Nursing position article

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Position ARTICLE , also known as a White ARTICLE, is a tool to educate and inform the public on a specific health issue. This authoritative document takes a specific position or recommends a specific approach to solving an identified problem. Choose a White ARTICLE  (THE WHITE ARTICLE IS ATTACHED AS A PDF USE THE TOPIC THAT I PROVIDED)

In this discussion, evaluate the White ARTICLE and consider the quality and source of the message should include:  

·  an overview of the White ARTICLE selected and how it relates to a health care policy effort of interest to the master’s prepared nurse (IMPORTANT YOU MUST TALK ABOUT THIS ) – include its’ source and purpose 

·  how the chosen White ARTICLE can advance current health systems, practice, and/or organizations to improve health outcomes

·  the selected White ARTICLE impact on economic, legal, and/or regulatory processes


The ASSIGMENT must be done with the document attached which is the WHITE TOPIC OF MY CHOICE








J Pe






ARTICLE Professional Issues

White Paper: Recognizing

Child Trafficking as a Critical
Emerging Health Threat

Mikki Meadows-Oliver, PhD, MPH, PNP-BC, RN, FAAN,
Stacia M. Hays, DNP, APRN, CPNP-PC, CNE, &
Dawn Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN

Human trafficking is a pandemic human rights violation with an
emerging paradigm shift that reframes an issue traditionally seen
through a criminal justice lens to that of a public health crisis, par-
ticularly for children. Children and adolescents who are trafficked
or are at risk for trafficking should receive evidence-based,
trauma-informed, and culturally responsive care from trained
health care providers (HCPs). The purpose of this article was to
engage and equip pediatric HCPs to respond effectively to human
trafficking in the clinical setting, improving health outcomes for
affected and at-risk children. Pediatric HCPs are ideally posi-
tioned to intervene and advocate for children with health dispar-
ities and vulnerability to trafficking in a broad spectrum of care
settings and to optimize equitable health outcomes. J Pediatr
Health Care. (2021) 35, 260−269

ica L. Peck, Clinical Professor of Nursing, Louise Herrington
ool of Nursing, Baylor University, Friendswood, TX.

i Meadows-Oliver, Associate Professor of Nursing,
nipiac University, Hamden, CT.

ia M. Hays, Clinical Assistant Professor, University of Florida,
esville, FL.

n Garzon Maaks, Clinical Professor, University of Portland,
land, OR.

flicts of interest: None to report.

espondence: Jessica L. Peck, DNP, APRN, CPNP-PC, CNE,
, FAANP, Louise Herrington School of Nursing, Baylor
ersity, 233 Mesquite Falls Lane, Friendswood, TX 77546;
ail: [email protected]
diatr Health Care. (2021) 35, 260-269


yright © 2020 by the National Association of Pediatric Nurse
titioners. Published by Elsevier Inc. All rights reserved.

lished online March 13, 2020.


Volume 35 � Number 3

Human trafficking, sex trafficking, labor trafficking, child traffick-
ing, pediatric nurse

Human trafficking (HT) is a pandemic human rights violation
(Scannell et al., 2018) with an emerging paradigm shift
reframing an issue traditionally seen through a criminal justice
lens to that of a public health crisis, particularly for children
(Greenbaum et al., 2018; Speck et al., 2018). Globally, it is
estimated that eight million children and youth are trafficked
annually, 5.7 million for labor and another 1.8 million for sex
(Reid et al., 2018). The International Labour Organization
estimates one in four of the 21 million worldwide victims of
forced labor are children (International Labour Organization,
2018). The United Nations Office on Drugs and Crime
found that children comprise 33% of 40,000 identified
victims of trafficking (Greenbaum & Brodrick, 2017). HT is a
growing problem in the criminal industry with estimates of
more than 40 million people currently victimized worldwide
(Gordon, Fang, Coverdale, & Nguyen, 2018). The number of
HT victims in the United States is unclear, although Polaris
(2018a) estimates the total number of victims easily ascends
into the hundreds of thousands when including both adult
and child sex and labor trafficking victims. Over the past
decade, the National Human Trafficking Resource Center
(National Human Trafficking Resource Center, 2019) reported
more than 40,000 cases of domestic HT with the majority
originating in California, Texas, Florida, Ohio, and New York
(Joint Commission, 2018). Women and girls account for up to
99% of victims in the sex trafficking industry and 58% of vic-
tims in other categories, including forced labor (International
Labour Organization, 2018; Owens et al., 2014).

