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ARTICLE Professional Issues

White Paper: Recognizing

Child Trafficking as a Critical Emerging Health Threat

Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, Mikki Meadows-Oliver, PhD, MPH, PNP-BC, RN, FAAN, Stacia M. Hays, DNP, APRN, CPNP-PC, CNE, & Dawn Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN

ABSTRACT Human trafficking is a pandemic human rights violation with an emerging paradigm shift that reframes an issue traditionally seen through a criminal justice lens to that of a public health crisis, par- ticularly for children. Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma-informed, and culturally responsive care from trained health care providers (HCPs). The purpose of this article was to engage and equip pediatric HCPs to respond effectively to human trafficking in the clinical setting, improving health outcomes for affected and at-risk children. Pediatric HCPs are ideally posi- tioned to intervene and advocate for children with health dispar- ities and vulnerability to trafficking in a broad spectrum of care settings and to optimize equitable health outcomes. J Pediatr Health Care. (2021) 35, 260−269

ica L. Peck, Clinical Professor of Nursing, Louise Herrington ool of Nursing, Baylor University, Friendswood, TX.

i Meadows-Oliver, Associate Professor of Nursing, nipiac University, Hamden, CT.

ia M. Hays, Clinical Assistant Professor, University of Florida, esville, FL.

n Garzon Maaks, Clinical Professor, University of Portland, land, OR.

flicts of interest: None to report.

espondence: Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, , FAANP, Louise Herrington School of Nursing, Baylor ersity, 233 Mesquite Falls Lane, Friendswood, TX 77546; ail: [email protected]. diatr Health Care. (2021) 35, 260-269

1-5245/$36.00

yright © 2020 by the National Association of Pediatric Nurse titioners. Published by Elsevier Inc. All rights reserved.

lished online March 13, 2020.

s://doi.org/10.1016/j.pedhc.2020.01.005

Volume 35 � Number 3

KEY WORDS Human trafficking, sex trafficking, labor trafficking, child traffick- ing, pediatric nurse

Human trafficking (HT) is a pandemic human rights violation (Scannell et al., 2018) with an emerging paradigm shift reframing an issue traditionally seen through a criminal justice lens to that of a public health crisis, particularly for children (Greenbaum et al., 2018; Speck et al., 2018). Globally, it is estimated that eight million children and youth are trafficked annually, 5.7 million for labor and another 1.8 million for sex (Reid et al., 2018). The International Labour Organization estimates one in four of the 21 million worldwide victims of forced labor are children (International Labour Organization, 2018). The United Nations Office on Drugs and Crime found that children comprise 33% of 40,000 identified victims of trafficking (Greenbaum & Brodrick, 2017). HT is a growing problem in the criminal industry with estimates of more than 40 million people currently victimized worldwide (Gordon, Fang, Coverdale, & Nguyen, 2018). The number of HT victims in the United States is unclear, although Polaris (2018a) estimates the total number of victims easily ascends into the hundreds of thousands when including both adult and child sex and labor trafficking victims. Over the past decade, the National Human Trafficking Resource Center (National Human Trafficking Resource Center, 2019) reported more than 40,000 cases of domestic HT with the majority originating in California, Texas, Florida, Ohio, and New York (Joint Commission, 2018). Women and girls account for up to 99% of victims in the sex trafficking industry and 58% of vic- tims in other categories, including forced labor (International Labour Organization, 2018; Owens et al., 2014).

Child trafficking (CT; with the term CT encompassing both labor and sex trafficking) is both underreported and understudied. In a recent literature review, a mere 9.7% of over 22,000 articles reviewed specifically addressed

Journal of Pediatric Health Care�

CT (Sweileh, 2018). Accurately collected estimates of CT incidence and prevalence do not exist, partly because of the illicit nature of trafficking, underreporting of victims, and absence of both standardized terms and a consolidated com- mon database. Existing evidence reports potential victims of CT present in all health care environments, creating an oppor- tunity for pediatric health care providers (HCPs) to act as first responders in prevention efforts, victim identification, and treatment referral (Polaris, 2018b; Sinha, Tashakor, & Pinto, 2019). The Joint Commission issued a Quick Safety bulletin in June 2018, urging health care environments to identify potential victims of HT (Joint Commission, 2018). Although well-designed evidence-based CT education has an important role in effectively equipping clinicians, awareness among HCPs remains low (Barron, Moore, Baird, & Goldberg, 2019; Sprang & Cole, 2018; Donahue, Schwien, & LaVallee, 2019; Fraley, Aronowitz, & Jones, 2018; Katsanis et al., 2019; Lutz, 2018; Recknor & Chisolm-Straker, 2018; Sinha et al., 2019; Viergever, West, Borland, & Zimmerman, 2015). Mis- conceptions regarding the nature and scope of trafficking persist and impede efforts to improve outcomes. Although the United States is one of the most significant locations for CT victims (Joint Commission, 2018), many U.S. HCPs mis- takenly believe that trafficking mainly occurs internationally and rarely affects U.S. residents, although most of those affected in the United States are American citizens and not foreign nationals (Viergever et al., 2015). Most notably, up to 88% of child and adult victims encounter at least one HCP without being identified as trafficked (Greenbaum et al., 2018; Reid, Baglivia, Piquero, Greenwald, & Epps, 2018). Child victims present in a variety of clinical environments, but most HCPs do not receive adequate training on identification or referral services appropriate to the pediatric population (Greenbaum et al., 2018; US Department of Health and Human Services [USDHHS], 2019).

Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma- informed, and culturally responsive care. The purpose of this article was to engage and equip pediatric HCPs to effectively respond to CT in the clinical setting as a critical effort to improve health outcomes for affected and at-risk children.

BACKGROUND CT is an illicit enterprise, making accurate analysis difficult because there are few uniform mechanisms for data collection. In particular, sex trafficking is often hidden and difficult to detect (Rajaram & Tidball, 2018). Moreover, affected children and adolescents often do not self-identify as victims or may not seek services for fear of criminal prosecution, deportation, stigmatization, and/or blame. Many consider victim identi- fication as the “tip of the iceberg,” and some argue that lack of attention to CT creates an environment that allows traffickers to evade criminal detection and prosecution (Rajaram & Tidball, 2018).

The Victims of Trafficking and Violence Protection Act, now referred to as the Trafficking Victims Protection Act, was established in 2000, defining HT at the federal level for

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the first time. Child sex trafficking (CST), also known as com- mercial sexual exploitation of a child or domestic minor sex trafficking, involves youth under the age of 18 years who are obtained, harbored, transported, advertised, recruited, soli- cited, or enticed to engage in commercial sexual exploitation (e.g., exotic dancing, massage parlors, escort services, pornog- raphy production, prostitution, pornography, or any other sex-related work) for some form of payment, either in money or goods. It is important to note that this includes all types of commercial sex work for victims under the age of 18 years, even in the absence of force, fraud, or coercion, which are elements required for prosecution in adult victims (USDS, 2019). Contrary to common misconceptions, not all children in CST entered through stranger coercion or abduction. Sprang & Cole (2018) found that approximately 31% of child victims were subjected to sexual acts, and 25% of children engaged in pornography related to family member coercion, typically involving selling the child for money, drugs, food, shelter, or something else of value. Child labor trafficking (CLT) involves forcing a child into labor acts through physical or psychological threats or debt bondage. Service, domestic (i. e., hospitality industries, such as hotels), and agricultural industries are most likely to involve CLT (Reid et al., 2018).

RISK FACTORS FOR CHILD TRAFFICKING Emerging research forms a consensus of commonly identified risk factors (Table 1). The varied nature of CST and CLT make the creation of a singular risk profile difficult (Reid et al., 2018); therefore, pediatric HCPs should know individual risk categories and include these in the routine assessment of youth. This information is particularly relevant to pediatric HCPs because many victims enter trafficking during adolescence. In a survey of 913 survivors of CST and CLT from Florida state records, Reid et al. (2018) found 47% entered trafficking at the age of 13−14 years, 15% entered at the age of 15 years, and 29% entered at the age of 12 years or younger.

Although some risk factors of CST and CLToverlap, other risk factors are more distinct. The most significant risk factor for CST is childhood trauma, especially experiencing sexual abuse (Choi, 2015; Reid et al., 2018). The longer or more fre- quent the abuse, abuse perpetrated by father figures, co-exist- ing emotional or physical abuse, and penetrative sexual abuse confer the greatest risk (Choi, 2015). The actual reasons for these connections remain speculated; however, it is believed that neurologic changes from toxic stress, damage to interper- sonal skills caused by abuse, and emotional numbing that fre- quently occurs after abuse provide susceptibility to CST and/ or CLT (Choi, 2015). The landmark Adverse Childhood Experiences (ACEs) study of more than 17,000 subjects (Centers for Disease Control [CDC], 2019) examined catego- ries of abuse, neglect, and household dysfunction experienced before the age of 18 years. ACEs are associated with down- stream health consequences occurring over the life span, including the adoption of health-averse behaviors, disrupted neurodevelopment, cognitive impairment, chronic disease burden, disability, and premature death. Higher ACE scores reveal a graded dose-response risk for adverse health

May/June 2021 261

TABLE 1. Risk factors for child trafficking

Individual Relational Community or societal

Age: early to middle adolescence Parental substance abuse Social isolation or bullying Runaway status Parental abuse or neglect Sexualization of children Identification as LGBTQI Family conflict, disruption, or dysfunction Indigenous or first nations children Foster care placement Forced out of their homes by family members Recent immigration or migration Juvenile justice system involvement Family domestic violence Gang involvement Substance abuse or misuse Single-parent families Children from impoverished communities Mental illness Children with a deceased parent Underserved neighborhoods and communities High ACE score Underresourced schools Survivors of abuse or neglect Lack of awareness of CT Intellectual and other disabilities Lack of available resources to respond to CT Immigrant or refugee status

Note. ACE, adverse childhood events; CT, child trafficking; LGBTQI, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex. Source: Choi, 2015; Niegarten, 2018; Reid et al., 2018; United States Department of State, 2019.

outcomes and should be considered when encountering a child at risk for trafficking.

Gender is also a particular CST risk factor because female survivors outnumber male survivors; however, people of all genders and sexual orientations are sexually trafficked. Youth who identify as lesbian, gay, bisexual, transgender, queer, or intersex (LGBTQI) have a higher risk of CST than their heterosexual peers (Choi, 2015). Because child survivors of maltreatment are more likely to run away, they may have a compounded risk because homeless youth and runaway youth are at a significant risk for a trafficking experience (Chisolm-Straker, Sze, Einbond, White, & Stoklosa, 2019) because of shelter, food, and resource insecurity. It is esti- mated that the United States has one to almost three mil- lion homeless youth. Approximately 20% of U.S. teens run away from home at some point during adolescence. Of these, one-third are recruited into CST within days, and almost 90% are sexually exploited within 3 months (Nier- garten, 2018). Although youth substance abuse and mental illness are known risk factors for CST, it is unclear whether these conditions occurred before trafficking or are the result of surviving trafficking (Choi, 2015).

