Interviews were audio- and/or video-recorded and transcribed verbatim. The analysis utilized a grounded theory approach, where researchers reviewed the data collected, then inductively generated codes and themes based on the findings from the interviews.

      Results

      The focus group interviews revealed the following themes: unequal treatment, barriers to patient care, risk identifiers, support, and survivor recommendations.

      Conclusions

      Youth survivors seeking healthcare reported multiple barriers based on their interaction with healthcare providers, such as the lack of provider awareness, education, training, feelings of shame, judgment, fear, racial biases, and lack of empathy. Improving patient outcomes relies on understanding the complexities of human trafficking and implementing an approach to decrease barriers to care.

      Practice implications

      This study resulted in invaluable survivor recommendations with practical solutions on addressing human trafficking and exploitation in the healthcare system. The solutions proposed by participants included strengthening relationships and experiences with healthcare providers by increasing awareness, establishing rapport, creating a safe space, asking questions about their safety and situation, using a non-judgmental approach, and providing resources.

      Keywords

      Human trafficking is a public health crisis that affects the pediatric population on a global, national, and local level. Human trafficking is a crime where force, fraud, or coercion is used to exploit someone for labor, services, and/or commercial sex acts (

      Trafficking Victims Protection Act of 2000, 2000, Pub. L. No. 106–386 (US).

      ). Youth sex trafficking specifically refers to children under the age of 18 who perform commercial sex acts (sex acts in exchange for anything of value), where force, fraud, and coercion are not a requirement (

      Trafficking Victims Protection Act of 2000, 2000, Pub. L. No. 106–386 (US).

      ). Although predominantly female, current evidence demonstrates that sex trafficking and exploitation affects all genders (
      • Moynihan M.
      • Mitchell K.
      • Pitcher C.
      • Havaei F.
      • Ferguson M.
      • Saewyc E.
      A systematic review of the state of the literature on sexually exploited boys internationally.
      ). These human rights violations lead to a wide range of serious, and often chronic, health consequences that include, but are not limited to, untreated chronic diseases such as diabetes and asthma, oral health problems, communicable diseases such as tuberculosis, sexually transmitted infections, injuries, and mental health disorders such as depression, posttraumatic stress disorder (PTSD), anxiety, and suicidal ideation (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Ijadi-Maghsoodi R.
      • Cook M.
      • Barnert E.S.
      • Gaboian S.
      • Bath E.
      Understanding and responding to the needs of commercially sexually exploited youth: Recommendations for the mental health provider.
      ;
      • Lederer L.
      • Wetzel C.A.
      The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities.
      ;
      • Price K.
      • Nelson B.D.
      • Macias-Konstantopoulos W.L.
      Understanding health care access disparities among human trafficking survivors: Profiles of health care experiences, access, and engagement.
      ). The burden of disease and injury related to trafficking not only impact youth, but also their families and communities.
      Human trafficking is often an invisible crime despite its pervasive consequences. In 2019, it is estimated that over 11,500 individuals, including more than 2,500 minors, were victims of human trafficking in the United States (
      • Polaris Project
      2019 Data report [PDF].
      ). In Southern California, the Orange County Human Trafficking Task Force (OCHTTF) reported 357 human trafficking victims in 2019 and 2020, with 30% of victims being under 18 years of age (
      • OC Human Trafficking Task Force
      2021 Human trafficking victim report [PDF].
      ). Despite efforts from anti-trafficking and government organizations including the
      • United Stated Department of Health and Human Services
      Federal government efforts to combat human trafficking.
      , the incidence of trafficking remains significantly under-documented. The challenges in gathering accurate data stem from limited awareness of human trafficking, lack of identification by professionals, reluctance of victims to disclose abuse, and the absence of a centralized database to track these occurrences (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • National Institute of Justice
      Gaps in reporting human trafficking incidents result in significant undercounting.
      ;
      • Price K.
      • Nelson B.D.
      • Macias-Konstantopoulos W.L.
      Understanding health care access disparities among human trafficking survivors: Profiles of health care experiences, access, and engagement.
      ).
      Nonetheless, nurses and healthcare professionals may directly impact the recognition and response to youth who are trafficked or are at risk of being trafficked. It is estimated that 68% to 88% of trafficking victims had contact with a healthcare professional while being trafficked (
      • Chisolm-Straker M.
      • Baldwin S.
      • Gaïgbé-Togbé B.
      • Ndukwe N.
      • Johnson P.N.
      • Richardson L.D.
      Health care and human trafficking: We are seeing the unseen.
      ;
      • Lederer L.
      • Wetzel C.A.
      The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities.
      ). This includes trafficked minors who seek medical care in various healthcare settings, from primary care offices and urgent care to emergency departments and free health clinics (
      • Chisolm-Straker M.
      • Baldwin S.
      • Gaïgbé-Togbé B.
      • Ndukwe N.
      • Johnson P.N.
      • Richardson L.D.
      Health care and human trafficking: We are seeing the unseen.
      ;
      • Ertl S.
      • Bokor B.
      • Tuchman L.
      • Miller E.
      • Kappel R.
      • Deye K.
      Healthcare needs and utilization patterns of sex-trafficked youth: Missed opportunities at a children's hospital.
      ;
      • Greenbaum V.J.
      Child sex trafficking in the United States: Challenges for the healthcare provider.
      ;
      • Henry T.A.
      How physicians can identify, assist human trafficking victims.
      ;
      • Lederer L.
      • Wetzel C.A.
      The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities.
      ;
      • Price K.
      • Nelson B.D.
      • Macias-Konstantopoulos W.L.
      Understanding health care access disparities among human trafficking survivors: Profiles of health care experiences, access, and engagement.
      ;
      • Richie-Zavaleta A.C.
      • Villanueva A.
      • Martinez-Donate A.
      • Turchi R.M.
      • Ataiants J.
      • Rhodes S.M.
      Sex trafficking victims at their junction with the healthcare setting: A mixed-methods inquiry.
      ). Nurses are on the frontlines of medicine, often spending the most one-on-one time with patients as they screen youth for depression, suicide, and other high-risk behaviors. This unique relationship allows for nurses to build rapport with their patients, which can facilitate early screening, recognition, and response. The healthcare response to youth trafficking is complicated and multi-faceted, including addressing the biopsychosocial consequences of youth sex trafficking, overcoming challenges to the identification of victims, and improving medical professionals' knowledge of trafficking.

