by MaryAlice Brislin, MD (’21)
Teaching Resident Capstone Project
Reviewed by Christine Barron, MD (Child Abuse Pediatrics)
As pediatricians, we are on the front lines when it comes to screening for a multitude of issues. A serious issue that continues to garner more attention within the medical community is domestic minor sex trafficking (DMST). Domestic minor sex trafficking is defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act within domestic borders in which the person is a US citizen or lawful resident < 18 years of age”. Within the broader realm of human trafficking, recent studies have shown that children make up approximately ⅓ of all human trafficking victims. Importantly, these children often present to outpatient clinics and emergency rooms for medical care, thus placing medical providers – especially pediatricians – in a key position to screen and intervene.
The question of who to screen, as well as how to go about screening, for DMST are both questions that have not been fully answered in the form of validated screening tools. However, research over recent years has been able to highlight several risk factors associated with a higher risk of DMST involvement. These risk factors include:
* Homelessness and/or frequent running away
* Prior CPS involvement
* LGBTQ status
* Family dysfunction (includes inter-partner violence, parental history of mental health disorders and/or substance use)
* Developmental delays
* History of maltreatment
* High risk sexual behavior (includes multiple presentations for sexually transmitted infections, untreated sexually transmitted infections, diagnosis of gonorrhea)
* Substance abuse
* History of mental health diagnosis
* Suicidal and/or self-injurious behavior
These risk factors all center around sensitive aspects of a patient’s history, and require both a high level of suspicion as well as strong provider/patient rapport. Taking the time to perform an adolescent interview during any medical encounter with these patients can help reveal these risk factors that should then promote further investigation.
While our typical adolescent assessments often involve a set of fairly standardized questions, we ask almost all of our adolescent patients, screening for DMST should be conducted less like a questionnaire and more like a conversation with the patient. The conversation should start with the provider asking whether or not the patient seems familiar with sex trafficking, if they have ever heard about this, if they know about it and/or know others that are involved. This can help the provider assess overall risk. The provider should ask questions with a manner of normalcy, as these topics can easily provoke a sense of judgement from the patient’s perspective. When asking about high-risk behaviors, the questions can initially ask about friends or acquaintances of the patient – for example, “Have any of your friends performed sexual acts in exchange for money, gifts, or a place to stay?”. The provider can then add more proximal questions to assess whether the patient themselves has engaged in these high-risk behaviors. When asking about sexual acts performed in an exchange, the provider can ask about specific forms of payment depending on their assessment of what the patient would most likely want or need, such as housing if they are a frequent run-away or gifts if the patient presents with an expensive handbag or clothing. While these questions may seem overly direct or uncomfortable, building rapport with the patient throughout the encounter and approaching the discussion with a sense of normalcy and neutrality can enable providers to elicit important information that can alter the course of care for that patient.
Here at Hasbro Children’s Hospital, we are extremely fortunate to have a team of child abuse pediatricians to help guide these types of screening discussions as well as to help us with next steps when a patient screens positive. The Aubin Center has written several published on DMST – for further reading, please see the references listed below.
Goldberg AP, Moore JL, Barron, CE (2019). Domestic Minor Sex Trafficking: Guidance for Communicating with Patients. Hospital Pediatrics, 9(4), 308-310. doi: https://doi.org/10.1542/hpeds.2018-0199
Brown, A. and Barron, C. (2018). Human Trafficking. Pediatrics in Review, 39(2), 102-103. doi: https://doi.org/10.1542/pir.2016-0181
Goldberg AP, Moore JL, Houck C, Kaplan DM, Barron CE. Domestic Minor Sex Trafficking Patients: A Retrospective Analysis of Medical Presentation. J. Pediatr Adoles Gynecol 2016, S1083-3188(16)30161-9. PMID:27575407
Barron CE, Moore JL, Baird G, Goldberg AP. Sex Trafficking Assessment and Resources (STAR) for Pediatric Attendings in Rhode Island. RI Med J. 2016 Sept 1;99(9);27-30. PMID:27764261
Raj A, Baird G, Moore JL, Barron CE. Incorporating Clinical Associations of Domestic Minor Sex Trafficking into Universal Screening of Adolescents. Clin Pediatr (Phila). 2019 April. PMID: 30991826