A 14-year-old male presents with a retained foreign body in his rectum. He states a glass bottle broke during sex with his boyfriend, who is 16 years old. He reports pain and bleeding. Chart review reveals a history of intravenous drug use, bipolar disorder, and history of child welfare involvement. He has had prior ED visits for psychiatric care, sexually transmitted infections, and an opioid overdose. On exam, he has moderate lower abdominal tenderness and bright red blood per rectum. His vital signs are stable. The foreign bodies are unable to be visualized. He repeatedly asks for pain medication.
Explore This IssueACEP Now: Vol 40 – No 01 – January 2021
Initial hematocrit is at the patient’s baseline. The surgical service is consulted. Staff members are noted to be joking about his condition. After treating the patient’s pain, you update him on the clinical plan. Sitting at eye level, you say, “Some of my patients have sex with people they would rather not have sex with. Sometimes they do that to pay for things they need to get by. If someone is hurting you, I’d need to tell someone. That also may get you help that I wouldn’t be able to connect you with otherwise.” The patient then discloses that he was with a “date” this evening and things turned violent. Since running away from his foster home two years ago, he does what he has to in order to survive, including commercial sex. You thank him for sharing this. The patient is taken to the operating room. You make a report to child welfare.
According to U.S. law, any individual under the age of 18 who has engaged in commercial sex is considered to be trafficked. While the word “trafficking” connotes movement, someone may be trafficked in their own home, without crossing town, state, or country borders. While prevalence estimates are limited, given the clandestine nature of the issue, what is known is that those with an experience of trafficking come into contact with emergency clinicians, and few emergency clinicians are equipped to respond.1–3
The goal of an encounter with a potentially trafficked person is not disclosure or rescue. It is educating and empowering them with resources. The recognition of exploited children may prove challenging. The trafficked child may be accompanied by someone posing as a family member, significant other, or friend but who is in fact a trafficker or another trafficking victim. In many cases, the trafficker may actually be a relative of the patient.4
There may be clues in the patient’s presentation suggesting they may be vulnerable to trafficking. Patients may present to the emergency department for a number of issues, including retained foreign bodies, sexually transmitted infections, substance use or overdose, psychiatric issues, chronic pain, pregnancy, or abortion complications. The adult accompanying the patient may be unwilling to leave the patient alone with emergency department staff.
Children who are in the child welfare system; runaways; children who identify as LGBTQ; those with a history of substance use; and those with a history of physical abuse, sexual abuse, or neglect are at high risk to become victims of sexual exploitation.5
Inquiring about a trafficking experience should be done thoughtfully and is not as simple as going through a checklist of questions. One approach, the Privacy, Education, Ask, Respect, Respond (PEARR) tool, adapted from the field of domestic violence, shows promise for assessing a patient for trafficking and was used in this patient scenario. It is important to speak with the patient alone and to use a trained interpreter if necessary. Questions should be direct and nonjudgmental. Of note, screening tools for child sex trafficking are currently in the process of validation.6,7
There are several potential barriers to disclosure. First, clinicians may unconsciously or consciously judge a patient, which obscures the ability to see their patient’s exploitation.8 Lack of awareness of trafficking and its diversity of presentations can prevent a clinician from identifying a trafficked person. On the patient side, males in particular may not recognize the exploitation of their situation or resonate with the word “victim.” Shame and stigma may also block disclosure. A patient may sense a judgmental attitude, as in the case described, and be less open as a result.9 Furthermore, if a patient’s presence in the United States is unauthorized, they may be afraid to tell their doctor for fear of deportation.10