      Biopsychosocial sequelae

      Youth are susceptible to trafficking for various reasons, including their developmental age, potential lack of resources, limited life experience, or specific exposures to adverse childhood experiences. Often, youth are groomed into a situation of exploitation as minors, which can have devastating long-term effects on their emotional and mental health (
      • Costa C.B.
      • McCoy K.T.
      • Early G.J.
      • Deckers C.M.
      Evidence-based care of the human trafficking patient.
      ;
      • Greenbaum V.J.
      Child sex trafficking in the United States: Challenges for the healthcare provider.
      ). Emotionally, trafficking can have a range of specific effects from fear, guilt, and helplessness to rage, betrayal, and distrust (
      • Bezpalcha R.
      Helping survivors of human trafficking, Ukraine: Winrock International.
      ). With the nature of trafficking often being extreme violence and repeated abuse, emotional and psychological trauma can compound, leading to more serious mental health disturbances and dysfunction. Victims of human trafficking report experiencing various complex trauma symptoms and mental health disorders, such as PTSD, anxiety disorders, major depression, suicidality, and substance abuse (
      • Greenbaum V.J.
      Child sex trafficking in the United States: Challenges for the healthcare provider.
      ). Trafficked women have also reported using substances to “self-medicate” and were more likely to inflict self-harm (
      • Bezpalcha R.
      Helping survivors of human trafficking, Ukraine: Winrock International.
      ). Some youth survivors describe self-medicating with alcohol and controlled substances to cope with their repetitive exposure to trauma and violence. Other survivors report being forced into substance use by their traffickers (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Ijadi-Maghsoodi R.
      • Cook M.
      • Barnert E.S.
      • Gaboian S.
      • Bath E.
      Understanding and responding to the needs of commercially sexually exploited youth: Recommendations for the mental health provider.
      ).

      Challenges with identification

      There are numerous challenges in addressing the complexity of human trafficking in the pediatric population, with some being survivor-driven and others being provider-related. Many survivors do not disclose their victimization status for a variety of reasons, such as not self-identifying as victims, not being aware of their exploitation, or carrying feelings of shame or self-blame. For instance, 95% of female adult and adolescent sex trafficking survivors reported experiencing either physical or sexual violence that occurred during their period of exploitation; 90% reported threats to themselves; 57% indicated that they had sustained physical injuries; and 35% reported threats to family (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Zimmerman C.
      • Hossain M.
      • Yun K.
      • et al.
      The health of trafficked women: A survey of women entering post trafficking services in Europe.
      ). Youth who have been trafficked may also fear punishment or retaliation from their traffickers, fear of judgment from healthcare providers, or prosecution from law enforcement and the justice system (
      • Rajaram S.S.
      • Tidball S.
      Survivors’ voices- complex needs of sex trafficking survivors in the Midwest.
      ), all of which inhibit disclosure. Youth generally have less access and fewer resources to protect themselves, often needing to rely on their trafficker for basic, life-sustaining needs (
      • Costa C.B.
      • McCoy K.T.
      • Early G.J.
      • Deckers C.M.
      Evidence-based care of the human trafficking patient.
      ). Survivors may believe, or have been told, that they are responsible for their actions, which may get them in trouble with the law. Therefore, to protect themselves, their traffickers, and other survivors, they will often avoid authority figures and mandated reporters.
      As for provider-related barriers, survivors report a number of interventions that could have assisted in their disclosure. For instance, in a mixed-methods study of survivors of sex trafficking with a mean sample age of 29.4 years, 48% of survivors reported “no one asked me questions about my situation,” 23% reported little privacy, 19% reported feeling rushed, and 14% reported wanting to talk about it but did not due to lack of trust in the healthcare provider (HCP) (
      • Richie-Zavaleta A.C.
      • Villanueva A.
      • Martinez-Donate A.
      • Turchi R.M.
      • Ataiants J.
      • Rhodes S.M.
      Sex trafficking victims at their junction with the healthcare setting: A mixed-methods inquiry.
      ). Additionally, even though healthcare providers are essential in anti-trafficking efforts, there remains a lack of adoption of standardized education, response, and evidence-based, survivor-informed protocols (
      • Kaufka-Walts K.
      Child labor trafficking in the United States: A hidden crime.
      ;
      • Murphy L.
      Labor and sex trafficking among homeless youth-A ten-city study: Full report.
      ). This creates a system where many victims continue to go unidentified.

