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Date: November 10th , 2018

Reference: Kaltiso et al. Evaluation of a Screening Tool for Child Sex Trafficking Among Patients with High-Risk Chief Complaints in a Pediatric Emergency Department. AEM October 2018.

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

You may have noticed there was no music for the introduction. Part of the SGEM brand is to have some fun and engaging theme music to help with knowledge translation. This topic of child sex trafficking is very serious and disturbing. I struggled with what would be an appropriate song choice. After thinking about it and not coming up with something acceptable I went to twitter to ask my #FOAMed friends.

It was Minh Le Cong (@Ketaminh) who suggested no music for this episode and perhaps a period of silence. Mitochondrial Eve (@BrowOfJustice) agreed and said that she uses silence to great effect frequently. I hold both of these wise people high regard and value their opinion. I listened, and I heard what they said and that is why there was silence rather than song to introduce this SGEMHOP episode on child sex trafficking.

TRIGGER WARNING:

As a warning to those listening to the podcast or reading the blog post, there may be some disturbing things discussed. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material could be considered explicit, graphic, offensive, and/or upsetting. As a trigger warning, if you are feeling upset by the content then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.

Case: A 15-year-old girl presents to the emergency department with pelvic pain. She is with a parent and after the initial introductions and history, you have her parent leave the room to ask more sensitive questions. Upon further history, you discover that she has been having pelvic pain with genital discharge and has had more than ten sexual partners in their lifetime. Eventually, you discover that she has also been drinking alcohol and endorses that she has exchanged sex for drugs in the past.

Background: Child sex trafficking (CST) is a global human rights violation and occurs when a minor is engaged in any sex act which involves an exchange of something of perceived value, whether monetary or non-monetary (1,2).

Examples of CST include prostitution of children by others, “survival sex” (runaway/homeless children having sex in exchange for shelter or something else needed to survive), working in sex-oriented businesses, or production of child sexual abuse materials (3,4).

Statistics from the United States Human Trafficking Reporting System indicate that 85% of identified sex trafficking victims were US citizens/legal residents and 55% were minors (5).

Statistics on trafficking in persons in Canada from 2016 reveal the following (Juristat Bulletin):

  • Number of police-reported incidents of human trafficking on the rise and is at the highest level since data became available in 2009 (0.94/100,00 people)
  • One in three police-reported human trafficking incidents is a cross-border offence
  • More than half of human trafficking incidents involve another offence, usually prostitution
  • The vast majority (95%) of the victims of human trafficking are women, 72% are under 25 years of age and most of the people accused of human trafficking are male (81%).

Risk factors associated with CST include a history of abuse, substance use, juvenile justice system involvement, a history of running away from home and LGBTQ status (6-12).

Victims of CST are at risk for a myriad of health-related consequences, including physical injury, chronic pain, STIs, substance use disorders and psychiatric disorders such as PTSD, depression and suicide (13-16).

Most of these victims seek medical attention at some point, with 88% having seen a physician during their exploitation (15).

Clinical Question: What is the utility of a CST screening tool in a high-risk patient population presenting to a large inner-city pediatric emergency department?

Reference: Kaltiso et al. Evaluation of a Screening Tool for Child Sex Trafficking Among Patients with High-Risk Chief Complaints in a Pediatric Emergency Department. AEM October 2018.

  • Population: Patients aged 10-18 years of age presenting with high-risk chief complaints or if the attending physician was concerned about high-risk sexual or social behaviour regardless of the chief complaint. (Chief complaints: vaginal/penile discharge, pelvic/genital pain, request for sexually transmitted infection testing, request for pregnancy testing, intoxication/ ingestion, suicide attempt, suicidal ideation, homicidal ideation, acute sexual assault, traumatic assault, clearance examination for social services, and behavioral complaints.)
    • Exclusions: Non-English speakers, patients with intellectual disabilities, acute emergencies, severe pain, or need for stabilization and if the attending physician requested that the patient not be interviewed (typically if they felt that the patient was too young to be asked questions about sexual history or drug use).
  • Intervention: Child sex trafficking (CST) screening tool
  • Comparison: None. The screening tool was previously developed from a comparison of CST victims to patients presenting with complaints of acute sexual assault without a commercial component.
  • Outcome: Diagnostic accuracy of the child sex trafficking screening tool (sensitivity, specificity, PPV and NPV).

