A screening tool designed specifically to assess for human trafficking was more likely to identify sexual and labor exploitation of youth, as well as the risk factors, than a commonly used psychosocial assessment, reported researchers from Baylor College of Medicine and the University of Texas Health Science Center at Houston (UTHealth).

Participants for the study were recruited from Covenant House Texas, the largest shelter in Houston for homeless youth and young adults. Results were recently published in the International Journal of Environmental Research and Public Health.

According to the United Nations Office on Drugs and Crime, Texas has the second-highest number of cases of human trafficking after California. A 2016 report by the Statewide Human Trafficking Mapping Project of Texas estimated that 313,000 people were experiencing human trafficking, including 79,000 minors and youth experiencing sex trafficking.

“An important part of this project was to have a screening process in place at Covenant House going forward to benefit the residents,” said first author Dr. Salina Mostajabian, an adolescent medicine fellow in the Department of Pediatrics at Baylor when the study was conducted. “Having a standard tool will maximize the likelihood of identifying victims and getting them the needed resources.”

Covenant House offers onsite psychiatry and psychology services provided by Baylor and employs a full-time mental health counselor and other mental health and trauma-informed care services to help meet the needs of these youth.

“This study emphasizes the need for healthcare providers to recognize how difficult it can be for youth who have been trafficked to open up to providers,” said co-author Dr. Claire Bocchini, assistant professor of pediatrics at Baylor and faculty member of the Texas Children’s Hospital Center for Child Health Policy and Advocacy. “Providers need to be trained on the importance of using a trafficking-specific screening tool to maximize the opportunity to identify trafficking survivors. We also have to offer the most supportive and accepting atmosphere as possible to help overcome mistrust in the healthcare system and optimize acceptance of resources.”

Bocchini, who has helped develop curricula on human trafficking for healthcare providers, and Mostajabian conducted focus groups with youth who completed the screening tool. Those sessions provided insight into the barriers that youth experience in being identified as victims, as well as in accessing services that could help them find safety and treatment. Youth reported mistrust of the system, fear of involving law enforcement, not wanting to interact with the mental health system, and stigma as barriers to disclosure.

"Identifying trafficking victims is a challenging process due to many factors, including extreme trauma and mistrust. This new screening tool will allow healthcare and social services providers to quickly identify and provide life-changing services to homeless young adults who have been victims of labor and sex trafficking," said Leslie Bourne, executive director of Covenant House Texas.

Groups identified as most at risk for trafficking include youth involved in the foster care or juvenile justice systems, those who experienced abuse, youth who run away from home and those who are unstably housed or homeless.

The study, which included 121 shelter residents ages 18 to 21, reported that 44 percent of youth in the study had been arrested at some point, with a third of those arrested as a child; 35 percent had a history of foster care; 71 percent had been kicked out of their homes; and 45 percent had run away from home. Of those who had run away, abuse was cited as the reason in 65 percent. Of those abused, 71 percent reported physical abuse; 80 percent reported emotional or verbal abuse; and 14 percent reported sexual abuse.

The sex trafficking screening tool asked specific questions about trade sex, and based on the data, 22 percent reported they had traded sex for food, clothing, money, shelter, favors or other necessities for survival. Of those, 70 percent were minors (under age 18) the first time they traded sex. Commercial sexual exploitation was more likely to be identified by the new tool than the standard psychosocial assessment.

“The new assessment tool was much more effective at finding exploitation. It is important for providers working with high-risk groups to add these questions specific to trafficking,” said corresponding author Dr. Diane M. Santa Maria, interim dean and Dorothy T. Nicholson, distinguished professor at Cizik School of Nursing at UTHealth. Identifying them allows these youth to access services that they otherwise wouldn’t receive. You can’t help someone you don’t know about.”

“We found that the entry into trafficking also happens through family, friends and acquaintances. This was extremely eye-opening and needs to be explored,” Santa Maria said. “These are kids who have fallen through every crack society has. When these youth are in desperate need of food and shelter, the vulnerability for trafficking is tremendous.”

Sexual history details from medical reports revealed that 19 percent reported more than 10 sexual partners in their lifetime, 29 percent had a prior history of a sexually transmitted infection, 2 percent were HIV-positive and only 64 percent reported any condom use.

“There’s difficulty in untangling what’s happening. Is it sexual abuse or sexual abuse and human trafficking? We want providers to be asking the right questions,” Santa Maria said.

The study also uncovered a link between homelessness and mental health issues in youth. According to the results, 53 percent had a recorded psychiatric diagnosis and more than half of those had more than one diagnosis. Half (49 percent) of the psychiatric diagnoses were for depression, more than half (59 percent) had a history of psychiatric hospitalization, and more than a third (42 percent) had at least one suicide attempt. More than half of all the participants, 54 percent, had used cannabis or synthetic cannabis; and 17 percent had polysubstance abuse in the past.

Half of the participants in the study had stayed on the streets in the past month; 29 percent had been in treatment centers, shelters, or detention facilities; and 19 percent reported spending most nights in parks, tents, cars, or abandoned buildings.

“These youth are very resilient survivors,” said Santa Maria. “We want providers to identify young people and then we need a coordinated response to meet their mental health, healthcare and social services needs so they can move forward.”

Dr. Connie Wiemann, director of research for the Section of Adolescent Medicine in the Department of Pediatrics at Baylor, and Dr. Elizabeth Newlin, vice chair for adolescent psychiatry at McGovern Medical School at UTHealth, also contributed to this project.

Mostajabian was principal investigator on a grant from Texas Pediatric Society Foundation that helped fund the study. She currently is a practicing adolescent medicine physician at a nonprofit adolescent health clinic in Austin.