Child trafficking (CT; with the term CT encompassing
both labor and sex trafficking) is both underreported and
understudied. In a recent literature review, a mere 9.7%
of over 22,000 articles reviewed specifically addressed

Journal of Pediatric Health Care�

CT (Sweileh, 2018). Accurately collected estimates of CT
incidence and prevalence do not exist, partly because of the
illicit nature of trafficking, underreporting of victims, and
absence of both standardized terms and a consolidated com-
mon database. Existing evidence reports potential victims of
CT present in all health care environments, creating an oppor-
tunity for pediatric health care providers (HCPs) to act as first
responders in prevention efforts, victim identification, and
treatment referral (Polaris, 2018b; Sinha, Tashakor, & Pinto,
2019). The Joint Commission issued a Quick Safety bulletin
in June 2018, urging health care environments to identify
potential victims of HT (Joint Commission, 2018). Although
well-designed evidence-based CT education has an important
role in effectively equipping clinicians, awareness among
HCPs remains low (Barron, Moore, Baird, & Goldberg,
2019; Sprang & Cole, 2018; Donahue, Schwien, & LaVallee,
2019; Fraley, Aronowitz, & Jones, 2018; Katsanis et al., 2019;
Lutz, 2018; Recknor & Chisolm-Straker, 2018; Sinha et al.,
2019; Viergever, West, Borland, & Zimmerman, 2015). Mis-
conceptions regarding the nature and scope of trafficking
persist and impede efforts to improve outcomes. Although
the United States is one of the most significant locations for
CT victims (Joint Commission, 2018), many U.S. HCPs mis-
takenly believe that trafficking mainly occurs internationally
and rarely affects U.S. residents, although most of those
affected in the United States are American citizens and not
foreign nationals (Viergever et al., 2015). Most notably, up to
88% of child and adult victims encounter at least one HCP
without being identified as trafficked (Greenbaum et al.,
2018; Reid, Baglivia, Piquero, Greenwald, & Epps, 2018).
Child victims present in a variety of clinical environments, but
most HCPs do not receive adequate training on identification
or referral services appropriate to the pediatric population
(Greenbaum et al., 2018; US Department of Health and
Human Services [USDHHS], 2019).

Children and adolescents who are trafficked or are at risk
for trafficking should receive evidence-based, trauma-
informed, and culturally responsive care. The purpose of this
article was to engage and equip pediatric HCPs to effectively
respond to CT in the clinical setting as a critical effort to
improve health outcomes for affected and at-risk children.

CT is an illicit enterprise, making accurate analysis difficult
because there are few uniform mechanisms for data collection.
In particular, sex trafficking is often hidden and difficult to
detect (Rajaram & Tidball, 2018). Moreover, affected children
and adolescents often do not self-identify as victims or may
not seek services for fear of criminal prosecution, deportation,
stigmatization, and/or blame. Many consider victim identi-
fication as the “tip of the iceberg,” and some argue that
lack of attention to CT creates an environment that allows
traffickers to evade criminal detection and prosecution
(Rajaram & Tidball, 2018).