      Medical professionals' knowledge

      Despite these challenges, healthcare professionals must be educated on human trafficking, including the risk factors and indicators of human trafficking, to intervene successfully on behalf of victims. History of child maltreatment, involvement in the child welfare or juvenile justice systems, homelessness, running away, being kicked out, and identification as LBGTQ+ can increase vulnerabilities (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Richie-Zavaleta A.C.
      • Villanueva A.
      • Martinez-Donate A.
      • Turchi R.M.
      • Ataiants J.
      • Rhodes S.M.
      Sex trafficking victims at their junction with the healthcare setting: A mixed-methods inquiry.
      ). For example, in a survey of sex trafficking survivors in Orange County, CA, 63% were first trafficked as a minor, 48% had a history of sexual abuse, 58% had a history of running away, and 71% were recruited by someone they knew (
      • OC Human Trafficking Task Force
      2021 Human trafficking victim report [PDF].
      ). Trafficked and sexually exploited youth may remain in their situations for any number of reasons including harboring a sense of helplessness, lacking resources, trauma bonding, debt bondage, shame, stigma, and not self-identifying as victims (
      • Greenbaum V.J.
      Child sex trafficking in the United States: Challenges for the healthcare provider.
      ,
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ). Given the significant lack of disclosure rates among human trafficking victims, it is important for healthcare professionals to know the risk factors to identify and ultimately intervene on behalf of victims. However, recent surveys underscore the lack of knowledge many professionals have in prevalence, scope, and appropriate response to human trafficking (
      • Beck M.E.
      • Lineer M.M.
      • Melzer-Lange M.
      • Simpson P.
      • Nugent M.
      • Rabbitt A.
      Medical providers’ understanding of sex trafficking and their experience with at-risk patients.
      ;
      • Titchen K.E.
      • Loo D.
      • Berdan E.
      • Rysavy M.B.
      • Ng J.J.
      • Sharif I.
      Domestic sex trafficking of minors: Medical student and physician awareness.
      ). For example, when presented a clinical vignette describing a sex trafficking victim, less than 50% of medical professionals were able to identify the described individual as such (
      • Beck M.E.
      • Lineer M.M.
      • Melzer-Lange M.
      • Simpson P.
      • Nugent M.
      • Rabbitt A.
      Medical providers’ understanding of sex trafficking and their experience with at-risk patients.
      ). Altogether, there appears to be a paucity of training for medical professionals on human trafficking and exploitation. In one study, 63% of healthcare professionals reported they had not received education or training on identifying human trafficking (
      • Beck M.E.
      • Lineer M.M.
      • Melzer-Lange M.
      • Simpson P.
      • Nugent M.
      • Rabbitt A.
      Medical providers’ understanding of sex trafficking and their experience with at-risk patients.
      ).
      The medical presentation of trafficking survivors will likely not be obvious to healthcare professionals, including nurses. In addition, healthcare professionals are not immune to the often mythical or stereotyped portrayal of human trafficking in the popular media (
      • Peck J.L.
      Child trafficking victims in pediatric surgical environments.
      ). Inaccurate depictions of trafficking, including the use of sensationalized images depicting trafficking as hypersexualized or the use of chains or handcuffs, further increase barriers to identification. HCPs who are not educated on the complexities of human trafficking may unknowingly be looking only for the media representation of a trafficked child or adolescent (
      • Peck J.L.
      Child trafficking victims in pediatric surgical environments.
      ). Another common misconception is that trafficking mainly involves foreign nationals. However, reports demonstrate that many persons trafficked in the U.S. are U.S citizens or legal permanent residents. For example, in Orange County, CA, 85% of victims assisted were U.S nationals, 95% were female, 42% Hispanic/Latino, 29% African American, and 18% Caucasian (
      • OC Human Trafficking Task Force
      2021 Human trafficking victim report [PDF].
      ). Contributing to misconceptions, child sex trafficking is often highlighted in the media while labor trafficking remains significantly overlooked and underreported. It is estimated that child labor trafficking affects 5.5 million youth globally (
      • Thomas S.
      • Stoklosa H.
      • Murphy L.
      Child labor trafficking is a health care issue [Web blog post].
      ). In a multi-city study of homeless youth in the U.S., more than 14% had been trafficked for sex, 8% had been trafficked for forced labor, and 3% were trafficked for both sex and labor. Despite evidence of child labor trafficking in the U.S, there is still a lack of data-driven research surrounding the issue (
      • Kaufka-Walts K.
      Child labor trafficking in the United States: A hidden crime.
      ;
      • Murphy L.
      Labor and sex trafficking among homeless youth-A ten-city study: Full report.
      ).

      Study design

      In order to comprehensively understand the lack of response by medical institutions, as well as barriers to recognition and subsequent response, this study was designed to assess perspectives on healthcare interactions from youth survivors of human trafficking. We conducted both one-to-one and focus groups, in which we interviewed eight survivors in the community who had exposure to the healthcare system while they were being trafficked. The research questions asked were: (1) What are the personal healthcare experiences of youth survivors of trafficking in Orange County, California? (2) How can this information be used to guide the survivor-driven component of a human trafficking protocol?

      Method

      Participants

      This study incorporated a phenomenology approach where the focus of inquiry was what individuals experienced in relation to a particular phenomenon (
      • Groenewald T.
      A phenomenological research design illustrated.
      ). Participants were recruited from two outpatient service agencies that provide services for survivors of human trafficking using purposive and snowball sampling. Prior to the study, participants were screened for eligibility using the Youth Thrive Survey. This survey is a validated, self-reported tool to measure protective and promotive factors such as resilience, social connection, and emotional well-being (

      Center for the Study of Social Policy. (n.d.). Youth Thrive survey. Retrieved from https://cssp.org/our-work/project/youth-thrive/#survey-instrument

      ). Eligibility for inclusion in the study required age 18–26 years with personal history of surviving human trafficking and receipt of healthcare services while being trafficked. Eight participants engaged in either one-on-one or focus group interviews conducted over a four-month period from April 2021 to July 2021.
      Demographically, participants were 20–26 years of age with racial and ethnic makeup of four African Americans, one Hispanic, one Pacific Islander, one Caucasian, and one mixed ancestry. The preliminary analysis described participants' access to healthcare during their period of exploitation. Participants were first sex trafficked between 4 and 18 years of age, with a duration of being trafficked ranging from 1 to 16 years. Seven out of eight participants reported a history of being in a foster care or group home. All participants expressed wanting to see a medical professional while being trafficked, and all but one was able to do so.