Dr. Sheri-Ann Kaltiso

This paper is Hot Off the Press, trying to cut the knowledge translation window down to less than one month. As such, we have the lead author from this AEM paper. Dr. Sheri-Ann Kaltiso is an intern in the Emergency Medicine program at Emory. She is originally from Jamaica and migrated to the United States for her undergraduate education. Sheri-Ann received a BS in Cognitive Sciences at Rice University and her MD at Emory University School of Medicine.

Child Sex Trafficking Screening Tool: 

Authors’ Conclusions: “Applied to an inner-city PED population of 203 participants with high-risk chief complaints, the screening tool has high sensitivity and high negative predictive value. This makes it appropriate for an initial screening to rule out CST in this high-risk population. Applicability for broader use and additional practice settings are warranted given the significant positivity rate among those presenting with high-risk concerns.”

Quality Checklist:

  1. The clinical problem is well defined. Yes
  2. The study population represents the target population that would normally be tested for the condition (i.e. no spectrum bias). Unsure.
  3. The study population included or focused on those in the emergency department. Yes
  4. The study patients were recruited consecutively (i.e. no selection bias). No
  5. The diagnostic evaluation was sufficiently comprehensive and applied equally to all patients (i.e. no evidence of verification bias). Yes
  6. All diagnostic criteria were explicit, valid and reproducible (i.e. no incorporation bias). Yes
  7. The reference standard was appropriate (i.e. no imperfect gold-standard bias). Unsure
  8. All undiagnosed patients underwent sufficiently long and comprehensive follow-up. Unsure

Key Results: This trial involved 203 participants out of 254 eligible patients. Almost half, (100/203) screened positive with the tool. There were eleven CST victims identified, for a prevalence of 5.4%. Ten out of the eleven victims screened positive with the screening tool.

Using a cut off score of two positive answers out of six, the tool demonstrated sensitivity of 90.9% and NPV of 99.0%

  • Primary Outcome: Diagnostic accuracy of CST screening tool
    • Sensitivity 90.9% (95% CI 58.7%-99.8%)
    • Specificity 53.1% (45.6-60.4%)
    • PPV 10.0% (5.0-17.6%)
    • NPV 99.0% (94.7-99.9)

  • Other Findings:
    • Mean age of CST victims was 15.9 years (13-18), nine females and two males.
    • Presentation of CST victims included alone, with a parent/guardian, with a friend, a police officer and a social services case manager.
    • 55% of CST victims had seen a medical provider within the past six months.
    • History items strongly associated with CST were: more likely to have run away from home, have used drugs/alcohol in the past twelve months, have had more than ten sexual partners and have had a prior sexually transmitted infection.
    • There was no chief complaint among the inclusion criteria that correlated significantly with CST presentation.

Listen to the podcast on iTunes to hear Sheri-Ann’s responses to our ten nerdy questions.

  1. Selection Bias: This was a convenience sample and could have introduced some selection bias into the study. You excluded non-English speaking patients. This would seem to be a high-risk group. You also excluded patients if the attending physician requested that the patient not be interviewed. This was typically if the clinician felt that the patient was too young to be asked questions about sexual history or drug use. Do you think that could have introduced some bias?
  2. 18-Years-Old: You included 18-year-olds in the study. This is a group that could be voluntarily participating in stripping/commercial sex work.
  3. Gold Standard: A patient was considered to be a “true” CST victim if the information obtained during the emergency department visit met with the US Department of State definition of CST. Do you think this represents a “true” gold standard?
  4. Follow-Up: Another concern we had was if the follow-up was long enough and comprehensive enough to identify any missed cases.
  5. Prevalence: The number of cases was small (11/203) and predictive value is based on prevalence. While the point estimate for NPV looked good (99%) because of so few cases and the 95% confidence interval was fairly wide (down to 94.7%). This means it would miss up to 1 in 20 case. Can you comment on this issue and if missing 5% of child sex trafficking cases would be acceptable?
  6. Tip of the Iceberg: How much is this a “tip of the iceberg” phenomenon in this study, and how many CST victims do you think we are missing?
  7. Labor Trafficking: This was not addressed and is more common than sex trafficking. Do you have any comments on this issue ?
  8. External Validity: This was a single center study done in an urban pediatric emergency department. How do you think this would translate into a community emergency department?
  9. Screening Tool: The CST screening tool was administered by an independent researcher. Do you envision the triage nurse adding this to their workload? If yes, will they be as good as a research assistant and how will this impact department flow?
  10. Anything Else? Is there anything else you would like to say about your screening tool or child sex trafficking in general?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

SGEM Bottom Line: Child Sex Trafficking is a global problem and can be discovered in the emergency department through application of a simple screening tool.

Case Resolution: After discovering that your patient has traded sex for drugs, you have your social worker see the patient while you continue the work up for her acute medical illness.