Environmental influences on the likelihood of CST and/or CLT include single-parent families, poor family interpersonal relations, dysfunctional family systems, unsafe or insecure living conditions, placement in foster care or juvenile justice, and significant financial insecurity (Choi, 2015; Niegarten, 2018; Zimmerman, Hossain, & Watts, 2011). These circumstances make children more vulnerable to sexual grooming lured by money, a feeling of being loved, or having somewhere “safe” to go. In addi- tion, financial insecurity and unsafe living conditions may result in parental decisions to offer them for domestic labor, making the children vulnerable to debt bondage (Toney-Butler & Mittel, 2019).

HEALTH IMPACTS OF TRAFFICKING Trafficking adversely affects physical, social, mental, emo- tional, psychological, and spiritual health. Acute and chronic

262 Volume 35 � Number 3

headaches are among the most frequently reported physical conditions experienced by victims of HT (Hemmings et al., 2016; Oram et al., 2016; Oram, St€ockl, Busza, Howard, & Zimmerman, 2012; Le, 2018). Fatigue and dizziness are also common (Hemmings et al., 2016; Oram et al., 2016; Zim- merman et al., 2011). Additional complaints include mem- ory problems, acute or chronic pain (especially headaches, backaches, and abdominal pain), and sleep disturbances (Hemmings et al., 2016; Oram et al., 2012; Oram et al., 2016; Le, 2018; Zimmerman et al., 2011). Other physical signs include unexplained or repeated traumatic injuries, such as bruising, fractures, ligature marks, and/or cuts. Vic- tims may experience frequent exposure to infectious dis- eases, including tuberculosis and vaccine-preventable illness (Richards, 2014). Because of preventive care neglect, victims may experience long-term dental or oral health problems resulting in dental pain (Oram et al., 2012; Le, 2018) from trauma or injuries to the mouth sustained during physical and sexual abuse (Zimmerman et al., 2011). Victims of CST often experience sexual and reproductive health prob- lems from sexual violence and unsafe sex practices including urinary tract infections, pelvic inflammatory disease, and unplanned pregnancy (Hemmings et al., 2016; Zimmerman et al., 2011). Sexually transmitted infections, including hep- atitis B or C and HIV, are among the most common sexual health issues reported (Cannon, Arcara, Graham, & Macy, 2018; Oram et al., 2016; Le, 2018; Zimmerman et al., 2011). Forced and unsafe abortions may occur (Richards, 2014). Similar to victims of CLT, those who experience CST may endure inhumane working and living conditions.

Victims of CLT work long hours with little rest and may be exposed to pesticides and other hazardous chemicals. Children are at risk for physical injury if they lack protective gear or operate machinery without proper training or oversight (Cannon et al., 2018; Ronda-Perez & Moen, 2017; Zimmer- man et al., 2011). Victims of CLT may develop musculoskeletal issues from repetitive motions and limb injuries. Children may work in extreme weather conditions and develop skin infec- tions from being exposed to poor sanitation and bacterial

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hazards (Cannon et al., 2018) and injury (e.g., limb amputa- tions). Child victims often live in overcrowded, unclean condi- tions where they are further exposed to communicable diseases (Zimmerman et al., 2011). Sexual abuse may occur during labor trafficking (Cannon et al., 2018).

CT victims experience repetitive traumatic events that result in cumulative psychological harm. The most common mental health conditions reported include anxiety, depression, post-traumatic stress disorder, and suicidal ideation (Hem- mings et al., 2016; Oram et al., 2016; Le, 2018; Richards, 2014; Zimmerman et al., 2011). In addition, substance abuse or misuse may occur because of forced or coerced use of sub- stances (Zimmerman et al., 2011).

PRESENTATION OF VICTIMS IN THE CLINICAL SETTING It is estimated that 88% of victims access health care services sometime during their exploitation (Greenbaum et al., 2018; Reid et al., 2018). Since 2016, 14 states have enacted legisla- tion addressing health professional education about HT (Atkinson, Curnin, & Hanson, 2016). Recent studies have demonstrated the inadequacy of identification and health care services of CT victims. The variability of each trafficking experience adds to the difficulty of recognizing victimization (Fedina, Williamson, & Perdue, 2019). HCPs are critical to identifying children at high risk for trafficking and offering timely, comprehensive, and multidisciplinary services.

Victims commonly present with a variety of behavioral clues that should raise CT suspicion. Often, illness or injury history is inconsistent with physical findings. The presence of a control- ling accompanying adult who does not allow the child or ado- lescent to speak, or observation of overly submissive, withdrawn, or fearful behaviors should be concerning. Identifi- cation documents may be absent or “misplaced” (Shared Hope, 2019). Victims may be unaware of the current date or time and their current location or may be unable to provide a home address. Other warning signs include aggression, extreme fear, or withdrawal manifested by flat affect (Dignity Health, n.d.).