The Victims of Trafficking and Violence Protection Act,
now referred to as the Trafficking Victims Protection Act,
was established in 2000, defining HT at the federal level for

the first time. Child sex trafficking (CST), also known as com-
mercial sexual exploitation of a child or domestic minor sex
trafficking, involves youth under the age of 18 years who are
obtained, harbored, transported, advertised, recruited, soli-
cited, or enticed to engage in commercial sexual exploitation
(e.g., exotic dancing, massage parlors, escort services, pornog-
raphy production, prostitution, pornography, or any other
sex-related work) for some form of payment, either in money
or goods. It is important to note that this includes all types of
commercial sex work for victims under the age of 18 years,
even in the absence of force, fraud, or coercion, which are
elements required for prosecution in adult victims (USDS,
2019). Contrary to common misconceptions, not all children
in CST entered through stranger coercion or abduction.
Sprang & Cole (2018) found that approximately 31% of child
victims were subjected to sexual acts, and 25% of children
engaged in pornography related to family member coercion,
typically involving selling the child for money, drugs, food,
shelter, or something else of value. Child labor trafficking
(CLT) involves forcing a child into labor acts through physical
or psychological threats or debt bondage. Service, domestic (i.
e., hospitality industries, such as hotels), and agricultural
industries are most likely to involve CLT (Reid et al., 2018).

Emerging research forms a consensus of commonly identified
risk factors (Table 1). The varied nature of CST and CLT make
the creation of a singular risk profile difficult (Reid et al.,
2018); therefore, pediatric HCPs should know individual risk
categories and include these in the routine assessment of youth.
This information is particularly relevant to pediatric HCPs
because many victims enter trafficking during adolescence. In
a survey of 913 survivors of CST and CLT from Florida state
records, Reid et al. (2018) found 47% entered trafficking at the
age of 13−14 years, 15% entered at the age of 15 years, and
29% entered at the age of 12 years or younger.

Although some risk factors of CST and CLToverlap, other
risk factors are more distinct. The most significant risk factor
for CST is childhood trauma, especially experiencing sexual
abuse (Choi, 2015; Reid et al., 2018). The longer or more fre-
quent the abuse, abuse perpetrated by father figures, co-exist-
ing emotional or physical abuse, and penetrative sexual abuse
confer the greatest risk (Choi, 2015). The actual reasons for
these connections remain speculated; however, it is believed
that neurologic changes from toxic stress, damage to interper-
sonal skills caused by abuse, and emotional numbing that fre-
quently occurs after abuse provide susceptibility to CST and/
or CLT (Choi, 2015). The landmark Adverse Childhood
Experiences (ACEs) study of more than 17,000 subjects
(Centers for Disease Control [CDC], 2019) examined catego-
ries of abuse, neglect, and household dysfunction experienced
before the age of 18 years. ACEs are associated with down-
stream health consequences occurring over the life span,
including the adoption of health-averse behaviors, disrupted
neurodevelopment, cognitive impairment, chronic disease
burden, disability, and premature death. Higher ACE scores
reveal a graded dose-response risk for adverse health

May/June 2021 261

TABLE 1. Risk factors for child trafficking

Individual Relational Community or societal

Age: early to middle adolescence Parental substance abuse Social isolation or bullying
Runaway status Parental abuse or neglect Sexualization of children
Identification as LGBTQI Family conflict, disruption, or dysfunction Indigenous or first nations children
Foster care placement Forced out of their homes by family members Recent immigration or migration
Juvenile justice system involvement Family domestic violence Gang involvement
Substance abuse or misuse Single-parent families Children from impoverished communities
Mental illness Children with a deceased parent Underserved neighborhoods and communities
High ACE score Underresourced schools
Survivors of abuse or neglect Lack of awareness of CT
Intellectual and other disabilities Lack of available resources to respond to CT
Immigrant or refugee status

Note. ACE, adverse childhood events; CT, child trafficking; LGBTQI, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and
Source: Choi, 2015; Niegarten, 2018; Reid et al., 2018; United States Department of State, 2019.

outcomes and should be considered when encountering a
child at risk for trafficking.

