Sex trafficking of children in the US: view from 2 doctors – and a survivor

Our healthcare system is unprepared to handle the commercial sexual exploitation of young people, say authors in a special issue of Current Problems in Pediatric Adolescent Health Care

Naomi A. Schapiro, PhD, RN, CPNP  For many years, I was on call several times a month for a team of forensic examiners in our local children's hospital. Late one weekend evening, I was called in to see a young teen who was suspected of being a victim of sexual trafficking. Exhausted and cranky, she refused an exam and most of the offered prophylactic medications, as she snuggled into the colorful fleece blanket and cuddled the stuffed animal that had been donated for our patients.

Despite the expertise of our nursing, medical and social work staff in caring for children and adolescents who have been sexually abused, and despite the existence of local organizations dedicated to working with sexually exploited children, we did not have the systems in place to adequately help this young woman. Our social workers arranged emergency foster care placement, as there was no dedicated shelter for commercially sexually exploited children (CSEC). Not her first time in shelter, they suspected she would have run away, again, by the time specially trained outreach workers visited her in the morning.

Our follow-up and resource handouts did not cover her specific situation. Although our local child protection and criminal justice systems are both aware of the problem and wanting to help, neither system is designed to adequately address this child's needs. And despite our own extensive training and experience, none of us felt well prepared to address this particular type of child abuse.

To shed light on the need for knowledge and resources, the October issue of Current Problems in Pediatric and Adolescent Health Care focuses on sexual exploitation and trafficking of young people in the United States.

"Medical information and resources have been sparse"

In her powerful and comprehensive review article, "Commercial sexual exploitation and sex trafficking of children in the United States," Dr. V. Jordan Greenbaum addresses these knowledge gaps and highlights the need for coordinated community resources. She has tackled every aspect of this difficult and painful topic, from what is known about scope and prevalence, to the five recognized stages of trafficking, to identification of victims, medical evaluation, treatment and healing. Dr. Greenbaum has provided us with helpful tables, including risk factors, consequences, and terms used by the children and youth we may be interviewing, as well as web links to help us find state and local resources dedicated to working with CSEC.

V. Jordan Greenbaum, MD"Trafficking may involve forced labor and/or sexual exploitation, as well as forced military service, slavery, or the removal of organs," she writes, citing the UN Human Rights Protocol. She points out that as many of 26 million people worldwide are victims of trafficking, and about 27 percent of them are children, according to a 2012 report by the UN Office of Drugs and Crime.

Despite the gravity of the problem, however, our medical system is not well prepared to respond. Dr. Greenbaum writes:

It is essential that medical professionals have the knowledge, skills, and resources to recognize victims, assess their needs, and treat them appropriately, including making key referrals for community services. However, to date, medical information and resources regarding commercial sexual exploitation and sex trafficking has been sparse. There are no clinically validated screening tools specifically designed to identify victims in the health care setting and since victims seldom self-identify, it is likely that the majority of victims are unrecognized. The opportunity for comprehensive assessment and intervention is lost. Further, professionals receive little training on appropriate interview techniques for this special population, and many are ill equipped to ensure safety and optimal medical evaluation during the visit.

A Survivor׳s Perspective: "Can You Help Me? Do You Care?"

We are fortunate to have two companion pieces on this important topic. One is an articulate and moving account by a survivor of sex trafficking, who details her experiences with medical care, and outlines some helpful dos and many don'ts in assessing and caring for suspected victims of exploitation. The writer, whose name we don't reveal to protect her privacy, said she endured four years of sexual exploitation. Now, as a mentor to other victims, she described the obstacles they face when they try to get help.

I take victims for medical care and I see re-victimization all over again. You turned us away because the clinic doesn't treat children under 18, 'rape victims' or those without insurance. You make us pay $25 up front for a pregnancy test, and that's hard for a victim who has no control over her money. Sometimes the victim's been sexually assaulted and the registration nurse and staff don't seem to care. They just go by the procedures — no emotion. That's hard on a victim.

One time I took a child to your clinic for a pregnancy test and the doctor just kept talking about how important it was to use a condom. I could tell that the doctor thought the girl shouldn׳t be there at all, that she needed prevention, and that she should have known to use a condom. He didn׳t know anything about the victim׳s life, what she׳s been through. The doctor didn׳t ask any questions at all. He told her that all a boy wants is sex but that she should make sure she uses a condom. Did the doctor ask if the child knew what a condom is or how to use one? No! You׳ve got to ask questions!