A variety of physical signs should alert the HCP to suspect HT. Note the discrepancy between stated age and observed age. Suspected victims who state their age to be over 18 years but appear to be younger should have age correlation with a physical examination and Tanner staging, although early- onset sexual abuse is associated with earlier pubertal onset (Noll et al., 2017). Physical signs of trafficking include evi- dence of physical or sexual violence, such as ligature marks, broken teeth or bones, and vaginal or rectal injury. Malnutri- tion or unmanaged chronic illness may be noted. Illegal sub- stance abuse, especially when testing results positive for multiple drugs, should raise trafficking suspicion. Recurrent visits for urinary tract infections, sexually transmitted infec- tions, pelvic inflammatory disorder, and partial or traumatic abortion are high-risk indicators (Shared Hope, 2019). Assess the entire body and document any tattoos because traffickers often brand their victims with permanent markings. In the United States, marking a youth under the age of 16 years with a tattoo is illegal in most states and should raise

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suspicion (National Conference of State Legislators, 2018). Commonly reported tattoos include using dollar signs, bar codes, or the words “daddy,” “bottom” (designating a “bot- tom girl” or a victim who moved up in the victim hierarchy and may receive better treatment), or “___’s girl” (Fang, Cov- erdale, Nguyen, & Gordon, 2018; Napnap Partners, 2019).

IMPLEMENTING A TRAUMA-INFORMED AND CULTURALLY RESPONSIVE APPROACH A trauma-informed approach minimizes triggers, stabilizes the patient, and de-escalates potentially volatile situations. Trauma response has significant impacts on psychological and physical outcomes, including long-term sequelae such as post-traumatic stress disorder (USDHHS, 2014). A trauma- informed framework encourages HCPs to adeptly recognize signs of trauma and its widespread impact while integrating trauma-related policies and procedures to help prevent retrau- matization (USDHHS, 2014; Dignity Health, n.d.). Through this process, HCPs provide care that empowers survivors by considering their wishes, maximizing their input in care- related decisions, reassuring safety, and providing care with transparency and trustworthiness (Greenbaum et al., 2018; Dignity Health, n.d.). The trauma-informed approach assists HCPs in identifying subtle indicators of trauma while creating a safer space for self-disclosure of victimization (Greenbaum et al., 2018; Peck & Meadows-Oliver, 2019).

A primary tenet of trauma-informed care is developing trust. An initial step is to provide safety and privacy for the health care encounter, away from the accompanying person (Barnet et al., 2018). Be aware that a child may be a victim of familial CST or CLT, or the “friend” may be someone appointed by the trafficker to supervise and ensure victimi- zation is not disclosed (Polaris, 2018; Sprang & Cole, 2018). Separate them via a required procedure that only the patient can attend, such as an x-ray or a urine test. Equally impor- tant is limiting the number of staff who are aware of the sus- pected trafficking situation to limit conversation and lessen the risk of the trafficker overhearing the conversation and leaving. Another aspect of establishing a trusting relationship and providing culturally responsive care is ensuring the patient can speak to HCPs in their native language. Three federal laws (The American with Disabilities Act, Title VI of the Civil Rights Act of 1964, and the Affordable Care Act) require HCPs or institutions who receive federal funds to provide qualified interpreters to patients with limited English proficiency and patients who are deaf or have impaired hear- ing, and explicitly bans the use of minor children or adult family members and friends as interpreters (USDHHS, 2014; USDS, 2019). People who accompany the suspected victim should never be translators. Never question potential victims about their immigration status.

Demonstrate respect for the child or adolescent by offering choices and control during the encounter. Ask patient permission before initiating a detailed history and physical. Throughout the encounter, ask, “How are you doing?” or “May I continue?” Use developmentally appropri- ate language and start with less invasive parts of the

May/June 2021 263

FIGURE 1. National Human Trafficking Hotline. Source: National Human Trafficking Hotline, 2019.

(This figure appears in color online at www.jpedhc.org.)

examination by asking, “Are you comfortable with me listen- ing to your lungs?” and then request permission to ask more probing questions and perform more intimate examinations (National Child Traumatic Stress Network [NCTSN], n.d.; Affordable Care Act, 2016).

Just as with other forms of trauma, many child victims, when questioned, are not willing to self-disclose as victims, and many do not recognize their victimization yet (NCTSN, n.d.; Polaris, 2018b). Some factors compelling nondisclosure include fear, distrust of authority, shame, hopelessness, and trauma bonds (Greenbaum et al., 2018). HCPs can provide support during the encounter (Table 2). Do not force, deceive, or coerce a patient to disclose with the intent to “save” or “rescue” them. Understand that survivors may express anger or be accusatory and/or belligerent as mani- festations of survival behaviors. Do not be discouraged if a patient does not disclose victimization. It may take several visits for a child to feel safe enough to disclose their traffick- ing situation. Validate and normalize their feelings (NCTSN, n.d.; Affordable Care Act, 2016), and discreetly, verbally

TABLE 2. Health care provider response to CT victims in the clinical setting

Response Action items

Evidence-Based Practice within the scope of your education, license, certification and training Adhere to mandatory reporting laws in your state Seek high quality continuing education from reputable entities

Provide appropriate care for presenting clinical concerns (i.e. injuries or illnesses) Advocate for use of scientifically-designed screening tools with evidence of reliability and validity Facilitate appropriate referral and connection to interprofessional holistic service entities

Trauma-Informed Safety- Ensure emotional and physical safety for all involved parties in the clinical setting Avoid unintentional re-traumatization by using well-intentioned but ill-informed interview techniques Make every effort to provide privacy during clinician interaction with the individual, separate from individuals potentially posing threats (i.e. traffickers)

Choice- Provide individuals with control and clear, appropriate messages about their rights and responsibilities Do not attempt to force the patient to self-disclose Know and adhere to federal and state laws as well as organizational policy governing mandatory reporting Collaboration- Share power in decision making and planning Collaborate with interprofessional disciplines Trustworthiness- Maintain respectful and professional boundaries Do not make promises you cannot keep Empowerment- Prioritize empowerment and skill building Do not “rescue” the patient Communicate messages of hope This is a safe place You are not alone This is not your fault You deserve to receive help

Culturally-Responsive Identify your personal potential biases Use a professional interpreter or interpreter service(s) to provide linguistically appropriate services to individ- uals who speak a different language

Recognize the differences between the cultures of law enforcement, the health care profession, trafficked individuals, and other interprofessional disciplines involved in care

Advocate trafficking response teams that are inclusive and representative of diverse perspectives

Note. CT, child trafficking. Source: Peck, 2019.