      Procedures

      This study was approved by the Children's Hospital of Orange County Institutional Review Board. After eligibility screening was completed, a study team member contacted the youth to describe the study (including purpose, voluntariness, risks, and benefits), assessed interest in participating, and scheduled the interview. Participants were compensated for their time with a gift card.
      After written, informed consent was obtained, each participant completed a brief demographics questionnaire. A standard procedure was followed to identify participant distress during the interview, including watching for stress indicators, asking questions regarding the level of distress experienced, providing options such as skipping the question or stopping the interview, and ensuring the participant had follow-up services in place. The interviewers were licensed healthcare professionals trained in trauma-informed care and the recognition of distress and retraumatization. A semi-structured interview framework was used to elicit information about participants' experiences with healthcare while being trafficked. Previously validated and established interviewing techniques were utilized, and questions were created to elicit complete and accurate responses (e.g., open-ended questions: “tell me more about that”, probing based on phrases used by the interviewee).
      Due to the COVID-19 pandemic, the investigators primarily used a teleconferencing software program that allows individuals to meet in a virtual setting. Interviews were conducted individually or in focus groups based on the participant's comfort level. Participants were given the option to turn their cameras off to protect their identity. One interview was conducted in person, while the remainder were performed using video conferencing. All interviews were audio recorded. Interview data was saved on a secure data drive within the CHOC Organization. The data were de-identified, password-protected, and did not contain information such as names, telephone numbers, or physical home addresses. Any identifying information was secured and stored in the primary investigator's hospital computer drive.

      Qualitative data analysis

      Content and thematic analyses were used to categorize, tag, and derive themes from participant responses (
      • Kleinheksel A.J.
      • Rockich-Winston N.
      • Tawfik H.
      • Wyatt T.R.
      Demystifying content analysis.
      ;
      • Nowell L.S.
      • Norris J.M.
      • White D.E.
      • Moules N.J.
      Thematic analysis: Striving to meet the trustworthiness criteria.
      ). This was done to gain a deeper insight into the survivors' experiences, help understand their experiences, and create relevant recommendations for the healthcare field. Narrative analysis was also used to gather more context on their experiences (
      • Nasheeda A.
      • Abdullah H.B.
      • Krauss S.E.
      • Ahmed N.B.
      Transforming transcripts into stories: A multimethod approach to narrative analysis.
      ). The use of an inductive approach was utilized, where codes are created based on the qualitative data itself (
      • Xu W.
      • Zammit K.
      Applying thematic analysis to education: A hybrid approach to interpreting data in practitioner research.
      ). There was not a priori codebook, meaning that all codes in this analysis have been empirically based on the participant's responses. More specifically, the investigators generated codes based on the common statements and themes that were mentioned during their interviews.

      Results

      Multiple challenges for seeking medical attention were revealed, including lack of transportation, lack of knowledge surrounding insurance coverage and usage (the barrier that prevented one participant from seeking medical care), inability to seek care without permission from the trafficker, and only seeking care when in critical condition.
      Five themes were identified from the semi-structured interviews with survivors regarding their experiences with healthcare while being trafficked. These themes were: (1) Unequal Treatment, (2) Barriers, (3) Risk Identifiers, (4) Support, and (5) Survivor Recommendations.

      Unequal treatment

      Survivors of human trafficking are impacted by their experiences with HCPs. A common theme found throughout survivors' interviews was that of unequal treatment during their healthcare visits. One way this was experienced was through the propagation of common myths and the demonstration of overt biases on the part of HCPs. Previous research showing that clinicians have significant deficits pertaining to their knowledge, attitudes, and beliefs about human trafficking (
      • Ram S.
      • Goldin D.
      Primary care clinician’s knowledge of trafficking in persons: A systematic review.
      ) was confirmed by the responses of study participants. Survivor 5 stated:It's sometimes people are like ‘REALLY, that's what trafficking is?’ And other times it's like, ‘Ohh,..ohhh … sweet like you know … Taken (movie)’ that's the first thing people think when they think (being) trafficked. It's like, ‘Ohhh … you're kidnapped’ and it's not always like that.
      The biases held by HCPs can be implicit or explicit.

      Implicit bias

      Survivor 2 described implicit bias in the way HCPs view persons who have been trafficked as liars:But like, literally, they don't listen to you. They immediately see you as a liar. They do not see you as a victim…They definitely see you as a perpetrator, not a victim. But even then, just cause you see someone come in with track marks on their arm doesn't mean that you have to treat them like a junkie. Or, ignore all of their history…or saying that they are selling themselves for drugs…you know. That was another thing that I got was, ‘Ohhh she must be doing it to herself for the drugs.’ Uggghhh no my pimp got me hooked on the drugs so I could keep selling myself and stay there! So that was like a manipulation tactic on his part. I didn't even want to take it.
      A factor that may have contributed to these implicit experiences was healthcare professionals' body language, as multiple survivors commented on this. Survivor 5 described their close attention to body language, which will either encourage them to come forward and trust people, or to remain detached and avoidant.But, body language and like how you speak is something that we are very attuned with people who act like with lots of trauma cause it's how we survive. Like we have to read the atmosphere…body language…like constantly, and so it's ingrained for us. And so, if we feel that the healthcare provider or somebody is judgmental, or disgusted. And it might not be to that degree, but it's like very small…minimal like hints we read it, and we know it and understand without it…being like blatantly said.

      Explicit bias

      Multiple survivors also detailed explicit instances of unequal treatment. For example, Survivor 8 recalled a time when she was shot, and the series of questions that followed:I was shot in my leg and…the…the…they were like, “Ohh…where are you from?” Like, “What gang are you from?” “What you claim?” It was like, “Huuuhhhh?? I don't claim nothing.” Like, I'm not….I'm not involved in anything…like….why would you even think that I'm involved in something because I have an injury?

      Racial bias

      Four of the 8 survivors reported experiencing some form of racial bias or discrimination. Racial bias within the healthcare system impacts the care a patient receives, potentially leading to poorer patient outcomes and influencing the way individuals perceive and engage with healthcare in the future. Survivor 1 shared her postpartum experience:Ohhh the healthcare providers mentioned some things to me, and it was just… she was not equipped. And if I would have known that you know, it got to a serious point where she even called the place where I was at because she wanted to take my baby. Like thinking that my daughter wasn't in a safe environment because… definitely one racially profiled my child's father being African American, being dark-skinned…you know. Knowing of my history of trafficking.
      Many survivors of human trafficking considered the care they received to have been affected by biased perceptions on the part of HCPs.

