CL is a 32-year-old female who presents for the first time to the clinic with the chief concern of vaginal discharge and burning with urination. She reports she does not have fever or abdominal pain and notes that her symptoms are similar to when she had chlamydia 3 months ago but not like the heavy discharge and vaginal itching she had when she had trichomoniasis 6 months ago. Her previous cervical cancer screening was 5 years ago, and she thinks they told her she had human papilloma virus. Her last menstrual period was 2 weeks previous. She reports sexual activity with males only, vaginal and oral. When asked how many sexual partners she has had, she quietly laughs and says she has no idea. She reports rarely using condoms for sexual encounters and does not use any other contraceptive method. CL says she has been pregnant four times and has had two miscarriages and two elective abortions. The most recent elective abortion was 10 months ago. A man who CL states is her boyfriend is with her in the exam room holding her hand, often answering questions asked to the patient. Further health history reveals that CL has frequent urinary tract infections (three in the last year), as noted previously has had chlamydia treated 3 months ago, and has had trichomoniasis twice in the past 2 years. Her only other medical history is mild, intermittent asthma managed with oral medication and an albuterol inhaler as needed. The patient states she was adopted and does not know her family history. She does not have living children and is not aware of any siblings. CL says she does not smoke cigarettes and does not use any drugs except for marijuana twice a week. She rarely drinks alcohol except about two times a year on special occasions. When asked about employment, her boyfriend squeezes her hand and quickly responds that she works in a restaurant part time.

Are there red flags for human sex trafficking?

Human sex trafficking must be in the forefront of the mind of the nurse practitioner (NP) caring for CL.¹ Red flags or significant warning signs that the NP observes in CL include recurrent or frequent sexually transmitted infections (STIs), repetitive miscarriages and abortions, frequent urinary tract infections, the boyfriend answering questions asked to the patient, vague answers regarding her work, and unknown number of sexual partners.² Each of these findings on its own may not raise a red flag for sex trafficking but when put together they do.

The NP is concerned and decides it is critical to have some time with CL without her boyfriend present. She asks the boyfriend to go to the waiting area while she does a physical exam. He reluctantly agrees to do so.

Physical assessment findings

CL appears to be well nourished and well groomed. During the physical exam, she makes limited eye contact and speaks quietly only when addressed while looking frequently at the exam room door. The physical exam reveals a soft, nontender, and nondistended abdomen. No bruises, burn marks, or other injuries to the skin are noted. CL’s external genitalia are shaved with excoriation noted to the labia majora, mild swelling of the labia minora, and no lymphadenopathy. As CL moves to the edge of the exam table for the pelvic exam, the NP observes a small tattoo of two initials on her left buttock. The pelvic exam reveals an erythematous cervix with mucopurulent discharge, no cervical motion tenderness, and a nontender uterus and adnexa. Specimens are obtained for chlamydia and gonorrhea testing, a wet prep exam, and cervical cancer screening. CL declines HIV testing. The wet prep reveals no yeast, trichomonads, or clue cells. White blood cells are too numerous to count. A dipstick urinalysis shows positive leukocytes only, and a pregnancy test is negative.

Are there more red flags?

The NP notices other red flags during her assessment of CL. Her hypervigilant behavior along with some anxiety and fear, a tattoo with initials, and signs of a recurrent STI when put together further raise suspicion of sex trafficking.² The boyfriend’s reluctance to leave CL alone with the NP also is a red flag. Other warning signs of human trafficking the NP assesses for are not present with CL. There are no bruises or burns, and she is well nourished and well groomed. See Box for red flags.

Safety and individual needs assessment

The NP recognizes that CL displays several red flags for being a victim of sex trafficking and that an assessment of her safety and any particular needs related to her individual situation is important. She asks CL if it would be okay for them to continue discussion after she is dressed and without the boyfriend present. Although CL appears anxious, she agrees. On returning to the exam room, the NP tells CL about her concerns and asks permission to talk with her about her living situation and her safety. CL agrees to the discussion. The NP asks CL if she feels safe when at home and work and if she is free to come and go and to talk with anyone as she pleases including getting regular healthcare. She asks her if she is being forced or coerced to engage in sexual activity by anyone and/or if she has been restricted in meeting her basic needs. CL confides that living with her boyfriend who she now refers to as her pimp and other women who are working for him is the most “normal” family she has ever had. They eat meals together and are a family unit, caring for each other and having fun together. CL says she finally has people who want her in the home, and she had not thought about it being odd that she could not leave until she was asked about it at this visit. She has been in this living situation for more than a year and does not think she is in any immediate danger. She admits that prior to this living situation she engaged in prostitution on her own and occasionally was without a place to live.

She shares that her pimp does like to control what she wears and wants to know where she is at all times. She had to ask him to make this clinic appointment and he had insisted on accompanying her. Although he has not been physically abusive, he has threatened to throw her out on the streets if she does not follow his rules. CL says she has nowhere else to go. The NP recognizes that CL is in a difficult situation but not likely in immediate danger of physical harm. She provides CL with a small card she can tuck away with the National Human Trafficking Hotline phone number where she can get questions answered and be advised on resources.³ She also provides her with information on local shelters and counseling centers.