Dr. Chris Bond

Clinical Application: Use a CST screening tool in adolescents with high risk presenting complaints in the ED.

What Do I Tell My Patient? I am very concerned about some of the things you are telling me, so I would like to have our social worker speak with you more about this concern.

Keener Kontest: There was no winner to last weeks’ question of how often is there hematoma enlargement in patients with an intracerebral hemorrhagic stroke. The correct answer would have been 30-40%, increasing the chance of a poor outcome 50-80%

Listen to the SGEM podcast on iTunes to hear this the new keener question. If you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode? Tweet your comments using #SGEMHOP. What questions do you have for Sheri-Ann and her team about screening for child sex trafficking? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learning website
  • Register and create a log in
  • Search for Academic Emergency Medicine – “November”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. 2016 UNODC Global Report on Trafficking in Persons. United Nations Publication, Sales No E16IV6. Vienna: United Nations Office on Drugs and Crime, 2016. 2.
  2. U.S. Department of State. Victims of Trafficking and Vio- lence Protection Act of 2000. Pub L No. 106-386 Division A. 2001 103(8); Available at: https://www.state.gov/j/tip/ laws/61124.htm. Accessed May 7, 2018.
  3. Greijer S, Doek J. Interagency Working Group on Sexual Exploitation of Children. Terminology Guidelines for the Pro- tection of Children From Sexual Exploitation and Abuse. Lux- embourg 2016. Available at: http://www.ilo.org/wc msp5/groups/public/—ed_norm/—ipec/documents/instruc- tionalmaterial/wcms_490167.pdf. accessed on 5/7/18
  4. Institute of Medicine and National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press, 2013.
  5. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008–2010. Washington, DC: U.S. Department of Justice, 2011.
  6. Williamson C, Prior M. Domestic minor sex trafficking: a network of underground players in the midwest. J Child Adolesc Trauma 2009;2:1–16.
  7. Reid JA. Risk and resiliency factors influencing onset and adolescence-limited commercial sexual exploitation of disadvantaged girls. Crim Behav Mental Health 2014;24:332–44.
  8. Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. Human trafficking of minors and childhood adversity in Florida. Am J Public Health 2017;107:306–11.
  9. Bigelsen J, Vuotto S. Homelessness, Survival Sex and Human Trafficking: As Experienced by the Youth of Cove- nant House New York. 2013. Available at: https://huma ntraffickinghotline.org/sites/default/files/Homelessness% 2C%20Survival%20Sex%2C%20and%20Human%20Traff icking%20-%20Covenant%20House%20NY.pdf. Accessed Oct 29, 2017.
  10. Chettiar J, Shannon K, Wood E, Zhang R, Kerr T. Survival sex work involvement among street-involved youth who use drugs in a Canadian setting. J Public Health 2010;32:322–7.
  11. Cimino AN, Madden EE, Hohn K, et al. Childhood mal- treatment and child protective services involvement among the commercially exploited: a comparison of women who enter as juveniles or as adults. J Child Sexual Abuse 2017;36:352–71.
  12. Dank M, Yahner J, Madden K, et al. Surviving the Streets of New York: Experiences of LGBTQ Youth, YMSM, YWSW Engaged in Survival Sex. Washington, DC: Urban Institute, 2015.
  13. Goldberg AP, Moore JL, Houck C, Kaplan DM, Barron CE. Domestic minor sex trafficking patients: a retrospective analysis of medical presentation. J Pediatr Adolesc Gynecol 2017;30:109–15. 14.
  14. Greenbaum VJ, Dodd M, McCracken C. A short screen- ing tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care 2018;34(1):33–7. 15.
  15. Lederer L, Wetzel C. The health consequences of sex traf- ficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23:61–91. 16. Zimmerman C, Yun K, Shvab I, et al. The Health Risks and Consequences of Trafficking in Women and Adoles- cents: Findings from a European Study. London: London School of Hygiene and Tropical Medicine (LSHTM), 2003.

 Additional Information and Resources:

  • National Human Trafficking Resource Center 24 hour Hotline 1-888-373-7888
  • Department of Health & Human Services (Call when suspect unaccompanied foreign national child is victim of trafficking) 202-205-4582
  • Resources for physicians HEAL Trafficking
  • Victim Services Huron County (Ontario, Canada) – Sex Trafficking is not only an Urban Isssue
  • Centre for Addiction Mental Health – Free online course helps service providers support survivors of human trafficking
  • British Columbia (Canada) – Office to Combat Trafficking in Persons