      Barriers

      In addition to experiences of unequal treatment, survivors identified barriers to receiving adequate care, likely due to bias on the part of HCPs. The first barrier identified was survivors' honesty with medical professionals.

      Honesty

      Survivor 1 discussed a specific experience of how she was taught to lie about who she was, in order to receive treatment.We were always taught to tell that you were older, in order to go to the hospital, because if they were to find out about our age. And we would always get through because they asked for a social security number, or they don't really ask for form of ID…so my trafficker would take me to a hospital that would be an emergency room…give them you know my sister's birthday, or give them one of the girl's birthdates, and give a social… a fake social security number, and I think that was one thing that really held it up.” “…I was never being able to be identified. As well as pulling up to the hospital with my trafficker and he dropped me off with one of the girls who were also in the life. And you know…not verifying who that person was with me.

      Fear

      Survivors may react to situations out of fear. Survivor 6 stated:…Are you…are you in danger…you know? Are you selling yourself for money, drugs?” You know…and I would check “no” because I was afraid.” “…It's illegal girls don't have a choice or the pimp will go kill their family.
      Survivor 2 stated:We are terrified. Every person that walks through that door, we do think it is either a client…or a pimp…or a friend of a pimp. We do not know and then it gets to the point that we are sitting there for so long we get up and we leave. Sometimes we don't even make it past the front desk, because it's terrifying. Like you don't want to sit there. You don't wanna be seen…you don't wanna be exposed. It's one of the scariest…
      Fear of legal action arose as well. In many cases, those who are trafficked are told that if they come forward to the police, they will be arrested. Five of the eight participants discussed this fear of HCPs calling law enforcement and/or possible arrest. Survivor 6 further explained:Yeah…because that's…trafficking is illegal. Like…it's…it's a crime and you can get arrested. Like….it sucks that the girls who are involved in trafficking end up getting arrested, because sometimes…sometimes there are girls who don't have a choice. And they have to do that…
      Survivor 1 stated:
      That's the number one thing we think about is the cops gonna roll up on me…you knowand take me to jail…take me in custody…or make this a whole thing.”

      Risk identifiers

      Risk identifiers (also referred to as “red flags”) were another theme identified by the survivors. Risk identifiers included hypervigilance, anxiety, substance abuse, physical injuries, suicide attempt(s), and sexually transmitted infections.

      Hypervigilance and anxiety

      Survivor 8 stated, “I would say the red flag would be a person coming in and brushing it off and just like ready to get up out of there.”
      Other instances of anxious reactions were reported by Survivor 6:Constantly looking around the room. Or like…constant looking behind your back …like as if someone's following you…like paranoia…as if someone's following you. Shaking of the leg…bouncing of the leg… short answers…short…short, but sweet answers you know that like…they'll be answers like of the question answered. But, they'll be very short.
      Survivor 4 further discussed how these body cues can be an indicator for noticing risk identifiers among persons who are being trafficked:Ohh yeah, so like… most people… kind of like give you that “look”…you know like, “ahhhh I need help.” Or, kind of like playing with their…like playing with their leg or something…like if they're scared or like…if they're like have anxiety. Or, they will be like…they'll ask you like…“No, this is private. Can I go the room and talk to you?”Or…just like kind of seem like their voice is cracky…most of the time, it's a look that they will just give you…

      Substance abuse

      The use of controlled substances at a young age can be an indicator of child maltreatment including sexual abuse, physical abuse, and human trafficking (
      • Ertl S.
      • Bokor B.
      • Tuchman L.
      • Miller E.
      • Kappel R.
      • Deye K.
      Healthcare needs and utilization patterns of sex-trafficked youth: Missed opportunities at a children's hospital.
      ;
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Richie-Zavaleta A.C.
      • Villanueva A.
      • Martinez-Donate A.
      • Turchi R.M.
      • Ataiants J.
      • Rhodes S.M.
      Sex trafficking victims at their junction with the healthcare setting: A mixed-methods inquiry.
      ). Unfortunately, many survivors are introduced to drugs while they are being trafficked (
      • Greenbaum J.
      A public health approach to global child sex trafficking.
      ;
      • Ijadi-Maghsoodi R.
      • Cook M.
      • Barnert E.S.
      • Gaboian S.
      • Bath E.
      Understanding and responding to the needs of commercially sexually exploited youth: Recommendations for the mental health provider.
      ). For example, Survivor 2 recollects how she was introduced to controlled substances:Plus, you're drugged out like I did heroin and meth from the ages of 9 to 16. With that being said, because I was an addict, I was not looked at seriously and I was very high half the time. I smoked heroin, which I am very to this day grateful for. Which I know that sounds weird to be grateful for smoking heroin. But, trust me…shooting it, I wouldn't have quit.

      Injuries

      Survivors reported that injuries were a common indicator of a person being potentially trafficked. All of the survivors within this study were injured while being trafficked.
      Examples of injuries disclosed in the study ranged from bruises, lip lacerations, sprained ankles to more serious injuries such as physical assaults and shootings. Survivor 1 stated:I remember, one time I was beaten up and I went to the hospital and I remember like I had this black eye, like…nose was leaking, busted lip, and this lady just like kept reiterating like…like…if it…it just made just feel really uncomfortable, like the way they squeezed my arm to get the blood… Like just…or just… having me sitting in the waiting room.
      Survivor 4 recalled having injuries that required urgent care and ER visits such as:A lot of them is cause I'm clumsy and like I would hurt my ankle. I have really bad ankles. And like, I would like…I would be going up and down stairs a lot for clientele and like I would fall.
      Survivor 3 stated:
      Sooo…gosh… Ok, there was an incident. I ended up actually getting…getting shot… so me being in the hospital I needed…they…I needed a nurse to come fill my wound.
      Many of the survivors were forced to endanger their lives to fulfill the demands of their traffickers.

