Screening Young People for Trafficking Experiences

2 April 2020
Research Innovation

Jordan Greenbaum  | Medical Director, International Centre for Missing and Exploited Children
Makini Chisolm-Straker  | Assistant Professor in the Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai

In 2000, the United States defined human trafficking with the Trafficking Victims Protection Act. Initially, anti-trafficking efforts were focused on prosecution of traffickers and supporting the survivors who left their situations and successfully engaged with structured support systems. As the numbers in the anti-trafficking movement grew, the anti-trafficking paradigm broadened. Still, the focus of the majority of anti-trafficking resources is at the intervention phase.

The intervention focus includes increasing calls for better recognition of trafficking, including the recognition of labour trafficking, and the recognition of boys, men, genderqueer people and US-born persons as experiencing all types of trafficking. To systematically recognize trafficked persons and those at risk who are from typically unrecognized populations, screening and assessment tools can be useful for busy, understaffed organizations and institutions. Such tools do not replace the value of comprehensive, trauma-informed, culturally and linguistically appropriate approaches to client and patient care. These tools are meant to be integrated into them.  Some intimate partner violence literature examines the inherent limitations of screenings and challenges their use in lieu of a holistic care approach as in the PEARR tool, for example. However, screening and assessment tools can complement holistic approaches and be used to minimize user bias in trafficking recognition. They can alert the practitioner to the need for additional resources and referrals beyond any universal, general resources offered.

To be effective, such instruments must be rooted in evidence whenever possible. And with patience and rigour, it is possible. In using validated screening and assessment tools, the users ensure they afford the client or patient a real opportunity to share a trafficking experience and be heard, rather than be misclassified or unrecognized. Below, we explore two screening tools that, while having limited application, model the patience and scientific rigour that trafficking-recognition tools merit.

Public hospital bed. Photo by Daan Stevens/Unsplash

Quick Youth Indicators for Trafficking (QYIT)

In 2015, the Covenant House federation prioritized trafficking screening for its homeless young adult clients. Covenant House New Jersey (CHNJ) saw this as opportunity to create an evidence-based tool to allow it, and similar service organizations, to better serve its client population. The Quick Youth Indicators of Trafficking, or QYIT, was thus derived and validated with this goal in mind. QYIT was derived from HTIAM-14, which is an assessment derived from the validated Trafficking Victim Identification Tool (TVIT). Developed by the Vera Institute, the TVIT was the first validated labour and sex trafficking identification tool. In some social service settings, the TVIT can work as a screening tool but because it requires trafficking expertise to interpret and a significant time commitment to administer, it may not function as a screening tool for many service organizations.

Comprised of only four, dichotomous questions (see Figure 1), QYIT allows social service organizations serving homeless young adults to screen all clients, regardless of gender, for labour and sex trafficking. A single positive answer yields a positive screen. Clients with a positive trafficking screen on QYIT can then be offered an expert assessment for labour and sex trafficking experiences. In the derivation and validation of QYIT, CHNJ staff systematically assessed (using HTIAM-14) for labour and sex trafficking. In doing so, they recognized that their clients were experiencing labour trafficking more than previously recognized—48 per cent of those with a trafficking experience were trafficked for labour. QYIT is not validated for and should not be used in service organizations serving populations other than homeless young adults. More research is needed to determine if the tool is appropriate for and successful in other settings and populations.

Figure 1. Quick Youth Indicators of Trafficking

The Short Screen for Child Sex Trafficking (SSCST)

Evidence suggests that trafficked persons have variable access to healthcare but may seek care for reproductive health, behavioural health, traumatic injury or other conditions. However, many trafficked and exploited persons are reluctant to disclose their exploitation due to shame, feelings of guilt, fear (of retaliation by a trafficker, of deportation or of arrest), and lack of awareness of their exploitation status and of their rights and options. Therefore, it is incumbent on the health-care professional to recognize those at risk for trafficking and exploitation. When used in the context of a sensitive, trauma-informed and culturally appropriate approach, screening tools can open doors to discussion and information-sharing that may uncover vulnerabilities that can be addressed to prevent or address exploitation. Patients may be less reluctant to discuss prior social history (e.g. involvement with child protective services, history of prior sexually transmitted infection) than they are to reveal specific exploitation. Nonetheless, it is important to keep in mind that a ”negative” screen does not guarantee the absence of vulnerability factors or of human trafficking.