264 Volume 35 � Number 3 Journal of Pediatric Health Care�

TABLE 3. Open-ended conversation approaches

Concern for labor trafficking Concern for sex trafficking

What type of work do you do? What are your work hours? How often do you get to see your family? Does someone prevent you from contacting them? Can you get another job if you want? Come you come and go as you please? How many people live with you? Are you being paid? Do you have a safe place to go? Do you owe money to your employer? Do you have control over your money and ID/documents?

Do you ever feel pressure to do something you don’t want to? Have you been physically hurt? Did someone tell you what to say today? Has your family been threatened? Has anyone asked you to have sex with someone else? Have you ever felt you had to have sex to get what you need, such as food or to stay in where you live?

Has anyone asked you to dance at a gentleman’s club or take your clothes off in front of someone?

*Note: Some questions overlap and may be appropriate for concern for both sex and labor trafficking. Principles of trauma-informed care should be implemented with any clinician-patient interaction. These may present a starting place for conversation to explore potential risk in the absence of a scientifically-designed screening tool with established validity and reliability. Source: National Human Trafficking Resource Center, 2019.

provide the information they may choose to act on in the future. This information may include providing them with the National Human Trafficking Hotline number (Figure 1). Avoid judgmental statements that may be abrupt or insensi- tive, such as, “Why didn’t you ask for help?” or “How could this have happened?” Be open to unfamiliar narratives. Although there is currently no universal screening tool

TABLE 4. Recommended calls to action

Evidence-Based, Trauma-Informed, Survivor-Informed, Culturally

Entity Action items

Individual HCPs Seek evidence-based continuing educatio Memorize the Human Trafficking Hotline p Learn how to be an effective advocate an Keep abreast of published scientific literat Advocate for the implementation of a prot Advocate for prevention of Adverse Child Educate children and families about risk f Volunteer with a local anti-trafficking advo Serve on a city, state, or federal taskforce

Health Systems/Clinical Environments

Establish an interprofessional workgroup Designate an organizational taskforce to r Require annual training for ALL employee Make trafficking awareness part of orienta Work collaboratively with local/state/fede Develop and evaluate the use of order set Take steps toward becoming a trauma-in and trustworthiness, choice, collaborati an exemplar)

Consider scientific development of screen Create an evidence-based, trauma-inform Ensure mandatory reporting protocols fol Implement and evaluate the use of traffick Include trafficking survivors in interprofess Consider the potential impacts of vicariou accessible

Academic Institutions Implement evidence-based education in i Support research agendas including soci prevention approaches with a public he

Implement trafficking awareness training f Establish policies and procedures to supp of trafficking

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recommended for routine use, HCPs can use therapeutic communication to ask open-ended questions (Table 3).

RECOMMENDATIONS FOR CALLS TO ACTION Pediatric HCPs play a pivotal role in raising CT awareness. Recommended calls to action are summarized in Table 4 with resources contained in Table 5. All pediatric HCPs

-Responsive

n specific to HCPs hone and text numbers d clinician for victims presenting in the clinical setting ure related to child trafficking ocol within your institution hood Events (ACEs) actors for trafficking cacy group or committee to develop and implement an interprofessional protocol espond in the clinical setting s, not just clinical personnel tion or onboarding ral law enforcement task forces s formed institution (5 primary principles include safety, transparency on and mutuality, empowerment- consider the Missouri Model as

ing tools with evaluation for reliability and validity ed and culturally-responsive organizational protocol low state and federal law ing-related ICD-10 CM codes ional teams to promote survivor-informed practices s trauma and ensure adequate support services are available and

nterprofessional health sciences curricula al determinants of health, theory-based interventions and upstream alth paradigm or ALL employees ort employees and students who are identified as potential victims

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TABLE 5. Resources for individual HCPs, health care organizations, and academic institutions

Organization Resource Website

ACT, National Association of Pediatric Nurse Practitioners Partners for Vulnerable Youth

ACT Advocates Train the Trainer program for healthcare professionals and speaker’s bureau

https://www.napnappartners.org/act-advo cates-program

Dignity Health Shared Learnings Manual https://www.dignityhealth.org/hello-humankind ness/human-trafficking

Dignity Health in partnership with HEAL Trafficking and Pacific Survivor Center

PEARR Tool (A Trauma-Informed Approach to Victim Assistance in Health Care Settings)

https://www.dignityhealth.org/hello-humankind ness/human-trafficking/victim-centered-and- trauma-informed/using-the-pearr-tool

HEAL Trafficking Protocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings Recent Publications and Reports Webinars

https://healtrafficking.org/protocol-toolkit-for- developing-a-response-to-victims-of-human- trafficking-in-health-care-settings/ https://healtrafficking.org/publications-and- reports/ https://healtrafficking.org/webinars/

Polaris National Human Trafficking Hotline https://humantraffickinghotline.org/ Shared Hope International State Report Cards for Sex Trafficking