      Reproductive health and systemic infections

      Sexually transmitted infections were reported by 4 of the 8 survivors. Survivor 6 explained:
      I caught multiple STDs, like multiple it was really bad.
      Survivor 2 stated:So…I actually do have one thing that I wanted to talk about. When I was around…let's say between the ages of 11 and 13 one of my systems for every period was to tie up two tampons and shove them in as deep as I could…and as far as I could… so the bleeding would not come out. That was my way of stopping the bleeding. That was my way of continuing to work, ya know…without getting in trouble. That was my way of getting things done. With that being said, I do not think that is healthy (laughter). And I'm pretty sure that I am not the only little girl who has thought of that. Ya know…like…we have to do what we have to do. Men do not like blood. We have to get rid of it somehow. And there was times where I shoved sponges up me…and things like that…which I honestly to this day don't think was healthy. I lost a lot of weight, I got really pale. I almost went into shock one time, because it was in there for too long. And I could barely move.

      Suicide

      Due to the consequences of victimization and extreme violence, there are increased rates of depression, PTSD, anxiety, and suicide among trafficking survivors. Survivor 2 explained her history of self-harm:There is one time that I remember that was really…really…really bad and I will probably never forget it because I did try to kill myself that time. I tried to overdose on, Ok…I did not know that you could overdose on IBUProfen…I didn't know that. But, I did…I tried. I took like a whole bunch of them and it just made me really…really sick. I had to go to the hospital.
      Survivor 4 explained:
      A lot of girls suffer from PTSD…like a lot of trauma, because it's a trauma experience being in the life. (pause) Like…you'll have clients that will not respect your boundaries. Will not respect your pimp's boundaries and do whatever the f**** they want because they're paying for it…you know? And, that's the sad reality and a lot of people don't understand that.

      Support

      Throughout the interviews, personal support was frequently discussed. Survivors reported lack of support from family, friends, and medical professionals. With regard to family, some families were responsible for introducing girls to the life of exploitation, or they ignored the warning signs of the child being trafficked. When asked to describe the relationship with their parents, Survivor 2 stated:My dad was horrible, but my mom… she was just blind I guess is a good word to put for her. She was…she was blind…she's a blind woman. So, she just did not see a lot of things that were happening.
      Survivor 3 reported being trafficked by a family member and stated:
      I definitely think uhhhh…Just to see where I was, and like the demographic I was in. I think I was just really scared. of like my family.…(pause)….I think my family knew a lot…a lot of people knew about my family.
      Notably, many survivors mentioned having received positive support from an advocate, mentor, or HCP, and how that support impacted their healthcare experience. For example, Survivor 2 stated:So…as I got older, I did end up having my advocate go with me, which was AMAZING cause she made things twenty-times better.
      Survivor 1 described, “Another time, my mentor sat with me in the hospital too as well.” Survivor 3 related that her nurse was critical in identifying she had been homeless and linked her to needed services.I left the…the hospital, but at the time I was homeless. So, I was hopping from like…my aunt…my aunt would let me shower at her house sometimes and then usually I was like at a park. Sooo…my nurse that I got assigned out to me, you know she would call me and be like, “Hey…I need the address to where were going.” I would just make excuses like….“Ohhhh, I'm not home, could you meet me at this park?” “I'm not home. Could you meet me at McDonalds or Jack in the Box?” So maybe like…The second time… ummmm…so I had two or three times…but she comes every week, like twice a week because she had to fill my wound. So like the third time she came she was like, “You can't be doing this in the bathroom.” You know, and I'm like, “I'm sorry. I just…I couldn't make my way home.” Like…trying to give her every excuse in the book. And she's like something is going on.You know, I know you're homeless, but don't you, you don't have to lie to me. Ummm…where's your stuff, we're gonna get your stuff like that. Same day…she packed all my stuff in her car and she drove me to a 24 h emergency shelter. And she said, “We're…gonna get the help that you…(laughs) she was like AWESOME! Just…I love her. She was my angel in disguise at that time. And she recognized,..she when went on her own time…umm. And even like after I was ok, I was you know, set, she still checked in on me. [We] would email each other back and forth. She was really there.
      Lastly, Survivor 5 shared this about a case manager.Yeah, my case manager at the emergency shelter took me and she helped me. She sat with me when I like, I was filling out the paperwork and I had questions, she helped me with them. Umm…She offered…she wanted to go in with me when they checked me and did everything and I kind of was like, “No you can stay out here.” but she was pretty much with me throughout the process.

      Survivor recommendations

      Finally, a major aim of the focus groups with these trafficking survivors was to gain their insight and recommendations to improve the quality, safety, and effectiveness of healthcare. Recommendations and intervention techniques were discussed during the interviews. The ensuing discussions touched on the importance of increased awareness and training on the topic, how medical professionals can recognize the signs of human trafficking, how to respond during patient care, and what resources would be helpful during the medical encounter.

      Awareness and training

      A recurring recommendation was increasing awareness and in-depth training for healthcare professionals on human trafficking and its consequential impact. Survivor 6 stated:
      If possible, like more training on like the life and like… (takes a deep breath) How can I say this? Like more training on the life but like…but get more in detail of the mental health portion of the girls in the life. Because there's some…a lot of girls suffer from PTSD…like a lot of trauma, because it's a trauma experience being in the life.

      Safe spaces

      The impact of creating a safe space and providing privacy was mentioned throughout the focus groups. Survivor 3 stated:So, like having a lot of people in the room was like so overwhelming for me. And Icouldn't handle it.
      Survivor 4 explained:Yeah, just making them feel like safe and comfortable. Talking to them…making sure they're in a safe space… Just like try to pay attention to the way they talk, or if they try to switch around their story…or something like that. Yeah…something like that.

