The Medical Needs of Victims of Commercial Sexual Exploitation
By Sharon W. Cooper, M.D., FAAP
Cancer InCytes Magazine - Volume 3, Issue 2, Winter 2014
Managing Editor: Arvin Gouw, Ph.D.
Commercial sexual exploitation, particularly within the realm of trafficking has become an increasingly recognized form of victimization today. Previously thought to be a voluntary or, when minors are involved, perhaps a delinquent behavior, it is now known that this is often a form of sexual slavery. The extraordinary explosion of information and communication technology has dramatically increased the ease and anonymity of trafficking. With thousands of online classified ads selling women and children for sex, health care providers must be prepared to obtain an accurate history and provide appropriate medical care. There are five areas of health impact which should be addressed in the sex trafficking victim.
General Medical Considerations
The first area of health care to consider is that of malnutrition and chronic infections (1). Victims of sex trafficking are often homeless with a very transient lifestyle. They are frequently moved from one location to another on very short notice, or they may be kept in close quarters with other victims such that they are exposed to respiratory infections, community acquired diseases such as Methicillin resistant infections or mutilations caused by the trafficker’s personal “medical” practitioners. There are often signs of physical abuse and possibly even torture as well as complications of alcohol, substance use, and addictions. Chronic respiratory problems typically from smoking or passive inhalation of smoke can exacerbate pre-existing asthma or become the origin of chronic reactive airway disease. These victims habitually have significant mental health problems, as well as general ill health related to exhaustion, chronic stress, and anxiety (2).
Because childhood adversities often contribute to runaway and/or risk taking behaviors, health care providers should take a careful medical history that include a family history (3). Ideally, when a victim is rescued, provision of a low stress environment with adequate nutrition, rest, and hydration is a very beneficial nonmedical first responder behavior. Promoting a wellness-based self-care plan can potentially fuel resilience in a survivor who is struggling to escape the damaging life forced upon him or her by a trafficker.
Other medical problems include exposure to tuberculosis related to residing with multiple people where drug use is often present. This circumstance can significantly increase the risk of an active infection.
Intimate Partner Violence Impact
Intimate partner violence (IPV) is a second area of medical concern and is one of the most common medical problems that sex trafficking victim’s experience(4). In fact, homicide is the leading cause of death in sex trafficking, usually within the context of IPV (5). The violent offender may be the trafficker, the buyer, or both. This form of victimization consequently is highly associated with endangerment. Domestic violence dynamics are very common in the sex trafficking enterprise, because of the persistent indoctrination of victims to comply with the power and the control of the trafficker. The offender as a “boyfriend or a husband” or the female trafficker as a “lover or a mother” significantly interferes with a victim’s recognition that the violence and exploitation are unwarranted. This complication is worsened by the nearly universal stalking component of IPV seen in sex trafficking victimization. One researcher described this as a “complex interplay of isolation, inhumane treatment, inconsistency, and indoctrination [which results] in a process of brainwashing where members gradually relinquish their own identity and develop robot-like patterns of adaptive behaviors” (6, 7). Of note, the presence of stalking worsens the actual violent acts against women victims. One study comparing battered women who were classified as “relentlessly stalked” to battered women who were “infrequently stalked”, found that the former group reported (6, 8):
More severe and concurrent physical violence, sexual assault, and emotional abuse
Increased post-separation assault and stalking
Increased rates of depression and PTSD and
More extensive use of strategic responses to abuse.
A victim of sex trafficking may present with evidence of acute injury requiring immediate attention, inclusive of fractures, blunt force trauma to the abdomen, or a traumatic brain injury (9, 10). In this circumstance, a victim may present to an emergency room setting with trauma-related injuries. Severe punching, kicking or stomping of the abdomen or chest can result in a ruptured solid organ such as the liver, pancreas or spleen, perforation of the gastrointestinal tract, or a hematoma of the mesentery, which can result in a fatality if there is no history provided of trauma. Since this type of trauma is inflicted on a conscious patient, there may also be spine injuries or renal damage as the victim struggles to avoid further injury. Thoracic injury with rib fractures also presents a potentially fatal outcome. Should a fracture become displaced, this may result in perforation of a lung and a resultant tension pneumothorax.
