AAP: Be Prepared to Help Victims of Child Sex Trafficking

Ricki Lewis, PhD

February 23, 2015

Commercial sexual exploitation of children (CSEC), which includes sex trafficking, is a global problem, yet pediatricians may not recognize or know how to help affected individuals. A report published online February 23 in Pediatrics details risk factors, recruitment practices, signs of CSEC, and medical and behavioral problems that victims may experience.

The idea for the report from the National Committee on Child Abuse and Neglect from the American Academy of Pediatrics (AAP) came from Jordan Greenbaum, MD, medical director of the Child Protection Center at Children's Healthcare of Atlanta, Georgia, and colleagues. "We don't have exact numbers on victims because the activities are illegal and victims don't self-identify, but we know it is common among runaway and school-age kids living at home," she told Medscape Medical News. Misidentifying victims as criminals contributes to the underestimation. "We realized that medical providers need to have some knowledge of the problem."

The crimes include trafficking for sexual purposes, prostitution, sex tourism, mail-order-bride trade, early marriage, pornography, stripping, and performing. CSEC also includes "survival sex," which is coercion to receive a necessity, such as food or shelter.

Victims Are Everywhere

Most victims begin to be exploited when they are between the ages of 12 and 16 years. Young people who are runaways or have been thrown out of their homes are more vulnerable. Also at elevated risk are those who have been abused; are from dysfunctional families; are lesbian, gay, bisexual, or transsexual; or have interacted with the juvenile justice system.

Girls are at greater risk than boys, but boys should not be ignored, Dr Greenbaum maintained. Actions may be violent or the opposite, luring a youngster with sweet talk and promises.

CSEC victims are often transported to cities, but they might come from anywhere, given the reach of the Internet and social media. Dr Greenbaum cited recent cases from rural Iowa, Arkansas, and Georgia.

Danger areas include "wherever transient male populations are, such as truck stops and interstates and military bases. Kids living near major airports and convention centers are at increased risk too. But we don't have good numbers on this," she said.

"A lot of recruitment is at school, but it doesn't need to be a metropolitan school. Traffickers send kids to recruit other kids," Dr Greenbaum added. Strangers or friends or relatives might be involved, even a family that a physician knows well.

Healthcare providers may encounter victims at clinics, in emergency departments or urgent care facilities, or in their own offices. Victims may present with a variety of physical problems.

How to Recognize CSEC and Help

It may take a team to handle CSEC victims, and including nonphysician staff and making referrals are entirely appropriate approaches, said Dr Greenbaum. "It isn't something that a family practitioner or pediatrician can just do, like an asthma treatment and send the child home. They need behavioral health, immediate housing and food and shelter, long-term medical needs, and life-skills training," she said.

Part of the work-up is asking questions, such as whether anyone has asked the patient to have sex in exchange for something or to have sex with another person or has taken sexual photos and perhaps posted them on the Internet.

Providers should photograph and describe skin injuries, particularly in protected body parts, that have a patterned appearance or when the patient's explanation of their origin does not make sense. Complete examination of the anogenital area is critical and may require referral if the physician or patient is uncomfortable.

Victims may experience posttraumatic stress disorder, major depression, suicidality, anxiety disorder, somatization, aggression, and oppositional behavior. Referrals may also be necessary to handle pregnancies, HIV and other STI exposures, and drug rehabilitation.

Despite medical attention, victims may return to a life of exploitation for several reasons, including attachment to the exploiter, unwillingness to return to a home situation, or ostracism.

The report offers guidance for pediatricians:

  1. Victims may present with infection, trauma, mental health problems, and/or reproductive issues.

  2. Victims are unlikely to self-identify. Risk factors include truancy, running away, child abuse, involvement with child protective services or the juvenile justice system, pregnancy, sexually transmitted infections, and substance abuse.

  3. A provider should be nonjudgmental and sensitive while taking a patient's history.

  4. Medical work-up may include diagnosing and treating sexually transmitted infections, obtaining evidence of sexual assault, treating chronic conditions, documenting injuries, and making appropriate referrals.

  5. Providers may educate families and professionals who work with children about Internet safety and recognizing recruitment tactics.

  6. Pediatricians are mandated to report suspected child neglect and abuse. In some states, CSEC and sex trafficking are considered abuse.

The AAP resolved any relevant conflicts among members of the Committee on Child Abuse and Neglect.

Pediatrics. Published online February 23, 2015. Full text

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