      Assessments

      In regard to explaining procedures, educating medical professionals on the importance of their touch and the actions they are taking during an examination is important. Survivor 1 stated:So, I remember when I was 12 years old, and I first walked into the hospital with a huge tattoo on my neck. Like, legally, you are not supposed to get a tattoo until you are 18 years old. Not one person ever asked me was I ok? Not one person ever asked who that was? Or tattoo? That was brandings on my body.
      Survivor 5 explained:But, I think essentially the set…a thing like now, where you talk with people who have dealt with trauma and you get like a further understanding of like the process that they think…or level of like triggers, and so you…you know things like that would be essentially very helpful because not a lot of the time you think about it. Like a simple touch to the shoulder to is like… could be very offsetting thing.
      Observations and screening
      Survivor 1 expressed a desire for medical professionals to ask more questions about her well-being. For example:“Are you sure you're ok?” They don't even say that…it's just like a checklist…like goingthrough the checklist. So, if I say “No” then it's all good to go.”
      This sentiment was echoed by Survivor 6:
      They were like…they always ask, “Ohhh, how many partners have you had in like the last six months?” Obviously, I would have a huge number, due to the fact of being in the life. And…they did seem a little concerned about that. But, they never asked more detail. They never asked, “Ohh why is the number so high? Are you involved in any like...anything?”
      Survivor 8 explained:
      A lot of minors probably are being unaccompanied to these places, if they are gonna get treated. And…they…they can lie…it's easy to lie about their age or whatever…being a John Doe in the hospital. But, just like…seeing like how someone is acting, their body language. The way they're fidgeting…the way they're talking. If they're scared… if they're completely denying the fact of where these bruises or marks or something is coming from and just totally brushing it off. Like, dig deeper…you know, because it's possibly more to a story.

      Compassion and empathy

      Many of the survivors stated that showing empathy would be very impactful for improving patient care. Survivor 7 stated:I would tell them to…treat them like their children. Cause that's in the name…We were children! It shouldn't be no reason why it's acceptable for a child to come in battered or sexually abused…or have contracted things….ughhhhh due to sexual abuse.”
      Humanizing the survivor is an important concept as well.
      Survivor 2 stated:
      Be strategic… but strategic…like make sure that person still feels human and that they feel humanized for a moment. Cause even just a little second of humanization can make such a big difference. And the entire person's view in the world…like, “Ohh my God, you see me. No one sees me. I walk down the street half naked at f****** 12, and, no one sees me…but you see me…THANK YOU! Like, it's so important.
      Survivor 7 expressed a similar view of how expressing compassion towards the youth and using similar language can assist with disclosure:I feel like if they would have just had the compassion to be like, “Hey, like what's up…” Like…it would have went longer and I feel like more of us would have been comfortable like, “Hey, this is what's going on.”
      Survivor 1 stated:It's not just being about educating, but it's about remembering why you're here and why you're in this service field to help other people. And, you can be educated all you want about human trafficking, but if someone doesn't have the empathy for it, or people don't understand, they're not willing to understand they're still gonna do a horrible job.
      Even small gestures, such as asking whether or not the patient wants something to eat or drink or explaining procedures before performing them, could help gain patients' trust. For example, Survivor 2 stated:Check on ‘em…make sure they ate…you know…make sure they drink something. Nine times out of 10 the person hasn't had a meal in soooo long. And, if they can't eat, that's literally not on purpose. There was one time where I thought a nurse was going to look at me. And she was put to the patient next to me. And I saw her give all the love and care in the world. She came back later and gave me some something to eat… for no reason. And she went home. That was amazing! She wasn't my nurse.

      Resource provision and addressing barriers

      Survivor 5 begins this conversation by highlighting that a major barrier for survivors is transportation. She suggested creating a hotline number for survivors in need to call:From what I know, especially in trafficking too… if there was like a shuttle or…something that they could call if they needed that level, because a bus…you…people know the times…they know when they are gonna be on there, so if it's…take a bus near a non-safe area, they're easily trackable especially if there's people that they know all around. But if there's a number that they can call for a shuttle. Or, see if they could take me to the hospital. Like a level before the police.
      Some practical strategies medical organizations can improve on are their access to resources. Survivor 7 stated,Just having like a list of people or organizations they can call and they can take with them. Ummm…even if it's like on a little keychain or something a little bit more discreet…you know…so if the abusers see it they won't be like, Ohhh, you tryna get away!
      Additionally, Survivor 6 stated, “Maybe like give them like a card or something that has their number on it. Or, like the hospital number. Like something quietly so that the guy doesn't notice anything.”
      Survivor 8 echoed this line of thought:
      I would say like even if it's like a little hand sanitizer like…with it wrapped over the label… get little hand sanitizers or lip glosses and then just like wrap it around like…

