In 2000, President Clinton signed into law, the Trafficking Victims Protection Act (TVPA). It defined sex trafficking as the recruitment, harboring, transportation, provision, obtaining, patronizing or solicitation of a person for the purpose of a commercial sex act induced by force, fraud or coercion or in which the person induced to perform such act has not attained 18 years of age. It clearly established that minors can not be willing participants in commercial sex acts such as prostitution. The TVPA defined every aspect of sex trafficking and propelled it into the public consciousness. It gave law enforcement the ability to vigorously investigate these crimes and prosecutors the opportunity to bring these predators to justice. Yet 20 years later, sex trafficking is still a billion-dollar business with more than 4.5 million victims worldwide with 2 million being children. In the United States, it is estimated there are 200,000 to 300,000 child sex trafficking victims alone.

I became involved in caring for child sex trafficking victims in 2014 when I was working in St. Louis Missouri. At the time, I was an attending in the Pediatric Emergency Department at Cardinal Glennon Children’s Hospital. I am both a Pediatric Emergency Medicine and Child Protection Physician so have expertise in caring for children who are victims of physical and sexual trauma. St Louis is a hub for Sex Trafficking. In 2014, the city was ranked 15^th in the country. It is currently ranked 10^th. The reasons are many. It has an international airport, intersecting highways, three military bases in close proximity to the city, successful sports teams, convention centers, and strip clubs. These attract transient men looking for sex. It was estimated at that time there were 1,000 victims of sex trafficking in a city of 300 ,000. In 2021, over 300 victims of human trafficking were rescued in Missouri. Over 200 were sex trafficking victims and half of those were children.

As part of our duties in the ED, we would perform “Fit for Confinement Examinations” for the St Louis Metropolitan Police Department. These were medical clearance exams on adolescents who were taken into state custody before being placed in residential facilities. They were remanded for placement for various reasons, one being “prostitution”. But they were not prostitutes but victims of sex trafficking. They were just getting simple physical exams, cleared of any acute life-threatening illnesses and then being sent to their facilities. It became clear we were not providing these children with appropriate and adequate care. They needed more than just a simple physical exam.

During this time, The St. Louis Metropolitan Police Department was training all their officers on how to recognize and respond to sex trafficking victims, child and adult. After discussion with the lead social worker in the ED, we asked permission from the St. Louis PD if we could attend the training and they graciously agreed. It was eye opening. The course educated us on how to recognize victims. What factors put them at risk, how the traffickers selected their victims, manipulated, brutalized and controlled them. They explained to us why victims do not come forward and how hard it is to escape. One speaker also enlightened us on the poor medical care these victims receive despite presenting to hospitals for treatment. She explained how they often go unrecognized as trafficking victims, and this represents missed opportunities for rescue.

After this training it became obvious, we needed to establish a program in St. Louis that would address all the medical needs of child sex trafficking victims. A program that would provide both acute medical intervention and comprehensive ongoing medical care. I decided that care should be delivered at my hospital. We would be their medical home providing acute care, routine and preventive care as well as ensuring any needed subspecialty care. These exams would be delivered in an environment where the victim felt safe, protected, not judged. She would be the focus, heard, and believed. In addition to medical care, we would also interface with other agencies including Children’s Division, Law Enforcement, Circuit Attorney’s Office, FBI, Homeland Security, and assist in arranging other needed services including placement, drug counseling etc.  I presented the idea to the hospital, and it was approved. Next, I approached the St. Louis Metropolitan Police Department. They were familiar with our hospital and staff as we always had a strong working relationship in the past. They enthusiastically supported the idea and agreed to partner with us.

The next step was to form a team and delineate responsibilities. I would be responsible for performing all the acute and follow-up exams as well as providing for all their medical needs. The acute exams would be performed in the ED since it is open 24/7, is fully staffed with nurses, social workers and has the ability to perform laboratory studies and administer any needed treatment. Follow up exams were performed in my clinic. If I was unavailable, one of the ED attendings would perform the acute exam. The ED social workers would perform a cursory forensic interview. They were all trained by the Lead ED Social worker on how to interview a trafficking victim in a non-traumatic manner with a script prepared by the St. Louis Metropolitan Police Department. The Lead ED social worker would interface with Law Enforcement, CPS and any other agencies. Finally, we had a Child Protection Nurse who performed all the follow up duties; checking the labs, arranging appointments and calling to check on the condition of the patient.

Next, I developed a Clinical Practice Guideline. This outlined the assessment and management of suspected victims of trafficking. It was a comprehensive aid and helped health care practitioners every step along the way from recognizing a victim, interviewing them, ensuring their safety, assessment and medical management, obtaining resources &, interfacing with other agencies, safe placement etc. Finally, it guided a healthcare professional on what to do if the patient did not disclose and advised them on how to remain an advocate for the patient informing them they can return to the ED anytime if their situation should change

Our program was successful. Detectives began bringing in victims. They did not act seasoned like criminals but just victimized children. They were not aggressive or angry.  They were quiet, cooperative, almost passive. They welcomed the care and the attention.  Often, they were tired and hungry. Their clothes were worn and dirty. They asked for simple items such as a comb or Vaseline for their lips. We noted other similarities. They were female, young in their early teens, had a prior involvement with Children’s Division, disclosed exchanging sex for money, drug use, being assaulted, prior history of STI’s, and even being involved in criminal activity including selling drugs or carrying weapons for their boyfriends.

In addition to providing medical care, our team served as a resource for education and training of medical personnel and the community. We lectured extensively to doctors, nurses and community groups. We shared our CPG with other institutions and even met with politicians who were interested in enacting legislation to prevent trafficking and aid victims.

Child sex trafficking is a public health crisis. It impacts all communities urban, suburban and rural. While some children are at higher risk, any child can be victimized. As health care professionals, it is our responsibility to advocate for these victims. We must have the knowledge to recognize them, learn how to respond appropriately to their vast medical and social needs and do so in a compassionate manner.  We must establish an environment where the victim feels safe to disclose, be heard and believed so they may seek care on their own. This means hospitals must create a comprehensive program with a multi-disciplinary team to coordinate the care these victims so richly deserve and desperately need.