Gender is also a particular CST risk factor because female
survivors outnumber male survivors; however, people of all
genders and sexual orientations are sexually trafficked. Youth
who identify as lesbian, gay, bisexual, transgender, queer, or
intersex (LGBTQI) have a higher risk of CST than their
heterosexual peers (Choi, 2015). Because child survivors of
maltreatment are more likely to run away, they may have a
compounded risk because homeless youth and runaway
youth are at a significant risk for a trafficking experience
(Chisolm-Straker, Sze, Einbond, White, & Stoklosa, 2019)
because of shelter, food, and resource insecurity. It is esti-
mated that the United States has one to almost three mil-
lion homeless youth. Approximately 20% of U.S. teens run
away from home at some point during adolescence. Of
these, one-third are recruited into CST within days, and
almost 90% are sexually exploited within 3 months (Nier-
garten, 2018). Although youth substance abuse and mental
illness are known risk factors for CST, it is unclear whether
these conditions occurred before trafficking or are the
result of surviving trafficking (Choi, 2015).

Environmental influences on the likelihood of CST
and/or CLT include single-parent families, poor family
interpersonal relations, dysfunctional family systems,
unsafe or insecure living conditions, placement in foster
care or juvenile justice, and significant financial insecurity
(Choi, 2015; Niegarten, 2018; Zimmerman, Hossain, &
Watts, 2011). These circumstances make children more
vulnerable to sexual grooming lured by money, a feeling of
being loved, or having somewhere “safe” to go. In addi-
tion, financial insecurity and unsafe living conditions may
result in parental decisions to offer them for domestic
labor, making the children vulnerable to debt bondage
(Toney-Butler & Mittel, 2019).

Trafficking adversely affects physical, social, mental, emo-
tional, psychological, and spiritual health. Acute and chronic

262 Volume 35 � Number 3

headaches are among the most frequently reported physical
conditions experienced by victims of HT (Hemmings et al.,
2016; Oram et al., 2016; Oram, St€ockl, Busza, Howard, &
Zimmerman, 2012; Le, 2018). Fatigue and dizziness are also
common (Hemmings et al., 2016; Oram et al., 2016; Zim-
merman et al., 2011). Additional complaints include mem-
ory problems, acute or chronic pain (especially headaches,
backaches, and abdominal pain), and sleep disturbances
(Hemmings et al., 2016; Oram et al., 2012; Oram et al.,
2016; Le, 2018; Zimmerman et al., 2011). Other physical
signs include unexplained or repeated traumatic injuries,
such as bruising, fractures, ligature marks, and/or cuts. Vic-
tims may experience frequent exposure to infectious dis-
eases, including tuberculosis and vaccine-preventable illness
(Richards, 2014). Because of preventive care neglect, victims
may experience long-term dental or oral health problems
resulting in dental pain (Oram et al., 2012; Le, 2018) from
trauma or injuries to the mouth sustained during physical
and sexual abuse (Zimmerman et al., 2011). Victims of
CST often experience sexual and reproductive health prob-
lems from sexual violence and unsafe sex practices including
urinary tract infections, pelvic inflammatory disease, and
unplanned pregnancy (Hemmings et al., 2016; Zimmerman
et al., 2011). Sexually transmitted infections, including hep-
atitis B or C and HIV, are among the most common sexual
health issues reported (Cannon, Arcara, Graham, & Macy,
2018; Oram et al., 2016; Le, 2018; Zimmerman et al.,
2011). Forced and unsafe abortions may occur (Richards,
2014). Similar to victims of CLT, those who experience
CST may endure inhumane working and living conditions.

Victims of CLT work long hours with little rest and may
be exposed to pesticides and other hazardous chemicals.
Children are at risk for physical injury if they lack protective
gear or operate machinery without proper training or oversight
(Cannon et al., 2018; Ronda-Perez & Moen, 2017; Zimmer-
man et al., 2011). Victims of CLT may develop musculoskeletal
issues from repetitive motions and limb injuries. Children may
work in extreme weather conditions and develop skin infec-
tions from being exposed to poor sanitation and bacterial

Journal of Pediatric Health Care�

hazards (Cannon et al., 2018) and injury (e.g., limb amputa-
tions). Child victims often live in overcrowded, unclean condi-
tions where they are further exposed to communicable
diseases (Zimmerman et al., 2011). Sexual abuse may occur
during labor trafficking (Cannon et al., 2018).

