Human Trafficking Should Be on Psychiatrists’ Radar

Sex trafficking of children and adolescents may be largely hidden from the eyes of the public, but when these young people seek medical care, it opens the door to intervention—provided the doctor becomes aware of their situation.

Psychiatrists should be especially alert to this population, said Rachel Robitz, M.D., a PGY-4 in psychiatry and family medicine at the University of California, San Diego, during a special session sponsored by APA’s Division of Diversity and Health Equity at APA’s Annual Meeting in Atlanta.

According to Robitz, only 13 percent of individuals in the United States who are recruited into sex trafficking are over the age of 25, and 83 percent are U.S. citizens. She noted that clinical samples show this population tends to have high levels of depression, anxiety, nightmares, substance abuse, overdoses, and suicide attempts.

“We also know that 88 percent of these young people saw a medical provider during the time they were being trafficked,” said pediatrician Jordan Greenbaum, M.D., of Children’s Healthcare of Atlanta.

“They are seen in the emergency room or as inpatients for many different reasons, but not for ‘trafficking,’ ” said Mariam Garuba, M.D., an assistant clinical professor of psychiatry at the Columbia University Medical Center. “The question in your mind should be: ‘Is this a survivor?’”

If children seem intimidated by the adults who brought them in or can’t say where they came from or give their address, clinicians should have a heightened level of suspicion, said Greenbaum. Other risk factors suggesting that a person might be being exploited for sex include illicit drug use, abuse or neglect, self-harm, or running away from home. Nearly half of those being trafficked have an active case of sexually transmitted infections, and 30 percent have been pregnant.

To best respond to the needs of a patient who may be being trafficked, an evaluation should ideally occur with the accompanying adult eased out of the room, she said.

“Obtain a history to assess both the health and the safety needs of the child,” said Greenbaum. “Diagnose and treat both acute and chronic conditions, since the latter may be a clue to long-term maltreatment. Document acute or remote head injuries, cigarette burns, or restraint injuries.”

Tests for pregnancy and sexually transmitted diseases may be appropriate, too, she said.

A trauma-informed approach to treating these patients is essential, she said. Many of these children might seem “belligerent,” but in fact they are traumatized, said Greenbaum.

Questions that address trafficking might include the following:

• “Has anyone ever asked you to have sex in exchange for something you wanted or needed—money, food, or shelter?”

• “Has anyone ever asked you to have sex with another person?”

• “Has anyone ever taken sexual pictures of you or posted such pictures on the Internet?”

While the role of the clinician is to assess the child’s emotional and physical health and safety, provide information to the child, and offer referral and resources, providers must be aware of mandated reporting laws and should explain those to the victim—early in the conversation—to avoid a sense of betrayal. “Watch for cues of stress to avoid retraumatization,” she said.

A program in Boston called “My Life, My Choice” seeks to prevent girls from being trafficked in the first place.

“Pimps pick on vulnerable girls in recruitment,” said Emily Rothman, Sc.D., an associate professor at the Boston University School of Public Health. Besides sexually seducing the girls, the pimps introduce them to a life that initially seems filled with money and glamour until they are entrapped.

The Boston program arranges group discussions with young women believed to be at risk of being trafficked, who are referred by schools and residential treatment centers. The program teaches about exploitation, unhealthy dating relationships, and the recruitment process in order to increase the girls’ perception of the industry’s dangers, not its purported glamorousness. They also hear firsthand from people who have been exploited.

Ultimately, young people who have been trafficked must decide for themselves that they want to get out of their situation, said Garuba. The trafficked life can be understood as a form of addiction, and relapse is likely.

“You need to plant the seed,” she said. “Maybe the next therapist will help them take that next step.” ■