Content uploaded by Lara Gerassi
Author content
All content in this area was uploaded by Lara Gerassi on Mar 30, 2021
Content may be subject to copyright.
‘Have you ever traded sex for money or drugs?’ Health care providers’ perspectives on sex trafficking risk assessments in clinics
Abstract
Objective
The United States’ Institute of Medicine recommends that health care providers be aware of sex trafficking (ST) indicators and conduct risk assessments to identify people at risk. However, the challenges among those who conduct such assessments remain largely understudied. The aim of this study was to understand the perceived barriers to ST risk assessment among health care providers in a large health care organization.
Methods
This study used a collective case study approach in five sites of a large health care organization that serves high-risk populations in a Midwestern state. Twenty-three in-depth, semi-structured interviews were conducted with health care staff (e.g. medical assistants, nurse practitioners). Two research team members conducted independent deductive coding (e.g. knowledge of ST), and inductive coding to analyse emerging themes (e.g. responses to ST risk or commercial sex disclosures, provider role ambiguity).
Results
Although staff routinely screened by asking ‘Have you ever traded sex for money or drugs?’, participants primarily described avoiding further discussions of ST with adult patients because they (1) aimed to be non-judgmental, (2) viewed following up as someone else’s job, and/or (3) lacked confidence to address ST concerns themselves, particularly when differentiating sex work from ST. Differences all emerged based on clinical context (e.g. urban location).
Conclusions
There may be missed opportunities to assess patients for ST risk and use harm-reduction strategies or safety plan to address patients’ needs. Implications for practice, policy, and future research are discussed.
... A set of studies explored professionals' awareness, perceptions, knowledge, and feelings about human trafficking for sexual exploitation (Breuil et al., 2011;Fehrenbacher et al., 2020;Gerassi & Pederson, 2021;Kuosmanen & Starke, 2011;Ruiz-Gonzalez et al., 2022;Tidball et al., 2016). Through a phenomenological approach, Tidball et al. (2016) studied the awareness, knowledge, and perceptions of NGO representatives, law enforcement officials, and public officers and found that most professionals were aware of human trafficking, although a minority admitted only having a basic knowledge of it. ...
... Knowledge of some cases of women with ID selling or exchanging sexual services for Authors/year Contents Outcomes some kind of payment seems to depend more on the type of organization (target grouporiented vs. general agencies) than on the specific work tasks or position of the professionals Professionals identify the need of recognition of the problem Knowledge of the places where sexual contacts take place (e.g., streets, hotels, internet) Professionals perceive three motives for selling or exchanging sexual services among women with ID: to create relationships and to gain affirmation; in exchange for products and goods or to change their living conditions; to obtain money Participants know the difference between engaging in sexual services out of one's free will or exploitation and express their concern over the vulnerability of the individuals with ID Professionals perceived as problematic the line between which is self-chosen and being exploited Liang (2023 The sexual services provided by children and teenagers are interpreted as a key feature of local port economies, sawmills, and local bars (e.g., a way of attracting customers to food and alcohol outlets) Image of the children and teenagers as symbols of pleasure and cleanliness The girls and young women are perceived as 'safer' and more 'fit for consumption', since the recruitment is made by family/kinship networks (continued on next page) perceived as judgmental; stigma; language or lack of documentation; law enforcement filtering of trafficking victims and the over-policing in trans communities as well as distinct international and national legal definitions and conceptions of human trafficking its victims and perpetrator (Breuil et al., 2011;Fehrenbacher et al., 2020;Fukushima et al., 2020;Gerassi & Pederson, 2021;Ruiz-Gonzalez et al., 2022). In opposition to these conclusions, the research article by Nguyen and Le (2021) suggests that policemen have high levels of knowledge and differ partly from the image of stereotypical trafficking victims. ...
... The relationship between sex trafficking, its impact on victims' health and the role of healthcare professionals has been studied by different researchers over the years (Chisolm-Straker et al., 2016;Gibbons & Stoklosa, 2016;Le et al., 2018;Lederer & Wetzel, 2014;McDow & Dols, 2021). Researchers have attempted to reveal both the perspectives of those directly involved in this type of violence and their perceptions of the care they receive from medical personnel (Baldwin et al., 2011;Bick et al., 2017;Westwood et al., 2016), as well as the experiences of both healthcare and other professionals with trafficking and the practical approach they take to address it (Beck et al., 2015;Gerassi & Pederson, 2021;Testa, 2020). ...
