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TREATMENT
who are involved in HT often have a history of abuse or neglect, homelessness or runaway status, LGBTQ sexual orientation or identity, or involvement with substance use,9 rendering them inherently vulnerable to exploitation.
Under U.S. federal law, HT is considered
to be a severe abuse subject to criminal penalties, and it is criminalized in every state.3 While use of HT as an umbrella term referring to victimization of both adults and nuances exist. For example, among adults where sexual coercion is occurring, there
is a lack of consent; in contrast, children (as minors) legally cannot consent to sex, therefore they cannot be coerced into sex 3 Despite differences in HT irrespective of survivor age violates basic human rights.10,11
BARRIERS TO HT SURVIVOR IDENTIFICATION
There is growing recognition that HT is an urgent public health issue affecting children and adolescents of all ages, genders, and races/ethnicities across the U.S. However, many pediatric survivors go unintentionally under-detected, missed by medical and mental health clinicians, social services, and legal professionals due primarily to limitations in disclosure capacity and diverse presentations across care settings. Inadequate detection of survivors has
unmet needs and failure to provide critical supportive services by multidisciplinary medical and mental health clinicians, social welfare, and legal professional stakeholders. Additionally, under-detection of this diverse population, whose variable risk factors, presentations, and outcomes largely derail the easy establishment of best practices for care.
The capacity of HT survivors to disclose their exploitation may be severely limited. Survivors are unlikely to disclose spontaneously; this is particularly true
for young children10 who may lack
the verbal skills or social maturity to understand their exploitation. Older adolescents may feel shame, guilt, and hopelessness or falsely identify exploitive acts as “consensual.”10 Failure to disclose HT experiences may relate to fear of stability.9 Children and adolescents
their own biological or non-biological caregivers, often in exchange for drugs, contributing to reluctance to disclose
HT. Those seeking medical care during return to an abusive home environment. Moreover, many survivors may not believe they are being exploited at all; adolescent survivors may have little to
no understanding of their rights and may have limited literacy/education, which hinders independent access to resources.12
When survivors seek medical or mental health care, the presentation rarely relates
9
Rather, vague chief complaints such as
back or abdominal pain, weight loss,
fatigue, headaches, or mental or sexual health concerns2 are subject to broad differential diagnoses and evaluation, and HT as an etiology may not be immediately considered. While some common risk factors contributing to HT vulnerability
have been established and include poverty, child welfare involvement, mental health problems, sexual orientation, or even cultural norms,10 population with complex mental and physical health concerns. These include changes in behaviors or school or work performance, depression, self-harm behaviors, posttraumatic stress, sexually transmitted
infections (STIs) or other infectious diseases, pregnancy, physical injury, or history of physical or sexual abuse9 that mimic a host of other medical and mental health conditions. for care with an authoritative companion, requesting testing for pregnancy or STIs (including frequent history of STIs), inconsistent history with presentation, or sexual innuendos during examination.9
Because limitations in disclosure and diverse presentations for care are barriers to recognition, not unsurprisingly, many clinicians endorse needing additional training on how to better identify and care for HT survivors.13 Studies increasingly show that pediatric HT survivors seek medical care frequently across a variety
and suspected child HT survivors, 80% reported seeing a clinician within the
year before detection14 indicating that clinicians are routinely interfacing with HT survivors. Despite the likelihood
of frequent interaction, recent research indicates clinicians are uncertain of next steps when HT is suspected; in one study, only 14% of clinicians reported their concerns to investigative authorities, although more endorsed they would have reported if they were properly trained.10
While this issue is multifactorial, lack
of awareness and education about HT, low comfort level, and cultural/language differences often prevent clinicians from incorporating HT screening questions routinely into their medical histories. resources and disjointed coordination
of community-based services leave vulnerable children and adolescents at risk for continued victimization following discharge from the health care setting.12
Survivors may be hesitant to present for care because of fear of judgment
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