(WITHDRAWN) Identifying People at Risk of Sex Trafficking in a High-Risk Healthcare Setting: Findings from a Collective Case Study in the Midwest

Background and Purpose: The Institute of Medicine and Center for Disease Control recommend that healthcare providers have knowledge of sex trafficking (ST) indicators and conduct screenings to identify people at risk. ST occurs when a commercial sex act is induced by force, fraud, or coercion, OR when the person induced to perform such an act is under 18 years of age. Domains of ST indicators include behavioral (e.g. patient accompanied by a controlling person), verbal (e.g. unable to provide key information), medical (e.g. repeat sexually transmitted infections), and physical (e.g. tattoos). However, how healthcare providers conduct ST screenings and what resulting challenges emerge in clinical practice remain largely understudied. The purpose of this study was to (1) understand the perceived barriers to ST identification among healthcare providers in a large, high-risk healthcare organization, and (2) explore the perceived clinical relevance of ST indicators.

Methods: This study used a collective case study approach in five sites of a large, high-risk health care organization in a Midwestern state (Crowe et al., 2008). Data sources included (1) ST materials from the healthcare organization (e.g. ST training modules, screening/risk assessment protocols), and (2) 23 in-depth, semi-structured interviews with healthcare providers. Interviews explored (1) knowledge and awareness of ST, (2) roles and challenges in screening and identifying people at risk of ST, and (3) perceived relevance of the ST indicators across domains in assessing for ST. The sample was entirely female, cisgender women, and predominantly White, non-Hispanic (n=19), medical assistants (n=14) who conduct preliminary screenings (at a minimum), and clinicians (n=7) who follow up and conduct physical examinations.

Two research team members conducted independent deductive coding, which stemmed from the interview guide (e.g. knowledge of ST), and independent coding analyze emerging themes, such as responses to ST risk disclosures and provider role ambiguity. We analyzed each site independently and collectively by searching for patterns to understand the circumstances and conditions under which challenges/assumptions emerged, e.g. assumptions that a different role would address ST risk.

Findings: Although staff routinely screened by asking “have you ever traded sex for money or drugs?,” they tended to introduce the question in ways that were not conducive to facilitating disclosures, and/or provided minimal follow up to disclosures. Occasionally, staff provided strong examples of follow up assessment practices they found helpful in soliciting more information (e.g. assessing patient risk by asking where/how sex exchanges happened). However, participants primarily described avoiding further discussions of ST because they (1) aimed to be non-judgmental and sex positive, (2) viewed following up as someone else’s job, and/or (3) lacked confidence in discussing it themselves.

When assessing ST risk, behavioral and verbal indicators were perceived as more helpful, particularly with a female patient in a relationship with a male. Medical and physical indicators were perceived as unseen or unhelpful.

Conclusions and Implications: There may be some missed opportunities to assess patients for ST risk and use harm reduction strategies or safety planning to address patients’ needs. Implications for healthcare trainings and future research will be discussed.