Emergency medicine providers must have keen interviewing skills, an ability to convey openness and kindness to the victim, and use a multidisciplinary treatment approach

A 19-year-old female presents to the ED with complaints of cough; rhinorrhea; sinus pressure; nausea; body aches; and mild, intermittent cramping abdominal pain. Her vital signs: T 100.1, HR 99, RR 18. She appears tired and thin and has a blunted affect. She is wearing open-toed pumps, leggings, and a tank top. It is winter and very cold outside. Accompanying her is a man who appears to be in his late 20s and is introduced by the patient as her boyfriend. He gives the registrar the patient’s identification.

The boyfriend insists upon accompanying the patient into the room. The patient is guarded during history and gives short, abrupt answers. She avoids eye contact with the examiner and keeps looking at her boyfriend. He interjects that he just wants her to get some antibiotics so they can get out of there.

Chart review reveals the patient was seen in the ED about two months ago for an arm injury. Today’s history is brief and focuses on the patient’s URI symptoms. No questions relating to social history and very few questions relating to past medical history are asked. The physical exam is performed quickly and is unrevealing.

The provider is pulled away to address another patient’s needs. The patient is given ibuprofen. Her boyfriend becomes agitated and tells the nurse they need to leave. The patient is discharged with a prescription for ibuprofen and for guaifenesin. She is instructed to call the referral line for PCP follow-up.

Four days later, the patient returns to the ED with severe abdominal pain and is pale, hypotensive, and tachycardic. She is septic. A girl claiming to be her cousin brought her in. The patient disrobes, and a thorough examination reveals several scars from cutting on her forearms, cigarette burns around her breasts and upper thighs, and the name “King Daddy” tattooed on her lower back. The patient has several healing bruises on her chest and abdomen. The pelvic exam reveals a large volume of pus and a retained “baby wipe” in the vagina. The patient is diagnosed with pelvic inflammatory disease and sepsis.

Case Commentary

The patient was actually a 15-year-old girl with counterfeit identification. The boyfriend was her “pimp,” or sex trafficker. The girl was reported as a runaway six months earlier. She left home to escape sexual abuse by her stepfather, a businessman in the community who was also having his “friends” come over to have sex with her for money. She was approached after school by a young man who told her he could get her away from her situation and help her become a model.

Two weeks later, the girl’s image was in a back-page online ad, and she was being sold for sex from an apartment complex while being abused into submission by the young man who was now her pimp. Three days before her last visit to the ED, the patient was brutally raped by three clients, or “johns.” Some of the bruises and burn marks were from this assault. The baby wipe found in the girl’s vagina had been inserted to hide the patient’s copious vaginal discharge to allow her to continue working.

Had a more detailed history been taken of this patient’s background, social history, and home situation, and a more thorough exam performed, some of the signs of abuse may have been noted.

A Crime We Must Learn to Recognize

Sadly, this case is an all-too-common occurrence in EDs just like yours. Domestic minor sex trafficking (DMST) is the commercial sexual exploitation of American children within US borders. Sex trafficking is also called sex slavery or often mislabeled as prostitution. An estimated 100,000 children under age 18 become entrapped in the sex-slave market every year in the U.S. The average age of entry into the sex-trade industry in the U.S. is 12–14, according to a 2009 report by the National Center for Missing and Exploited Children.¹

Victims come from all socioeconomic and racial backgrounds and may be male, female, or transgender. This article focuses on underage female victims, but there is no doubt that women, boys, and men experience this scourge in significant numbers as well.

Despite being well-educated about child abuse, elder abuse, and domestic violence, most providers lack the training and ability to recognize victims of the sex-slave industry. Most victims of sexual exploitation never report “sexual assault.” DMST victims frequently present to EDs, but are rarely detected as such.

Supply and Demand

Children who experience violence and/or lack of support at home are at increased risk of becoming victims of sex slavery. Once indoctrinated, victims may be found in strip clubs, 24-hour massage parlors, and escort services. They may be walking the street (“track”) but often are bought online and directed via cell phone to meet johns at hotel rooms.^2,3

We live in a world that demands women and children be sold for sex. From movies to music to clothing lines, the sexualization of girls and women is rampant. The “pimp and ho” and “porn star” culture is commonly referenced and portrayed as either humorous or admirable. The abusive nature of prostitution is ignored or disguised.

Pornography, a multimillion-dollar industry, is viewed as an acceptable outlet for sexual gratification, yet it creates victims (50 percent of sex-trafficking victims have been involved in pornography) and buyers/johns who may turn to the sex trade when watching provocative films no longer satisfies their desires.⁴

When a girl is sold, the money almost always goes entirely to her pimp. The profits of this illegal business are enormous because girls may be sold many times per night and many nights per week.