... As some studies show, factors linked to the victim and their environment, such as fear of retaliation by traffickers or the continued control imposed on them, delay access to health services or distort the real reasons why care is being sought(Rajaram & Tidball, 2018;Ravi et al., 2017;Westwood et al., 2016). In addition, the healthcare system and healthcare providers play a major role in the incorrect identification of victims as well as delays in adopting control measures(Gerassi & Pederson, 2021;Tracy & MacIas-Konstantopoulos, 2017). Participants in several studies have recognized and linked this problem to the limited train- ...
Aim: To explore the perceptions and experiences of midwives in the treatment of sex trafficking victims.
Design: The study was qualitative with a hermeneutic-phenomenological approach, using semi-structured interviews and focus groups.
Methods: Two focus groups and six interviews were carried out on fourteen midwives in primary care, delivery and emergency rooms. Data was collected in three hospitals in Spain in June 2021. ATLAS.ti 9 software was used to conduct a content analysis of the focus group and interview data.
Results: The results revealed two primary themes and six subthemes. The two primary themes were (i) sex trafficking: a camouflaged reality on the invisible spectrum, and (ii) a thirst for attention in the aftermath of violence. Representative quotations were used to illustrate both the main themes and the subthemes.
Conclusions: This study provides new insight into midwives’ experiences treating sex trafficking victims. Professionals view this type of violence as a silent issue that negatively impacts victims’ health and livelihood. However, a number of different factors stand in the way of correctly identifying and treating victims. Therefore, healthcare workers must be provided with practical tools and continuous professional development on this topic.
Impact: This study indicates the importance of the midwives’ key role in identifying and assisting victims of sex. Not only do measures in the healthcare setting, such as on-going specific-related content training or up-to-date protocols, need to be implemented to ensure proper care for those affected by sexual exploitation, but focusing on suspicious characteristics and reducing obstacles to patient communication will help bring the true situation to light and better respond to patients’ priority needs.
... Health care providers' perspectives on sex trafficking risk assessments in clinics,' Lara Gerassi and Anna Pederson share their findings about how health care providers made decisions about screening for sex trafficking (ST) among adult patients. 1 Table 2 in the article provides strategies for assessment. The authors report that clinicians indicated some confusion about three main factors: (1) how to differentiate between consensual and trafficked commercial sex, (2) questions around balancing safety planning with patient choice, and (3) concern around offering support and inquiry about trafficking in respectful ways. ...
... 1 Table 2 in the article provides strategies for assessment. The authors report that clinicians indicated some confusion about three main factors: (1) how to differentiate between consensual and trafficked commercial sex, (2) questions around balancing safety planning with patient choice, and (3) concern around offering support and inquiry about trafficking in respectful ways. The first of these interrelated concerns points to broader ideological discourse within the human trafficking movement, and the latter two point to the value of protocols and frameworks that create the conditions for trust and empathy. ...
Aims
The aims of this study were to (1) explore the barriers and challenges of sex trafficking identification and (2) understand how sex trafficking indicators are perceived (i.e. relevance and utility) by healthcare providers at five sites of a large sexual health care organization in a Midwestern state within the United States.
Design
A qualitative, collective case study was conducted.
Method
In-depth, semi-structured interviews were conducted with 23 healthcare staff (e.g. medical assistants, nurse practitioners) who provided sexual and reproductive healthcare between fall 2018 and spring 2020.
Results
Findings suggest that providers perceived behavioural and verbal sex trafficking indicators (e.g. patients appearing nervous or being unable to answer questions) as relevant, particularly with a female patient accompanied by a ‘controlling’ male. Medical and physical indicators (e.g. repeat STIs, bruises and tattoos) were perceived as generally lacking clinical utility or irrelevant. Some indicators were only perceived as relevant when combined or only later, upon reflection (e.g. older, female adult accompanying one or more female patients).
Conclusion
Healthcare providers may be aware of sex trafficking indicators conducive to identifying female patients, in relationships with older men, who are at risk of sex trafficking. Our study finds that healthcare providers may not be aware of all recommended sex trafficking indicators and the nuances of how patients present.
Impact
Provider trainings on sex trafficking dynamics and nuanced clinical presentations should include observing ST indicators in simulated interviews, assessing and safety planning (including using harm reduction strategies) with seemingly ambiguous cases. In addition, we recommend that trainings emphasize the relationship between the continuum of agency and victimization in sex trafficking and patient presentations.
Motivational interviewing is an evidence-based practice designed to collaboratively strengthen a person’s commitment to change. Used in a wide variety of practice settings, motivational interviewing is recommended for use with individuals who are at risk of sex trafficking when discussing sex trading or relationships with potential traffickers. However, little is known about the uses of motivational interviewing with this population in practice. The current study examined whether and how social workers who encounter individuals at risk of sex trafficking use motivational interviewing. We explored perceptions of motivational interviewing use, applicability, and engagement practices by conducting in-depth, semi-structured interviews with 24 hour service providers in a Midwest region.