The Short Screen for Child Sex Trafficking (SSCST) is one of a few screens developed for and evaluated in health-care settings, and the only screening tool validated for use in these settings. This six-item tool is based on research conducted in the US comparing differences between sexually abused and sex trafficked adolescents. The tool inquires about medical and injury history, mental health symptoms and behaviours commonly associated with commercial sexual exploitation. It is designed to help practitioners recognize sex trafficking or adolescents at risk of being sex trafficked  (Figure 2).  A positive screen is defined as an affirmative response to two or more questions (>5 sexual partners is considered ”affirmative” for scoring purposes). If a youth screens ”positive”, the health provider follows up with open-ended questions about the affirmative responses to assess level of risk for commercial sexual exploitation. Using trauma-informed techniques (e.g. nonjudgmental attitude, active listening, transparency, rapport-building and empowerment), the clinician may obtain not only information on level of risk but also determine the need for additional resources to address specific risk areas.

The Short Screen for CST has been evaluated with adolescents (11-17 years) in emergency departments, teen clinics and child advocacy centres, with sensitivities ranging from 83-90.9 per cent and specificities from 49-61 per cent. In both studies, populations evaluated were girls (70 per cent and 85 per cent) and boys (30 per cent and 15 per cent) residing in the US. The screen has not specifically been evaluated in LGBTQ populations, or within immigrant/refugee groups. It has not been studied in health-care facilities outside the US.  Additional research is needed to validate the tool in these groups and settings.

Figure 2Short Screen for Child Sex Trafficking

** Data from a recent study suggested that altering Question 1 improved specificity by nearly 10 per cent, while sensitivity remained stable. The altered form of the question is:

“Have you ever been knocked unconscious?”  (that is, eliminate mention of fractures and cuts)

Using Screening Tools

Use of these or other screening tools is only helpful when delivered in the context of a trauma-informed, culturally and linguistically appropriate approach to patient/client care, in which a trafficked or at-risk person is able to trust the provider and feel comfortable sharing concerns and experiences. The screening questions identify conditions commonly associated with trafficking but do not, in and of themselves, confirm that trafficking has occurred. This is consistent with the purpose of the screen, which is to identify not only those who are being or have been trafficked, but those who are at risk for trafficking. The latter group deserve information and resources that may prevent their future exploitation, and screening introduces the possibility of primary prevention of their trafficking.

There are other screening tools available to professionals and these vary in length, target population, type of exploitation screened for, and validation status.  It is likely that no single screen will be effective with every population. Regional differences, cultural practices and changes in social norms will impact the effectiveness of any given tool. In addition, the environment in which the screen is administered, the relationship between patient/client and professional, and the wording used to ask questions will influence the results of a screening tool. Provider bias, discomfort with questions about high-risk behaviour and social background, and lack of training; patient fear, shame and varied interpretation of questions; and environmental factors such as lack of privacy all may preclude effective screening so that a negative screen in no way rules out the possibility of trafficking, nor does it guarantee the absence of a vulnerability. Repeated screening at future visits—preferably within an ongoing trusting relationship between professional and patient/client—may help to mitigate these shortcomings and lead to positive screen (if relevant) and the offer of resources in the future.

Global research is needed to develop and validate brief, effective tools that will identify children, youth and adults who are being trafficked for sex and/or labour, or at risk of such exploitation.  These need to be adjusted and assessed to ensure relevance and feasibility across cultures and settings. Ideal tools are brief, validated, easily understood by patients/clients, simply incorporated into routine care in the setting in which they are used, and require limited training to administer and interpret. Ideal screening tools are delivered within the context of trauma-informed, culturally and linguistically appropriate care and accompanied by general information and resources for patients/clients, with additional resources available to address identified vulnerabilities.

The media and law enforcement reports paint an incomplete picture of who experiences trafficking in the US, and how. Using evidence-based tools to systematically look for labour and sex trafficking, regardless of gender, service organizations can tell a different story, that is closer to the truth.

Makini Chisolm-Straker, MD, MPH is Assistant Professor in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in Brooklyn, New York.

Jordan Greenbaum, MD is Medical Director for the International Centre for Missing and Exploited Children and Medical Director for the Institute on Healthcare and Human Trafficking at the Stephanie V. Blank Center for Safe and Healthy Children at Children’s Healthcare of Atlanta.

This article has been prepared by Dr Makini Chisolm-Straker and Dr Jordan Greenbaum as contributors to Delta 8.7. As provided for in the Terms and Conditions of Use of Delta 8.7, the opinions expressed in this article are those of the authors and do not necessarily reflect those of UNU or its partners.

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