Laws https://sharedhope.org/what-we-do/bring-jus tice/reportcards/2018-reportcards/

U.S. Department of Health and Human Services; National Human Trafficking Training and Technical Assistance Center; Administration for Children and Families; Office on Trafficking in Persons; Office on Women’s Health

SOAR to Health and Wellness Online Training Modules: Trauma-Informed Care; Culturally and Linguistically Appropriate Services; SOAR for: Behavioral Health, Public Health, Health Care, Social Services, School-Based Professionals

https://www.acf.hhs.gov/otip/training/soar-to- health-and-wellness-training/soar-online

U.S. Department of Homeland Security

Blue Campaign- A national public awareness campaign designed to educate the public, law enforcement and other industry partners to recognize and respond to human trafficking

https://www.dhs.gov/blue-campaign

Note. ACT, Alliance for Children in Trafficking; HCPs, health care providers; HEAL, Health, Education, Advocacy, Linkage; PEARR, Privacy, Educate, Ask, Respect and Respond; SOAR, Stop, Observe, Act, Respond.

should seek evidence-based, survivor- and trauma-informed, culturally responsive continuing education to inform their clinical practice. Questioning and examining children in a well-intentioned but poorly informed manner can cause fur- ther trauma, jeopardize subsequent criminal proceedings, and risk violating the limits of clinician licensure (Gordon et al., 2018). Pediatric HCPs should not conduct forensic interviews if not properly trained to do so.

Pediatric HCPs should support evidence-based, scientifi- cally rigorous approaches to the development and subse- quent evaluation of CT preventive efforts. Use a holistic assessment approach and recognize that all body systems may be involved. A thorough review of symptoms and a comprehensive physical and mental health assessment should be performed to identify risk factors (Richards et al., 2014). Health care professionals should contribute to critical efforts to identify situations CLT in addition to situations of CST (Ronda-Perez & Moen, 2017). Victims of forced labor should not be underserved with preferential prevention and intervention efforts diverted or prioritized to vctims of CST.

In the broader context of health care organizations, pedi- atric HCPs should lead efforts to implement best practices through policies, protocols, and governance for children who experience and are at risk for trafficking. Health care

266 Volume 35 � Number 3

organizations should ensure that trafficking awareness is included in the onboarding process for all new employees and in annual compliance training. Every health care delivery environment should develop and implement a clinical proto- col with input from an interprofessional organizational coali- tion including clinicians, administrative leadership, staff support, institutional security personnel, ancillary care serv- ices, social service disciplines, child life specialists, sexual assault nurse examiners, and local and federal law enforce- ment (Dignity Health, n.d.). In particular, the collaboration between health care and law enforcement professions is an area needing further development to maximize resources and optimize patient outcomes. A clinical interprofessional protocol is critical to employ an evidence-based, trauma- informed, and culturally responsive approach. Protocols should address case management, patient referral, and care coordination. Of utmost critical importance, each protocol should address mandated reporting obligations for HCPs, which vary according to state law. Clinicians need clear direction on how to report suspected cases of child traf- ficking and the differences in reporting adult cases (Barnert et al., 2017). Reporting instructions should comply with federal and state law, including, but not limited to, protec- tions for reporting confidential patient information and

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avoiding violations of the Health Insurance Portability and Accountability Act. In addition, organizations should be aware of federal and state efforts and legal implications for trafficking victims including: criminalization of trafficking crimes, survivor protections in court, coordination between state and federal agencies, and business regulations (National Conference of State Legislatures, 2018). Organi- zations should ensure that employees know how to contact the National Human Trafficking Hotline (2019) and the appropriate guidelines for communication therein, consider- ing state laws for mandatory reporting and boundaries for Health Insurance Portability and Accountability Act viola- tions. Protocols should address discharge planning, patient safety counseling, and discreet provision of further resour- ces for those who choose not to self-disclose victimization and who do not qualify for mandated reporting. Other con- siderations include safety considerations for victims, families, and staff; a procedure for handling care refusal or leaving against medical advice; and potential order sets for evalua- tion and treatment. HCPs must understand and abide by their education and mandated scope of practice to avoid unintentional revictimization, providing poor care, or poten- tially damaging criminal cases.

Although there is no diagnostic standard for trafficking, International Classification of Diseases, 10th Revision, Clini- cal Modification (i.e., ICD-10-CM) codes (Figure 2) were approved in October 2018, offering options for adult or child confirmed or suspected labor or sex trafficking. It is important for clinicians to use these codes to provide a bet- ter understanding of the scope of this problem (OTIP, 2018). When these codes are used in an electronic medical record, consider confidential use to protect victims from potential retribution for seeking health care. It is important to note that there is insufficient evidence to support univer-

FIGURE 2. International Classification of Dis- eases, 10th Revision, Clinical Modification codes for trafficking. Source: Office on Trafficking in Persons, 2018.

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sal adoption of a standardized screening tool for CST and CLT (Peck, 2019). Care should be taken to construct tools with a strong scientific approach and implement rigorous efforts to assess reliability and validity.

Academic institutions should prioritize and support schol- arly efforts to research clinician response to CTwith emphasis on scientific inquiry inclusive of individual, relationship, com- munity, and societal impacts on social determinants of health (i.e., a public health paradigm construct) and theory-based interventions. Care should be given to thoughtful construc- tion of prevention and intervention efforts, with consideration and implementation of rigorous scientific studies with statisti- cal outcomes measurement. Inclusion of child victimization should be examined scientifically, comparing unique experien- ces and holistic impacts of child vs. adult victims (Le, 2018).