"What can I do as a physician?"

Aisha Mays, MDIn her commentary "There is Hope: CSEC and the Medical Community," Dr. Aisha Mays of the Native American Health Center in Oakland, California, describes the frustrations from the view of a doctor trying to help these victims.

I work at a community health center on a main street in Oakland where young girls are being exploited every day. I see girls standing on the corners when I come into the clinic in the morning and I see them again when I leave for home in the evening. Many times I thought about what I could do as a physician to address what is happening right outside our clinic doors.

One day, a 16 year-old girl, accompanied by her boyfriend, came to see me complaining of burning with urination and a "weird" vaginal discharge. She said that her boyfriend, who appeared much older, wanted her to have it checked out, so she came into clinic. She had a very sweet demeanor and smile that I will always remember. When I told her that I needed to perform a vaginal exam, she became shy as she changed out of her hot pink and black zebra striped cat suit and put on the paper clinic gown, and after the exam, she broke into tears when I told her that she would need a shot to treat her gonorrhea infection.

After holding her hand to help her tolerate the ceftriaxone injection, I closed our visit by reminding her that because she has an infection, she cannot have sex for a week. Her eyes grew wide and she said, "Are you serious?" I replied, "Yes, it's important to let the infection clear." She looked around nervously and said, "…well, can you write that down on a prescription pad?" I was shocked, but I followed her instructions. As she left the clinic I saw her give the prescription paper to her boyfriend. I felt so saddened by this encounter and I knew that I wanted do more to support these youth.

Dr. Mays goes on to suggest ways to improve identification and care of child victims by describing the steps that school-based health centers associated with this health center have taken.

Read the articles

The October issue of Current Problems in Pediatric and Adolescent Health Care focuses on the sexual exploitation and sex trafficking of young people in the US. The following articles are freely available until December 31, 2014:

Over the years, pediatric providers have incorporated screening and care for many difficult and sensitive issues, ranging from child abuse and intimate partner violence (IPV), to adverse childhood experiences in general and trauma in particular. Factors that may have impeded our effective screening and reporting include inaccurate perceptions of children at risk, discomfort, and fear of alienating a child, adolescent or family, time factors, lack of awareness of community resources, and not knowing what to ask.1,2

There is one additional factor, which is starting to receive more attention among providers: vicarious traumatization, or the effect on clinicians of caring for victims of trauma.3,4

Vicarious traumatization can be exacerbated in today's fast-paced health care economic climate, when we have scarcely time to complete our work, let alone debrief.4 Yet debriefing and other forms of self-care can help us to be more satisfied and effective in our work, and more helpful to our traumatized patients. As you read and start to incorporate the important content in this issue, I encourage you to remain aware of and take care of your own reactions. The journal will be here when you come back.

A shorter version of this article appears as the foreword to the October 2014 issue of Current Problems in Pediatric Adolescent Health Care.



  1. Flaherty EG, Sege RD, Griffith J, et al. "From suspicion of physical child abuse to reporting: primary care clinician decision-making," Pediatrics,2008.
  2. Sprague S, Madden K, Simunovic N, et al. "Barriers to screening for intimate partner violence" Women Health, 2012.
  3. Coles J, Astbury J, Dartnall E, Limjerwala S. "A qualitative exploration of researcher trauma and researchers' responses to investigating sexual violence," Violence Against Women, 2014.
  4. Mathieu F. "Occupational hazards: compassion fatigue, vicarious trauma and burnout," Canandian Nurse, 2014.


Elsevier Connect Contributor

Dr. Naomi A. Schapiro is a pediatric nurse practitioner and Clinical Professor at the University of California, San Francisco. She is the Project Director of UCSF Elev8 Healthy Students & Families, which recently received an Academic-Practice Partnerships Award from the American Association of Colleges of Nursing, and Principal Investigator for a Health Resources and Services Administration (HRSA) training grant: Interprofessional Nurse Practitioner Education for the Collaborative Care of Children with Chronic Conditions.

Dr. Schapiro has worked with children and adolescents for over 30 years and current practice is in a high school health center. Her areas of expertise include pediatric and adolescent primary care, school-based care and behavioral issues, immigrant health, and child maltreatment. Her dissertation on family reunification of transnational Latino immigrant adolescents received an award from the UCSF School of Nursing in 2013. Dr. Schapiro has been on the Editorial Board of Current Problems in Pediatric and Adolescent Health since 2005.

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