      Discussion

      The complexity of exploitation, especially among youth, is evident. Overall, youth survivors reported multiple barriers based on their interactions with HCPs: lack of provider awareness, education, training, feelings of shame, judgment, racial biases, and lack of empathy. Survivors also demonstrated how these experiences shaped their engagement with the healthcare system. Similar to current research, the results reinforce the need for the adoption of widespread awareness and in-depth training of HCPs to increase the identification of and response (
      • Chisolm-Straker M.
      • Miller C.L.
      • Duke G.
      • Stoklosa H.
      A framework for the development of healthcare provider education programs on human trafficking part two: Survivors.
      ;
      • Ijadi-Maghsoodi R.
      • Bath E.
      • Cook M.
      • Textor L.
      • Barnet E.S.
      Commercially sexually exploited youths’ health care experiences, barriers, and recommendations: A qualitative analysis.
      ;
      • Rajaram S.S.
      • Tidball S.
      Survivors’ voices- complex needs of sex trafficking survivors in the Midwest.
      ). Survivors also provided positive healthcare experiences and strategies for building rapport, increasing identification, fostering patient disclosure on sensitive topics, and providing an appropriate medical response. Survivor voices are critical to providing an ethical, comprehensive, and trauma-informed approach in responding to patients with a history of exploitation. Survivors reported wanting to be asked more questions about their safety and the situations they were experiencing. The findings of this study highlight the need for a safe, non-judgmental approach to care and provide specific indications of what to look for and how to respond during healthcare delivery.
      Throughout the one-to-one and focus groups, survivors suggested the importance of mental health both during and after exploitation. Healthcare must not only include physical health, but emotional and psychological health as well. Injuries and sexual violence are common during youth victimization, and this trauma relates to higher levels of posttraumatic stress disorder, anxiety, and depression (e.g.,
      • Hossain M.
      • Zimmerman C.
      • Abas M.
      • Light M.
      • Watts C.
      The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women.
      ), further highlighting a need for mental health interventions. This begins with a trauma-informed assessment that can be conducted by healthcare professionals. Acknowledging the impact of survivors' trauma while highlighting their strengths and resiliency can be a beneficial way to initiate recovery and healing process (
      • Hopper E.K.
      Trauma-informed psychological assessment of human trafficking survivors.
      ). This healing may be further supported by access to different therapy modalities (e.g., trauma-focused cognitive behavioral therapy, narrative therapy, and art therapy;
      • Coleman S.R.
      • Kometiani M.K.
      The exploration of vulnerabilities to sex trafficking and the role in art therapy treatment.
      ;
      • Countryman-Roswurm K.
      • DiLollo A.
      Survivor: A narrative therapy approach for use with sex trafficked women and girls.
      ;
      • Wright N.
      • Jordan M.
      • Lazzarino R.
      Interventions to support the mental health of survivors of modern slavery and human trafficking: A systematic review.
      ). While intervention efficacy is still being established for best practices for sex trafficking survivors, health should be considered in a more holistic manner. This is particularly important as previous research has demonstrated the success of utilizing multidisciplinary teams (e.g., physicians, counselors, legal assistance, etc.) with the rehabilitation of youth trafficking victims (
      • Clawson H.J.
      • Dutch N.
      Addressing the needs of victims of human trafficking: Challenges, barriers, and promising practices.
      ;
      • Wright N.
      • Jordan M.
      • Lazzarino R.
      Interventions to support the mental health of survivors of modern slavery and human trafficking: A systematic review.
      ). The present study further demonstrates that a multidisciplinary approach is essential to meeting the needs of youth who have been exploited. Improving healthcare outcomes and fostering long-term recovery requires services that extend beyond urgent physical needs and must include ongoing support from a holistic perspective.

      Practice implications

      Based on survivor recommendations, essential aspects of implementing a comprehensive, survivor-driven approach include:
      • Provide regular and up-to-date staff education and training
      • Establish a response protocol that uses a non-judgmental, trauma-informed approach
      • Provide privacy which includes, providing a private room, when possible, limiting the number of providers walking in and out of the room to only essential staff, communicate with the patient before asking them to disrobe, give control and provide options throughout the process.
      • Complete assessment and ask questions in a “gentle way”, include follow up questions regarding assessment findings such as bruises, tattoos, and verifying who their accompanied person is, use a professional interpreter when indicated
      • Reflect the principles of transparency and safety assurance
      • Long-term multidisciplinary resource provision
      Increased disengagement rates within the healthcare system create barriers to achieving better health outcomes (
      • Judge A.M.
      • Murphy J.A.
      • Hidalgo J.
      • Macias-Konstantopoulos W.
      Engaging survivors of human trafficking: Complex health care needs and scarce resources.
      ). This can affect both the survivor as well as their families. Survivor 7 explained by saying,…as for me, I'm really like…I guess traumatized in a sense…sooooo…ughhh I deliver in 5 days…sooo…I don't go to the doctor when I'm supposed to…like… I think I went first and third trimester, but I skipped second. Even for my daughter if she don't feel good then we will figure it out at home because I don't want them…I don't know…I don't feel comfortable with doctors and nurses. I don't feel like it's a safe place. It would have to have to be something that's like dire need that I know that I cannot Wikipedia and try figure out for me to be like, “Ohhh, ok I'm gonna take her to the doctor.
      Creating a safe space, building trust, and providing comprehensive care are all within the nursing scope of practice and will assist in providing optimal care to survivors and increase future engagement with healthcare.

      Limitations

      Although the present study is based on a small sample of participants who experienced sex trafficking in one geographical location, it contributes to the current literature on youth sex trafficking survivors' perspectives of, and experiences within, the healthcare system. Like all retrospective studies, recall bias may be a limiting factor, as the accuracy of the data reported depends on survivors' memories. However, the saliency of such memories also emphasizes which aspects of their experiences are most important to them and, thus, most important to future intervention. Further research should also include survivors from other areas in the U.S., labor trafficking survivors, male survivors, and those who identify as LGBTQIA+ to determine whether the themes extracted from the present study generalize to other populations.

      Conclusion

      Lack of awareness and inadequate treatment have severe consequences for how survivors perceive and engage with healthcare. Youth survivors seeking healthcare reported multiple barriers: lack of provider awareness, education, training, and feelings of shame, judgment, racial biases, lack of empathy, and lack of identification and response. Positive responses from healthcare providers were also identified including meeting their immediate needs such as providing food in the emergency room, organizing shelter and long-term resources. Improving patient outcomes relies on understanding the complexities of human trafficking and implementing an approach to decrease barriers to care. This study provided invaluable survivor insights and practical solutions that can be applied to healthcare delivery to impact the identification and response to youth who are being sex trafficked.

      Credit authorship contribution statement

      Lisa Murdock: conceptualization, data collection, writing the manuscript.
      Candice Hodge-Williams: methodology, data analysis, writing, reviewing.
      Kaitlin Hardin: focus group consultation and support, writing, reviewing.
      Corey Rood: writing, reviewing, editing.

      Funding

      Funding in part provided by The DAISY Foundation’'s J. Patrick Barnes Grant for Nursing Research and Evidence-Based Practice Projects.

      Declaration of Competing Interest

      The authors have no conflict of interest to declare.

      Acknowledgments

      The authors acknowledge the brave and resilient youth survivors who were open and candid about their experiences and provided invaluable insight on the healthcare provided to victims of exploitation.

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