CONCLUSIONS Pediatric nurse practitioners and other pediatric HCPs are ide- ally positioned to lead efforts for trauma-informed, culturally responsive, and evidence-based care of children who have experienced or are at risk for experiencing trafficking (Peck, 2019). Adopting incremental and evidence-based clinical prac- tice changes amplifies the impact of pediatric HCPs as effec- tive leaders with a cohesive and collective response to child trafficking. By recognizing previously unidentified victims and employing upstream prevention approaches, pediatric HCPs can positively impact health outcomes for children.

SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. pedhc.2020.01.005.

REFERENCES Affordable Care Act, 45 C.F.R. x 92.201. (2016). Retrieved from

https://www.govinfo.gov/content/pkg/CFR-2016-title45-vol1/ xml/CFR-2016-title45-vol1-part92.xml#seqnum92.201

Atkinson, H. G., Curnin, K. J., & Hanson, N. C. (2016). U.S. state laws addressing human trafficking: Education of and manda- tory reporting by health care providers and other professionals. Journal of Human Trafficking, 2, 111–138.

Barnert, E., Iqbal, Z., Bruce, J., Anoshiravani, A., Kolhatkar, G., & Greenbaum, J. (2017). Commercial sexual exploitation and sex trafficking of children and adolescents: A narrative review. Aca- demic Pediatrics, 17, 825–829.

Barron, C. E., Moore, J. L., Baird, G. L., & Goldberg, A. P. (2019). Domestic minor sex trafficking in the medical setting: A survey of the knowledge, discomfort, and training of pediatric attend- ing physicians. Journal of Human Trafficking, 5, 13–24.

Cannon, A. C., Arcara, J., Graham, L. M., & Macy, R. J. (2018). Traf- ficking and health: A systematic review of research methods. Trauma, Violence and Abuse, 19, 159–175.

Centers for Disease Control and Prevention (CDC). (2019). About the CDC-Kaiser ACE study. Retrieved from https://www.cdc.gov/ violenceprevention/childabuseandneglect/acestudy/about. html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2F violenceprevention%2Facestudy%2Fabout.html

Chisolm-Straker, M., Sze, J., Einbond, J., White, J., & Stoklosa, H. (2019). Screening for human trafficking among homeless young adults. Children and Youth Services Review, 98, 72–79.

May/June 2021 267

Choi, K. R. (2015). Risk factors for domestic minor sex trafficking in the United States: A literature review. Journal of Forensic Nurs- ing, 11, 66–76.

Dignity Health (n.d.). Taking a stand against human trafficking. Retrieved from https://www.dignityhealth.org/hello-humankind ness/human-trafficking

Donahue, S., Schwien, M., & LaVallee, D. (2019). Educating emer- gency department staff on the identification and treatment of human trafficking victims. Journal of Emergency Nursing, 45, 16–23.

Fang, S., Coverdale, J., Nguyen, P., & Gordon, M. (2018). Tattoo recognition in screening for victims of human trafficking. Jour- nal of Nervous and Mental Disease, 206, 824–827.

Fedina, L., Williamson, C., & Perdue, T. (2019). Risk factors for domestic child sex trafficking in the United States. Journal of Interpersonal Violence, 34, 2653–2673.

Fraley, H. E., Aronowitz, T., & Jones, E. J. (2018). School nurses’ awareness and attitudes toward commercial sexual exploitation of children. Advances in Nursing Science, 41, 118–136.

Gordon, M., Fang, S., Coverdale, J., & Nguyen, P. (2018). Failure to identify a human trafficking victim. American Journal of Psychi- atry, 175, 408–409.

Greenbaum, J., & Bodrick, N. (2017). Global human trafficking and child victimization. Policy statement. American Academy of Pediatrics, 140, e20173138.

Greenbaum, V. J., Dodd, M., & McCracken, C. (2018). A short screening tool to identify victims of child sex trafficking in the healthcare setting. Pediatric Emergency Care, 34, 33–37.

Hemmings, S., Jakobowitz, S., Abas, M., Bick, D., Howard, L. M., Stanley, N., . . . Oram, S. (2016). Responding to the health needs of survivors of human trafficking: A systematic review. BMC Health Services Research, 16, 320.

International Labour Organization. (2018). Forced labour, modern slavery and human trafficking. Retrieved from https://www.ilo. org/global/topics/forced-labour/lang−en/index.htm

Joint Commission. (2018). Identifying human trafficking victims. Quick Safety. Retrieved from https://www.jointcommission.org/assets/ 1/23/QS_41_Human_trafficking_6_12_18_FINAL1.PDF

Katsanis, S. H., Huang, E., Young, A., Grant, V., Warner, E., Larson, S., & Wagner, J. K. (2019). Caring for trafficked and unidentified patients in the EHR shadows: Shining a light by sharing the data. PLoS One, 14, e0213766.

Le, P. D. (2018). Human trafficking and health research: Progress and future directions. Behavioral Medicine, 44, 259–262.

Lutx, R. M. (2018). Human trafficking education for nurse practi- tioners: Integration into standard curriculum. Nurse Education Today, 61, 66–69.

