New study shows need for better awareness, training and intervention on sex trafficking in the health system

Victims' agency and needs, independent of their desire to exit trafficking, should be the focus of health care services for individuals who have been sexually exploited, concludes a new study by researchers with McGill University's Ingram School of Nursing (ISoN).

"Unfortunately, we found a lack of awareness on the part of health care professionals and the inability to recognize the signs and symptoms of sex trafficking. This represents a lost opportunity to provide appropriate support, resources and services," says Johane Lorvinsky, RN, MSc(A), one of the study's co-authors and a former graduate student at the ISoN.

Now published in PLOS ONE, the study was conducted in Montreal, Quebec, in conjunction with the directors of "Les Survivantes," a unit within the Service de police de la Ville de Montréal (SPVM) that raises awareness of trafficking while supporting and educating service providers who interact with sex-trafficked individuals.

"This is a very hard-to-reach population," explains Ms. Lorvinsky. With the assistance of Les Survivantes, the researchers contacted 12 sex trafficking survivors who had left their abusers. Of these, seven participated in in-depth interviews that explored their experiences with the Quebec health care system. The goal of the study was to inform future education programs for health care professionals tailored to the complex needs of this underserved population.

Sex traffickers use force to coerce their victims to perform commercial sex acts. "The problem is largely hidden but experts believe that is far more prevalent than the 1,700 police-reported human trafficking cases in Canada from 2009–2018, of which sex trafficking is the largest subset," says Ms. Lorvinsky.

Signs of sex trafficking not recognized by health care professionals

Sexually exploited individuals often experience acute injuries, sexually transmitted infections, untreated anxiety and depression and post-traumatic stress symptoms. Fear of their trafficker, low self-esteem and feelings of shame often prevent victims from disclosing the abuse to health care professionals.

"At the same time, health care professionals often do not suspect these patients may be trapped in situations of sexual exploitation," says Ms. Lorvinsky. Visual cues included marks of physical abuse (e.g., cigarette burns, bruises) and/or sexual abuse, and dress code (e.g., "stripper clothes"). Behavioral clues were more subtle and included being anxious, stressed, fearful, pressed, and constantly texting, while contextual cues included stories inconsistent with injuries.

"Individually, these signs may be insufficient to indicate trafficking, but in combination, they ought to raise alarm," explains Ms. Lorvinsky.

Training on sex trafficking in university curriculums and the workplace recommended

Study participants also noted that the attitudes of health care professionals played a key role in building relationships of trust, which are essential for disclosure of abuse.

"Care was perceived as more impersonal, hasty and perfunctory in hospitals and private walk-in clinics. By contrast, in settings where health care professionals had higher exposure to marginalized groups, such as community care centers and sexual health clinics, they provided non-judgmental, holistic care. Yet, even in these more positive environments, study participants reported that health care professionals who may have suspected abuse or trafficking did not act on their suspicions," says Ms. Lorvinsky.

Complicating matters further, in some cases, sex-trafficked individuals lacked self-awareness of their situation. Once they were able to define their situation as one of sexual exploitation and felt ready to exit sex trafficking, they had no idea how to access resources that could help them to safely leave their abusers. Given these challenges, based on the accounts of study participants, the authors recommend a multifaceted approach for health care providers that includes:

• Identifying personal biases and misconceptions about sex trafficking
• Training on sex trafficking in university curriculums and in the workplace
• Routinely querying psychosocial well-being and assessing for signs of abuse and trafficking
• Developing screening tools to identify victims of sex trafficking
• Creating a catalog of resources to meet the complex needs of survivors
• Establish a network of health care professionals trained in anti-trafficking responses
• Raising public consciousness of sex trafficking through awareness campaigns

"There is definitely a need for more evidence-based research to inform protocol and care delivery for this extremely vulnerable population," concludes Ms. Lorvinsky. Accordingly, the authors suggest that future research should be geared towards the creation and validation of screening tools to identify trafficked individuals as well as best practice intervention guidelines.