Findings
Practitioners discussed a wide variety of perceptions of motivational interviewing, ranging from completely unfamiliar, to inapplicable to their service population, to favoring its use. Those who did implement motivational interviewing described challenges to engagement with this population and provided examples in which they did not validate the clients’ perceived benefits of situations that enhanced their risk, a principal tenant of motivational interviewing. Such actions may have contributed to practitioner-client discord and ultimately reduced clients’ engagement.
Applications
Providers who encounter sex trafficking in practice should be trained in the use of motivational interviewing and applicability, specifically regarding how to validate the client’s internal arguments for and against sex trading and related behaviors. Future research should continue to understand whether and how motivational interviewing can be adapted for transient populations, and continue testing the efficacy of motivational interviewing with these populations.
Despite an increase in knowledge about human trafficking, little is understood about interpersonal power dynamics between traffickers and their victims; particularly in relation to coercion. Understanding victims’ perceptions of power is critical to developing trauma informed, targeted services for prevention, intervention, and aftercare services for survivors. This paper explores human trafficking victims’ (n = 31; adult, female, international) perceptions of traffickers’ interpersonal social power as influenced by prior entrapment factors and traffickers’ characteristics during the controlling period of the exploitation, the “maintenance phase”. Findings from this study reveal that entrapment factors and shared characteristics between victims and traffickers influenced perceptions of specific kinds of power. Moreover, findings suggest that more investigation is need to explore how much influence dynamics outside of the trafficking relationship (i.e., social and environmental factors) have on victims’ perceptions of traffickers’ power. Further, results suggest a need for anti-trafficking professionals to be particularly cognizant that victims may perceive individuals in positions of power such as social service providers and law enforcement, as similar to their traffickers.
Study objective:
Because of the high reproductive health risks that commercially sexually exploited youth (CSEY) face, we sought to understand facilitators and barriers related to their use of condoms and hormonal contraception. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted semistructured interviews with 21 female CSEY. Interviews were audio-recorded, transcribed, and coded for emergent themes. Participants were enrolled through group homes and a juvenile specialty court serving CSEY.
Results:
Overall, CSEY reported relatively easy access to hormonal contraception and condoms, expressing a strong preference for condoms as their primary form of contraception. Most respondents described an aversion toward hormonal birth control, attributed to personal experiences and peer accounts of side effects. Many also shared a common belief that hormonal methods are "unnatural," cause infertility, and have low efficacy. Although youth expressed a preference for condom use, they also reported frequent unprotected sex. Furthermore, there were notable barriers to hormonal contraception and condom use that were specific to youths' sexual exploitation, primarily because of their lack of control while trafficked.
Conclusion:
Although participants noted relatively easy access to contraception, a number of barriers to condom and hormonal contraceptive use exist. Many of these barriers align with youth identified in other at-risk adolescent populations, however, CSEY also face a number of barriers that might be attributable to their unique experience of commercial sexual exploitation. Contraceptive education that dispels prevailing myths, sets clear expectations regarding side effects, and emphasizes autonomy is most likely to resonate with their world view and experiences.
Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.
It is estimated that 21 million people are trafficked worldwide, including 11.4 million women and girls. Approximately 4.5 million are forced to do sexual labor. The exact prevalence of human trafficking is difficult to ascertain, however, given the limitations of data collection in an illegal industry. Obstetrician-gynecologists should not only be aware of the widespread nature of human trafficking, but also have the tools to assess patients for trafficking and respond to victim identifications. Patients may present with signs of physical abuse, depression, anxiety, posttraumatic stress disorder, substance use, sexually transmitted infections, pregnancy, and nonspecific somatic complaints. As with intimate partner violence, clinicians should be suspicious if the patient is accompanied by an individual who refuses to leave her side. Other potential red flags include patients with wounds in various stages of healing, patients appearing fearful or unable to answer specific questions, and patients who do not have any personal identification. Health care providers should speak with the patient privately, using professional interpreters when indicated. Although there are no validated screening questions for the health care setting, in this article, we provide sample questions such as, "Is anyone forcing you to do anything physically or sexually that you do not want to do?" The physical examination should be thorough with appropriate workup, sexually transmitted infection prophylaxis, and emergency contraception. Physicians and patients should be aware of their state's mandatory reporting requirements and careful documentation is essential. Finally, to ensure a comprehensive, interdisciplinary response to trafficked patients, practitioners should engage hospital-based and community-based services when appropriate.