CT victims experience repetitive traumatic events that
result in cumulative psychological harm. The most common
mental health conditions reported include anxiety, depression,
post-traumatic stress disorder, and suicidal ideation (Hem-
mings et al., 2016; Oram et al., 2016; Le, 2018; Richards,
2014; Zimmerman et al., 2011). In addition, substance abuse
or misuse may occur because of forced or coerced use of sub-
stances (Zimmerman et al., 2011).

It is estimated that 88% of victims access health care services
sometime during their exploitation (Greenbaum et al., 2018;
Reid et al., 2018). Since 2016, 14 states have enacted legisla-
tion addressing health professional education about HT
(Atkinson, Curnin, & Hanson, 2016). Recent studies have
demonstrated the inadequacy of identification and health care
services of CT victims. The variability of each trafficking
experience adds to the difficulty of recognizing victimization
(Fedina, Williamson, & Perdue, 2019). HCPs are critical to
identifying children at high risk for trafficking and offering
timely, comprehensive, and multidisciplinary services.

Victims commonly present with a variety of behavioral clues
that should raise CT suspicion. Often, illness or injury history is
inconsistent with physical findings. The presence of a control-
ling accompanying adult who does not allow the child or ado-
lescent to speak, or observation of overly submissive,
withdrawn, or fearful behaviors should be concerning. Identifi-
cation documents may be absent or “misplaced” (Shared Hope,
2019). Victims may be unaware of the current date or time and
their current location or may be unable to provide a home
address. Other warning signs include aggression, extreme fear,
or withdrawal manifested by flat affect (Dignity Health, n.d.).

A variety of physical signs should alert the HCP to suspect
HT. Note the discrepancy between stated age and observed
age. Suspected victims who state their age to be over 18 years
but appear to be younger should have age correlation with a
physical examination and Tanner staging, although early-
onset sexual abuse is associated with earlier pubertal onset
(Noll et al., 2017). Physical signs of trafficking include evi-
dence of physical or sexual violence, such as ligature marks,
broken teeth or bones, and vaginal or rectal injury. Malnutri-
tion or unmanaged chronic illness may be noted. Illegal sub-
stance abuse, especially when testing results positive for
multiple drugs, should raise trafficking suspicion. Recurrent
visits for urinary tract infections, sexually transmitted infec-
tions, pelvic inflammatory disorder, and partial or traumatic
abortion are high-risk indicators (Shared Hope, 2019). Assess
the entire body and document any tattoos because traffickers
often brand their victims with permanent markings. In the
United States, marking a youth under the age of 16 years
with a tattoo is illegal in most states and should raise

suspicion (National Conference of State Legislators, 2018).
Commonly reported tattoos include using dollar signs, bar
codes, or the words “daddy,” “bottom” (designating a “bot-
tom girl” or a victim who moved up in the victim hierarchy
and may receive better treatment), or “___’s girl” (Fang, Cov-
erdale, Nguyen, & Gordon, 2018; Napnap Partners, 2019).

A trauma-informed approach minimizes triggers, stabilizes
the patient, and de-escalates potentially volatile situations.
Trauma response has significant impacts on psychological
and physical outcomes, including long-term sequelae such as
post-traumatic stress disorder (USDHHS, 2014). A trauma-
informed framework encourages HCPs to adeptly recognize
signs of trauma and its widespread impact while integrating
trauma-related policies and procedures to help prevent retrau-
matization (USDHHS, 2014; Dignity Health, n.d.). Through
this process, HCPs provide care that empowers survivors by
considering their wishes, maximizing their input in care-
related decisions, reassuring safety, and providing care with
transparency and trustworthiness (Greenbaum et al., 2018;
Dignity Health, n.d.). The trauma-informed approach assists
HCPs in identifying subtle indicators of trauma while creating
a safer space for self-disclosure of victimization (Greenbaum
et al., 2018; Peck & Meadows-Oliver, 2019).