The medical history is often inaccurate such that complete attention to the multiple medical problems may not occur. As is typically seen in intimate partner violence cases, a history of trauma may be contrived by the victim because of fear of retaliation by the trafficker. Continued follow-up care is needed, though if the trafficking enterprise has not been interrupted, victims will often be intimidated into returning to the offender with further exploitation.
One of the most significant but poorly recognized complications of chronic IPV is that of traumatic brain injury (TBI) (9). This complication usually occurs from direct blunt force trauma to the head. Though not from physical trauma, additional brain dysfunction can be seen from the loss of oxygen to the brain associated with recurrent strangling of a victim to the point of loss of consciousness. Patients with these complications have a higher incidence of recurrent headaches, clumsiness, and cognitive impairment. A percentage of victims may also have a residual seizure disorder. For this reason, a thorough evaluation should include brain imaging and a neuropsychological evaluation to best determine rehabilitative interventions and if a survivor is eligible for disability supplementation (10).
Reproductive Health Impact
Sexual assault is the rule more so than the exception for victims of sex trafficking. The illusion that each sexual contact is consensual and under the control of the trafficked victim is erroneous. Most victims report having experienced numerous episodes of rape by both the trafficker and the buyers (9). The health complications of sexual assault, unprotected sex, and violent offender behaviors are woven into the impact of IPV. However, there are specific injuries associated with violent sexual assault to such an extent that this area requires specific medical attention.
Additional complications more likely to occur in the trafficked sexual assault victim include severe genito-rectal injury secondary to penetration with foreign objects or fists. This often results in deep vaginal lacerations so severe as to even cause evisceration of the pelvic or abdominal organs and potential fatal hemorrhaging. Anal sphincter lacerations and/or rectosigmoid colon perforations are also complications of sexual assault which can be fatal if not recognized in a timely fashion (11).
Sexually transmitted diseases, pelvic inflammatory disease, infertility, unplanned as well as ectopic pregnancies, and complications of recurrent urinary tract infections are among many other reproductive health problems (12). A complete gynecologic examination with nucleic acid amplification tests for GC and Chlamydia, as well as cultures for other STIs, and serological studies for syphilis, and HIV is indicated in this very high risk population. A final concern includes exposure to the human papilloma virus which increases the risk of cervical dysplasia, and a pap smear should be included.
Substance Use and Abuse
The use of alcohol and drugs is relatively common in the sex trafficking population either because use or abuse is encouraged or coerced by the trafficker. This is done in order to maintain control over a victim or because this becomes a form of self-medication by the victim. At times substance use preceded a victim being recruited into sex trafficking and knowledge of this weakness became a tool used by a trafficker (3, 12). Tenets of successful addiction therapy require a realization that addiction is a complex disease and no single treatment is appropriate for everyone. One of the most important components of success is that treatment must be readily available. Effective interventions must address multiple needs of the individual as compared to just the victim’s drug use or abuse. Remaining in treatment for at least 3 months is critical to significantly reduce or stop drug use. But then it should be followed by longer durations of treatment.
Behavioral therapies most commonly include individual, family or group counseling, and medications are often an element of treatment. One size does not fit all and modifications of the treatment plan are to be expected. Surveillance for co-occurring mental health disorders is important and treatment does not need to be voluntary to be effective. Medically-assisted detoxification is only the first stage of addiction treatment and drug use during treatment. It must be monitored continuously as lapses during treatment do occur.
Finally, testing patients for HIV/AIDS, Hepatitis B and C, tuberculosis and other infectious diseases as well as providing targeted risk reduction counseling will render the best outcomes for the sex trafficking victim with addictions (12).
Mental Health Impact
The final area of medical care is that of evaluation and treatment of the multiple mental health disorders associated with sex trafficking victimization. The most common diagnoses are depression, anxiety, and post traumatic stress disorder (PTSD). The rates of PTSD have been significantly higher in this population than that seen in war veterans (9). Various forms of treatment have been used successfully to include trauma-focused cognitive behavioral therapy, eye movement desensitization and reprocessing, dialectical behavioral therapy, and others. When victims report acts of torture however, highly specialized mental health services are indicated because of the risk of causing a dissociative disorder with standard treatments.