Immediate healthcare needs and follow-up

Today, the NP will provide CL with medication for presumptive chlamydia because of the mucopurulent cervicitis. They discuss whether it is safe to let recent sexual partners know they need to be evaluated and treated or if they can arrange for expedited partner treatment. They also discuss strategies to safely negotiate condom use with sex partners. The NP listens in an empathetic and nonjudgmental manner, as women in CL’s position may be reticent and embarrassed to talk about what they are doing. They may have experienced stigmatization and discrimination in healthcare settings because of their sexual activity. Condom negotiation with sex customers can potentially cause women to be in danger or to lose the job. Some women report the trafficker insists on condom use with customers and no condom use with him. Women who are trafficked report unsafe and ineffective practices such as using mouth wash and even sitting in bleach if the condom breaks or no condom is used to try to prevent STIs and HIV.⁴ The NP uses this opportunity to educate CL about safer sex, how to properly use male and female condoms, and provides her with condoms. She also provides her with information about HIV testing and preexposure HIV prophylaxis.

A follow-up visit is scheduled to review test results and will provide for maintaining contact and engagement with CL. Providing compassionate care will build rapport and trust. An assessment of any changes in safety or other needs can take place at the follow-up visit. CL was not initially ready for a referral for counseling or alternative housing, but this can be revisited when she returns. Psychological healing will be needed. Many nonprofit organizations offer safe, protected, anonymous places for women to live so they can be away from the trafficker. The NP can develop a network of trusted professionals such as counselors, social workers, and law enforcement to ensure individuals experiencing sex trafficking have all the aspects of care and protection that they need.

Lessons learned

Sex trafficking is defined as the recruitment, harboring, transportation, provision, or obtaining of a person through force, fraud, or coercion for the purpose of a commercial sex act. It is a criminal activity.⁵ Worldwide, it is estimated that 4.8 million persons are victims of forced sex trafficking with 99% being women and girls.⁶ Unfortunately, many individuals experiencing sex trafficking are seen by healthcare providers and are never identified. CL shared that no other healthcare provider ever asked questions about her living situation. Often patients are asked if they feel safe and the questions for trafficking end there.

The US Department of Health and Human Services through the Office of Trafficking in Persons has created a toolkit along with a screening tool to assess for human trafficking in patients.⁷ This tool is not yet validated but has been created to be used in a variety of settings with diverse groups of patients. There is not one universal screening tool for sex trafficking. According to a recent review, there are 22 human trafficking screening tools (16 developed in the US; only four discuss evaluation of the tools) that give options for screening depending on the setting and age of the patient.⁸ Providers and clinics can decide which tool is best for the situation.

In some ways CL does not “fit” the typical description of an individual who is being sex trafficked, and this is a reminder that all victims are not teens, newly migrated to the US, from the foster care system, homeless, or struggling with drug abuse or mental health disorders.³

CL’s story is an example that we need to be aware of the numerous red flags that can indicate possible sex trafficking with any patient. In fact, CL did not see herself as a victim and did not initially recognize the emotional coercion tactics used by the trafficker and the unsafe nature of the sexual activity in which she was involved. It is not the NP’s role to label the patient as a victim. It is the NP’s responsibility to recognize red flags, provide trauma-informed care, and to listen to the patient to understand specific needs and provide resources.

Kristen C. Johnston is Associate Professor at Moffett & Sanders School of Nursing, Samford University, in Birmingham, Alabama. The author has no actual or potential conflicts of interest in relation to the contents
of this article.

Womens Healthcare. 2023;11(5):27-29. doi: 10.51256/WHC102327

References

¹ National Association of Nurse Practitioners in Women’s Health. Position Statement. Human Sex Trafficking. Washington, DC: NPWH; 2021.

² McDow J, Dols JD. Implementation of a human trafficking screening protocol. J Nurse Pract. 2021;17(3):339-343. doi:10.1016/j.nurpra.2020.10.031.

³ Polaris. National Human Trafficking Hotline. 2023.

⁴ Ravi A, Pfeiffer MR, Rosner Z, Shea JA. Identifying health experiences of domestically sex-trafficked women in the USA: a qualitative study in Rikers Island Jail. J Urban Health. 2017;94(3):408-416. doi:10.1007/s11524-016-0128-8. https://humantraffickinghotline.org/en/human-trafficking.

⁵ 106th United States Congress. Victims of Trafficking and Violence Protection Act of 2000. www.congress.gov/106/plaws/pub1386/PLAW-106pub1386.pdf.

⁶ International Labour Organization. Report. Global estimates of modern slavery: forced labour and forced marriage. International Labour Office (ILO), Geneva, September 19, 2017.

⁷ National Human Trafficking Training and Technical Assistance Center. Macias-Konstantopoulos W, Owens J. Toolkit: Adult Human Trafficking Screening Tool and Guide. January 2018. https://nhttac.acf.hhs.gov/resources/toolkit-adult-human-trafficking-screening-tool-and-guide.

⁸ Macy RJ, Klein LB, Shuck CA, et al. A scoping review of human trafficking screening and response. Trauma Violence Abuse. 2021;15248380211057273.

⁹ U.S. Department of Health and Human Services, Administration for Children and Families, Office on Trafficking in Persons. “Red flags” that may indicate human trafficking. https://nhttac.acf.hhs.gov/resource/fact-sheet-flags-may-indicate-human-trafficking.