Recognizing an exploited child

Some sex traffickers tattoo young victims to mark their "property," using expletives, symbols, or even bar codes.
Some sex traffickers tattoo young victims to mark their "property," using expletives, symbols, or even bar codes. (WLADIMIR BULGAR /

Too many children in shelters and runaways on the street report trading sex for drugs or money, putting them at risk for coercion by sex traffickers.

Posted: September 01, 2014

'Michelle" has been our patient since she was 4. She came in yearly for routine checkups and other minor illnesses. Beginning at age 11, she started to miss appointments, and by 12, she became "lost to follow-up." She made sporadic appearances in our emergency department for respiratory infections, sexually transmitted diseases, and menstrual irregularities.

I met Michelle when she was admitted to a local teaching hospital for recurring severe abdominal pain. Along with STDs, Michelle had a history of drug addiction, irregular menses, and runaway status, and had dropped out of school. I did the math, and it didn't add up: How could a homeless teen with little education get money for drugs? My attending physician stared back at me: "She has admitted to over 100 sexual partners."

The United Nations defines human trafficking as recruiting or harboring someone by threat or deception and controlling them for "exploitation."

The most common age to be coerced or seduced into sex trafficking is 12 to 14 years old, and runaway status is a primary risk factor. While data are scant, a 2006 study found that 10 percent of U.S. children in shelters and 28 percent of children on the streets report trading sex for drugs or money, putting them at risk for trafficking.

This means more than 100,000 American children are at risk each year, according to the U.S. Department of Justice. Social workers, police officers, teachers, and doctors all may interact with these children regularly and not know it. A 2005 U.S. study found that more than a quarter of trafficked victims interacted with health-care practitioners while in captivity.

Michelle said she was introduced to narcotics at age 11 when she received a prescription for codeine during a doctor's visit.

Then came her discovery of street drugs. Michelle stole from family and friends to support her drug habit. One day on the street, a man offered her $40 to perform a sexual act on him. She declined, but kept thinking about the drugs that money would buy, so she relented.

Traffickers use a variety of means to control victims, often mixing affection with threats, alternating jewelry and clothes with starvation, rape, and beatings, and mixing family-style meals with payments in heroin, crack, and other drugs.

An older man took in Michelle when she was 12 and persuaded her to live with him in exchange for sex and drugs. It wasn't long before he was hiring her out to friends.

Michelle described to me the sense of belonging she had with her pimp and the other girls who worked for him. She told me she was "lucky": Her pimp never beat her. She told me about the symbol that was tattooed on her arm while she was unconscious, one she shared with roughly a dozen other girls.

Many traffickers brand their victims to mark their "property." Some traffickers tattoo their own names, some tattoo expletives in the groin or on the neck or breasts, and some use symbols and even bar codes.

Michelle was trafficked for four years. She said it was her 10th drug overdose that persuaded her to leave. "I woke up on the bathroom floor with a bloody nose and blood all over my face. The guy who bought me that night was long gone, just left me there to die. I looked in the mirror, and I had just had it. I wanted my mom."

Physicians are not recognizing these children, partly because they have almost no training, a 2007 article in Academic Emergency Medicine found.

While trafficked children can present as male or female, straight or gay, and of any race or ethnic background, they tend to have a few common characteristics. They may be runaways or from the foster care system or from broken homes. Many are taught by their abusers to avoid eye contact. Thus, they appear "defiant" or "rude" to caregivers. Many are dressed inappropriately for the weather. Some show signs of physical abuse, especially dental, back, or head injuries, or repeated STDs.

Chronic abdominal pain is a common complaint of sexually violated girls. Some will be "branded" with tattoos. Occasionally, a controlling adult who speaks for the child or refuses to leave the exam room will accompany the child to appointments.

It is important for caregivers to treat them as they would any other patient, attending to physical needs, establishing trust, and inquiring sensitively yet directly about the patient's safety, nutrition, and autonomy.

It is critical to avoid the rescue fantasy, especially with older teens: One visit is unlikely to fix everything. At the same time, it is imperative to be up front about physician-mandated reporting and confidentiality.

Above all, doctors should give the patient a reason to return, scheduling a follow-up appointment, getting them plugged into social work resources, and providing written instructions about follow-up. This may be the patient's only legitimate excuse to meet with a caregiver again. Written notes about abuse hotlines and other resources may endanger the patient, whereas the easily memorized 888-3737-888 trafficking hotline phone number can be passed on orally.

Michelle is trying to put her life back together. But resources for kids like her are scant, and the road to recovery is long.

Kanani Titchen is a Jefferson pediatric resident at A.I. duPont/Nemours. To learn more, go to

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