The production of pornography is also included as an aspect of sex trafficking. Research has shown that the production of images and videos is a relatively common report by victims (13). At times, pornographic videos are used to extort victims into compliance in conjunction with battering, as well as a means of advertising victims on online classified sites. In some cases videos are sold for commercial movies as additional source of income for the trafficker (13). When sexual assault images are produced and placed online, victims have a higher incidence of guilt, self-blame, shame, and in many cases, non-delusional paranoia that others will be able to view these images well after they may have escaped from the power and control of the trafficker. Victims also report a fearfulness that viewers will look for them, as if they were still available for potential sexual assault.
Treatment must be provided by professionals who are mindful of these numerous issues. There should be no castigation, blaming or negative provider behavior as this reinforces a victim’s feelings of stigmatization and is a barrier to a therapeutic relationship. A successful treatment protocol exists in the program, Breaking Free, located in St. Paul and Minneapolis, Minnesota. The necessary components cited in this treatment program include:
• Cultural sensitivity
• Comprehensive and ongoing medical care;
• Youth Rescue programs to shorten the amount of time that a victim is exploited, as the majority of women who have been victims of sex trafficking were brought in as under-aged minors;
• Case Management to assure that all needs are met and that there is ongoing compliance with interventions;
• Intensive group victim education regarding sex trafficking victimization (10 weeks);
• Intermediate victim education regarding self-esteem, money management and health care (10 weeks);
• Chemical Dependency treatment using medications, behavioral therapies and recognized group support;
• Transitional Housing for up to 2 years;
• Permanent Supportive Housing;
• Life Skills and job training;
• Education as numerous victims had pre-existing poor school performance and early drop-out rates;
• Parenting education to facilitate efforts to regain custody of biological children who were often in kinship or foster care;
Based upon the Breaking Free model, the average period needed to become fully independent and successfully exit the life of sex trafficking is 5-6 years (14). It is clear that the medical care of trafficking victims must address each of the five components briefly outlined in this article. In the minor victim, researchers have stated that this is the most underreported form of child abuse in America (15). For adult victims, sexual slavery is one of the greatest international travesties to date. Health care providers must be part of the solution, and not part of the problem.
Sharon Cooper, M.D., FAAP, is a developmental and forensic pediatrician who evaluates and treats children who have been victims of all forms of abuse, though her area of expertise is that of sexual exploitation. Dr. Cooper holds faculty positions at the University of North Carolina Chapel Hill Department of Pediatrics and the Uniformed Services University of Health Sciences in Bethesda, Maryland. She is a consultant to the National Center for Missing and Exploited Children and has served on numerous boards focused on child maltreatment and exploitation. She is the lead author of one of the most comprehensive text on child sexual exploitation. She is a member of the American Professional Society on the Abuse of Children and its working group which recently published clinical practice guidelines on the medical care of victims of sex trafficking. She actively evaluates victims of all forms of child abuse including sex trafficking and has been qualified as in expert witness in more than 300 court proceedings.
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[12.] United States Department of Health and Human Services Administration, National Institute on Drug Abuse. National Institute of Health Publication NO. 12-4180. (2012). Principles of Drug Addiction Treatment – A Research-Based Guide, 3rd Edition. Accessed at http://www.drugabuse.gov/sites/default/files/podat_1.pdf. Accessed 4 August, 2014.
[13.] Raymond, J., & Hughes, D. (2001). Sex trafficking of women in the United States: International and domestic trends. Coalition Against Trafficking in Women, Accessed at http://www.uri.edu/artsci/wms/hughes/sex_traff_us.pdf Accessed on Aug 4, 2014.
[14.] Carter, V. & Cooper, S.W. Trauma recovery and healing are a lifelong journey in M. Leary, S.W. Cooper, P. Wetterling, D. Broughton (eds). Perspectives on Missing Persons. Durham, NC. Carolina Academic Press (2014). (in press).
[15.] Estes, R.J. & Weiner, N.A. The commercial sexual exploitation of children in the United States In , In S. W. Cooper, Estes RJ, A. P. Giardino, N. D. Kellogg & V. I. Vieth (Eds.), Medical, legal and social science aspects of child sexual exploitation: A comprehensive review of child pornography, child prostitution and internet crimes against children (2005). St. Louis, MO: GW Medical Publishing. pp 95-128.