Relationship Safety: Screening and Support for Survivors of Child Trafficking

by Jordan Lo

Perpetrators of child sex trafficking often start by establishing trust with their target, then using physical, sexual, and/or psychological abuse to maintain their control. Therefore, survivors of child trafficking are also survivors of relationship trauma, manipulation, and controlling behavior (Allan, 2023). These survivors may have difficulty trusting others and forming safe and healthy relationships with others. Survivors may also face other intersecting forms of trauma based on their culture, gender, religion, or other aspects of their identity. Some cultures discriminate against or blame survivors due to beliefs that people who have been trafficked “deserve” their exploitation because of their clothing or behavior (Crisp & Bellatorre, 2024). These issues can threaten survivors’ relationships with others, and social isolation is considered a risk factor for intimate partner violence victimization (Capaldi et al., 2012). Consequently, discussing the components of a healthy relationship is important for survivors to recognize and develop safe relationships with others in order to break the cycle of sexual abuse and exploitation.

Screening

The US Preventive Services Task Force recommends screening for intimate partner violence in all female patients of childbearing age during encounters for annual wellness, reproductive health, and mental health (Forke, 2024). Some examples of screening tools include the Humiliation, Afraid, Rape, Kick (HARK) and Hurt, Insult, Threaten, Scream (HITS) tools for primary care settings, while the Partner Violence Screen (PVS) is used in emergency departments. The American College of Obstetricians and Gynecologists (2018) has provided examples of questions that providers may ask if their patient is dating, including, “What do you do if you are feeling sad, angry, or hurt by your partner?” This gives the patient the opportunity to discuss both positive and negative coping mechanisms that they use, and encourages further conversation about their partner. Healthcare providers should also screen survivors of child sex trafficking for unhealthy dynamics in non-romantic relationships. Asking open-ended questions is important in order to avoid influencing their answers, and providers may use questions like, “What sort of things do you do with your friends? How would your friends describe you?” If a patient presents with a playground injury, a provider may start with, “How did you fall? Who was there with you? What happened after?” In contrast, questions like “Did anyone push you?” can be answered with a brief yes or no, and may lead the patient to answer in a certain way. Finally, they may screen for unsafe behavior from teachers by asking, “What teacher do you spend the most time with? Tell me more about that.” Open-ended questions provide a more accurate narrative and demonstrate genuine interest in the patient and their relationships, which facilitates trust between the patient and provider.

Education

Educating patients on the components of healthy, safe relationships will equip them to better navigate their own interpersonal relationships. Survivors of child trafficking may have had dysfunctional relationships modeled for them during childhood, and may not have the vocabulary or context to realize that certain behaviors are harmful. Education is still beneficial when patients are currently in healthy relationships, as some relationships may unfortunately become unsafe over time. Offering online resources like LoveIsRespect.org can help patients assess their relationships on their own time, and often contain a function to quickly leave the webpage if the viewer feels unsafe. Conversations about safe relationships may include the following components (American Academy of Pediatrics, 2024):

Honest Communication - Both people share their feelings and important information with each other. One person does not lie or withhold information from the other, and they both place trust in each other and give each other the benefit of the doubt.

Mutual Support - Both partners treat each other the way they want to be treated, and respect the other person’s friends, interests, and property.

Cooperative Decision-Making - Partners share decisions and responsibilities. One person does not make all the decisions or tell the other what to do. Both people compromise while problem solving together.

Comfort and Safety - Both people have fun and enjoy the relationship. They both feel physically safe and respect each others’ personal space. One person does not use physical force to get their way, and the other does not feel extremely worried about upsetting them.

Clear Boundaries - Each person has their own identity, interests, and friends separate from their partner. Both partners should be supportive of the other wanting to make new friends or hobbies.

Special Considerations - In addition to their peers, children and adolescents also develop relationships with other adults such as teachers, counselors, and healthcare providers. It is important to emphasize that, just like peer-to-peer relationships, a healthy relationship with an adult doesn’t feel embarassing or secret. Survivors should know that they can decline an exam or procedure if they feel uncomfortable during a doctor or dentist appointment. If students are having one-on-one meetings with a teacher, they can ask for the door to be open during the meeting or for a parent/guardian or another teacher to be present as well. By promoting autonomy early, providers can prevent a patient from entering an unsafe situation later in life.

Conclusion

Survivors of child sex trafficking may have difficulty establishing safe relationships with others due to a lack of healthy models while growing up and difficulty trusting others as a result of their abuse. Therefore, providers should screen for potentially unsafe relationships in patients who may be at risk, and provide education on the components of a healthy relationship. Patient education will also equip survivors with the vocabulary and resources to analyze their own relationships and avoid potentially unsafe situations.

Sources

ACOG Committee Opinion No. 758: Promoting Healthy Relationships in Adolescents. (2018). Obstetrics and gynecology, 132(5), e213–e220. https://doi.org/10.1097/AOG.0000000000002945

Allan, C., Winters, G. M., & Jeglic, E. L. (2023). Current Trends in Sex Trafficking Research. Current psychiatry reports, 25(5), 175–182. https://doi.org/10.1007/s11920-023-01419-7

American Academy of Pediatrics. (n.d.). Healthy Adolescent Partner Relationships. Pediatric Mental Health Minute Series. Retrieved October 14, 2024, from https://www.aap.org/en/patient-care/mental-health-minute/healthy-adolescent-partner-r elationships/

Capaldi, D. M., Knoble, N. B., Shortt, J. W., & Kim, H. K. (2012). A Systematic Review of Risk Factors for Intimate Partner Violence. Partner abuse, 3(2), 231–280. https://doi.org/10.1891/1946-6560.3.2.231

Crisp, J., & Bellatorre, C. (2024). The Impact of Trauma on Child Trafficking Survivors. https://www.state.gov/the-impact-of-trauma-on-child-trafficking-survivors/

Forke, C. M., Ellenbogen, R., & Thompson, K. M. (2024). Practical Advice for Addressing Adolescent Relationship Violence During Clinical Encounters. Primary care, 51(4), 703–713. https://doi.org/10.1016/j.pop.2024.05.009