NAPNAP Partners. (2019). Tattoos of human trafficking victims. Retrieved from https://www.napnappartners.org/tattoos- human-trafficking-victims

National Child Traumatic Stress Network (NCTSN). (n.d.). Under- standing and addressing trauma and child sex trafficking. Pol- icy Brief. Retrieved from https://www.nctsn.org/resources/ understanding-and-addressing-trauma-and-child-sex-traffick ing-policy-brief

National Conference of State Legislatures. (2018). Human trafficking overview. Retrieved from http://www.ncsl.org/research/civil- and-criminal-justice/human-trafficking.aspx

National Human Trafficking Hotline. (2019). National human traffick- ing hotline. Retrieved from https://humantraffickinghotline.org/

National Human Trafficking Resource Center. (2019). Comprehen- sive human trafficking assessment. Retrieved from https:// humantraffickinghotline.org/resources/comprehensive-human- trafficking-assessment-tool

Niergarten, M. B. (2018). International child health: Identify, screen, treat and advocate for child victims of human trafficking. Con- temporary Pediatrics, 35, 8–10.

268 Volume 35 � Number 3

Noll, J. G., Trickett, P. K., Long, J. D., Negriff, S., Susman, E. J., Shalev, I., . . . Putnam, F. W. (2017). Childhood sexual abuse and early timing of puberty. Journal of Adolescent Health, 60, 65–71.

Office on Trafficking in Persons (OTIP). (2018). CDC adds new human trafficking data collection fields for health care providers. Retrieved from https://www.acf.hhs.gov/otip/news/icd-10

Oram, S., Abas, M., Bick, D., Boyle, A., French, R., Jakobowitz, S., . . . Zimmerman, C. (2016). Human trafficking and health: A sur- vey of male and female survivors in England. American Journal of Public Health, 106, 1073–1078.

Oram, S., St€ockl, H., Busza, J., Howard, L. M., & Zimmerman, C. (2012). Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review. PLoS Medicine, 9, e1001224.

Owens, C., Dank, M., Breaux, H., Banuelos, I., Farrell, A., Pfeffer, R., . . . McDevitt, J. (2014). Understanding the organization, opera- tion, and victimization process of labor trafficking in the United States. Washington, DC: Urban Institute. Retrieved from https://ncjrs.gov/pdffiles1/nij/grants/248461.pdf

Peck, J. L. (2019). Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the develop- ment of a practice guideline: Part two. Journal of Pediatric Health Care. doi:10.1016/j.pedhc.2019.11.005

Peck, J. L., & Meadows-Oliver, M. (2019). Human trafficking of chil- dren. Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part one. Journal of Pediatric Health Care, 33, 603–611.

Polaris. (2018a). 2018 U.S. National Human Trafficking Hotline Sta- tistics. Retrieved from https://polarisproject.org/2018statistics

Polaris. (2018b). Healthcare providers play a crucial role in victim identification. Retrieved from https://polarisproject.org/blog/ 2016/11/03/healthcare-providers-play-crucial-role-victim- identification

Rajaram, S. S., & Tidball, S. (2018). Survivor’s voices - Complex needs of sex trafficking survivors in the Midwest. Behavioral Medicine, 44, 189–198.

Recknor, F. H., & Chisolm-Straker, M. (2018). Human trafficking: It’s not just a crime. Journal of Family Strengths, 18(1) Article 7.

Reid, J. A., Baglivio, M. T., Piquero, A. R., Greenwald, M. A., & Epps, N. (2018). No youth left behind to human trafficking: Exploring profiles of risk. American Journal of Orthopsychiatry, 9, 704–715.

Richards, T. A. (2014). Health implications of trafficking. Nursing for Women’s Health, 18, 155–162.

Ronda-Perez, E., & Moen, B. E. (2017). Labour trafficking: Chal- lenges and opportunities from an occupational health perspec- tive. PLoS Medicine, 14, e1002440.

Scannell, M., MacDonald, A. E., Berger, A., & Boyer, N. (2018). Human trafficking: How nurses can make a difference. Journal of Forensic Nursing, 14, 117–121.

Shared Hope. (2019). Report trafficking. Retrieved from https:// sharedhope.org/join-thecause/report-trafficking/

Sinha, R., Tashakor, E., & Pinto, C. (2019). Identifying victims of human trafficking in central Pennsylvania: A survey of health-care profes- sionals and students. Journal of Human Trafficking, 5, 165–175.

Speck, P. M., Mitchell, S. A., Ekroos, R. A., Sanchez, R. V., & Messias, D. K. H. (2018). Policy brief on the nursing response to human trafficking. Nursing Outlook, 66, 407–411.

Sprang, G., & Cole, J. (2018). Familial sex trafficking of minors: Traf- ficking conditions, clinical presentation, and system involve- ment. Journal of Family Violence, 33, 185–195.

Sweileh, W. M. (2018). Research trends on human trafficking: A biblio- metric analysis using Scopus database. Globalization and Health, 14, 106.

Toney-Butler, T. J., Mittel, O. (2019). Human trafficking. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430910/

US Department of Health and Human Services [USDHHS]. (2019). The role of healthcare providers in combating human trafficking

Journal of Pediatric Health Care�

during disasters. Retrieved from https://www.phe.gov/Pre paredness/planning/abc/Pages/human-trafficking.aspx

US Department of Health and Human Services [USDHHS]. (2014). Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma- informed approach. Retrieved from https://store.samhsa.gov/ product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a- Trauma-Informed-Approach/SMA14-4884.html

United States Department of State. (2019). United States Advisory Council on Human Trafficking: Annual Report 2019. Retrieved

www.jpedhc.org

from https://www.state.gov/wp-content/uploads/2019/05/ US-Advisory-Council-2019-Report.pdf

Viergever, R. F., West, H., Borland, R., & Zimmerman, C. (2015). Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Frontiers in Public Health, 3, 6.

Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science and Medicine, 73, 327–335.

May/June 2021 269