Recognition and Treatment

Victims of sexual trafficking undergo immeasurable physical and emotional abuse. Traffickers (pimps) go to great lengths to ensure their victims continue to service as many buyers as possible. Pimps may use the “lover boy” approach of promising love, marriage, or a brighter future to victims—or may physically and psychologically coerce victims. Victims are given a false sense of “love” from professional con artists in one of the oldest con schemes in history. Basic human needs, including food, shelter, and clothing, are withheld from victims for not reaching their quota (a minimum daily earnings expectation determined by pimps). Victims are threatened, beaten, and raped into staying with traffickers and often feel they have nowhere else to turn. Ironically, even when fearful, victims will appear to enjoy themselves during their transactions. The appearance of enjoyment by the victims helps johns ignore that what they’re doing is a heinous crime.

DMST victims commonly have experience with authority figures who fail to protect them, including their parents, foster parents, teachers, and case managers. They are often purchased (i.e., raped for profit) by clergy members, physicians, police officers, and other professionals. They have been taught not to trust. This, along with the fact that victims often do not consider themselves victims or in need of rescue, makes it difficult to emancipate these girls. They may have Stockholm Syndrome and relate to their abusers/pimps. Sex-trafficking victims may present in the ED as “difficult patients”: rebellious and disrespectful.

A realistic goal for a visit with a sex-trafficking victim is to convey that you are trustworthy and nonjudgmental and that your ED is a safe, accepting place for her. A major breakthrough/rescue within one encounter is unusual but, nevertheless, worth the effort.

As an emergency medicine provider, you will need keen interviewing skills and the ability to convey openness and kindness to a victim. It is crucial to aggressively pursue any opportunity to interview the patient while separated from the individual who may have brought her in for evaluation. This may display to the victim that you recognize something is amiss and you are willing to intervene. She is fearful and will not ask to speak with you alone. You must take on the burden of attempting separation for her safety. A realistic goal for the visit is to convey to the victim that you are trustworthy and nonjudgmental and that your ED is a safe, accepting place for her. A major breakthrough/rescue within one encounter is unusual but, nevertheless, worth the effort.

Victims often have psychological problems such as anxiety, depression, and PTSD. Be vigilant to notice characteristics commonly found in victims, such as a history of running away multiple times or having been placed in many foster homes. Sex slavery victims may use street slang or present with an older “boyfriend.” They may be missing school.⁵

Providers may detect sex-trafficking victims by noticing inappropriate attire or the presence of a “branding” tattoo of a pimp’s name. Victims often use illicit drugs. Pimps will get their victims addicted to drugs to have more power over them, and trafficking victims may use drugs as a coping mechanism. Victims may have a history of many ED visits.

Victims may have a wide range of physical ailments including STIs/pelvic pain, traumatic injuries/bruises, malnutrition, and poor hygiene. They may appear hypervigilant or, alternatively, exhausted.⁶ They may answer many calls or texts during their visit.

Calm, open-ended questioning is key at the start of the social-history interview and will help build rapport with a patient. Her response will depend on the your attitude toward her. Avoid questions starting with “Have you ever… ” because the answer will be “no,” and you will have lost an opportunity. You may ask the patient where she lives and who takes care of her, how she met her “boyfriend,” or whether she must contribute money to her family. You may suggest, “Tell me about your tattoo.” Later in the interview, it may be appropriate to ask her if her body has been used for money, whether anyone has posted photos of her on the Internet, or if she is forced to have sex with men she doesn’t want to have sex with.⁵

When it comes to offering services to the patient, having a plan/protocol in place specific to the needs and safety of this population within your ED is essential. A multidisciplinary approach employing law enforcement, social work, nursing, and hospital administration is needed.⁷ Identifying best practices and developing efficient, user-friendly protocols and comprehensive aftercare options are desperately needed.

Ms. Munoz is a practicing lead nurse practitioner with EMP on Oahu. She has spent the past five years working in the arena of human trafficking. She is currently the volunteer director for the Courage House Hawaii project, whose goal is to build a long-term residential home for underage victims of sex trafficking in Hawaii. Contact Ms. Munoz at jessica.munoz@hoolanapua.org.

References

1. National Center for Missing and Exploited Children. Missing children statistics. 2009. Available at: www.missingkids.com.
2. Polaris Project. Human trafficking resources for the service provider. 2012. Available at: www.polarisproject.org. Accessed April 4, 2012.
3. Shared Hope International. Human trafficking–demand. 2009. Available at: www.sharedhope.org.
4. Farley M. Human trafficking and prostitution. 2013. Available at: www.prostitutionresearch.com.
5. Cooper S, Estes R, Giardino A, Kellogg N, Vieth V. Child Sexual Exploitation Quick Reference. St. Louis, Mo: GW Medical Publishing Inc.; 2007.
6. Zimmerman C, Yun K, Watts C, et al. The health risks and consequences of trafficking in women and adolescents: findings from a European study. London School of Hygiene & Tropical Medicine and the Daphne Program of the European Commission: London. 2003.
7. Hodge D. Sexual trafficking in the United States: a domestic problem with transnational dimensions. Soc Work. 2008;53:143-152.