A primary tenet of trauma-informed care is developing
trust. An initial step is to provide safety and privacy for the
health care encounter, away from the accompanying person
(Barnet et al., 2018). Be aware that a child may be a victim
of familial CST or CLT, or the “friend” may be someone
appointed by the trafficker to supervise and ensure victimi-
zation is not disclosed (Polaris, 2018; Sprang & Cole, 2018).
Separate them via a required procedure that only the patient
can attend, such as an x-ray or a urine test. Equally impor-
tant is limiting the number of staff who are aware of the sus-
pected trafficking situation to limit conversation and lessen
the risk of the trafficker overhearing the conversation and
leaving. Another aspect of establishing a trusting relationship
and providing culturally responsive care is ensuring the
patient can speak to HCPs in their native language. Three
federal laws (The American with Disabilities Act, Title VI of
the Civil Rights Act of 1964, and the Affordable Care Act)
require HCPs or institutions who receive federal funds to
provide qualified interpreters to patients with limited English
proficiency and patients who are deaf or have impaired hear-
ing, and explicitly bans the use of minor children or adult
family members and friends as interpreters (USDHHS, 2014;
USDS, 2019). People who accompany the suspected victim
should never be translators. Never question potential victims
about their immigration status.

Demonstrate respect for the child or adolescent by
offering choices and control during the encounter. Ask
patient permission before initiating a detailed history and
physical. Throughout the encounter, ask, “How are you
doing?” or “May I continue?” Use developmentally appropri-
ate language and start with less invasive parts of the

May/June 2021 263

FIGURE 1. National Human Trafficking Hotline.
Source: National Human Trafficking Hotline,

(This figure appears in color online at

examination by asking, “Are you comfortable with me listen-
ing to your lungs?” and then request permission to ask more
probing questions and perform more intimate examinations
(National Child Traumatic Stress Network [NCTSN], n.d.;
Affordable Care Act, 2016).

Just as with other forms of trauma, many child victims,
when questioned, are not willing to self-disclose as victims,
and many do not recognize their victimization yet (NCTSN,
n.d.; Polaris, 2018b). Some factors compelling nondisclosure
include fear, distrust of authority, shame, hopelessness, and
trauma bonds (Greenbaum et al., 2018). HCPs can provide
support during the encounter (Table 2). Do not force,
deceive, or coerce a patient to disclose with the intent to
“save” or “rescue” them. Understand that survivors may
express anger or be accusatory and/or belligerent as mani-
festations of survival behaviors. Do not be discouraged if a
patient does not disclose victimization. It may take several
visits for a child to feel safe enough to disclose their traffick-
ing situation. Validate and normalize their feelings (NCTSN,
n.d.; Affordable Care Act, 2016), and discreetly, verbally

TABLE 2. Health care provider response to CT victims in the clinical setting

Response Action items

Evidence-Based Practice within the scope of your education, license, certification and training
Adhere to mandatory reporting laws in your state Seek high quality continuing education from reputable

Provide appropriate care for presenting clinical concerns (i.e. injuries or illnesses)
Advocate for use of scientifically-designed screening tools with evidence of reliability and validity
Facilitate appropriate referral and connection to interprofessional holistic service entities

Trauma-Informed Safety-
Ensure emotional and physical safety for all involved parties in the clinical setting
Avoid unintentional re-traumatization by using well-intentioned but ill-informed interview techniques
Make every effort to provide privacy during clinician interaction with the individual, separate from individuals
potentially posing threats (i.e. traffickers)

Provide individuals with control and clear, appropriate messages about their rights and responsibilities
Do not attempt to force the patient to self-disclose
Know and adhere to federal and state laws as well as organizational policy governing mandatory reporting
Share power in decision making and planning
Collaborate with interprofessional disciplines
Maintain respectful and professional boundaries
Do not make promises you cannot keep
Prioritize empowerment and skill building
Do not “rescue” the patient
Communicate messages of hope
This is a safe place
You are not alone
This is not your fault
You deserve to receive help

Culturally-Responsive Identify your personal potential biases
Use a professional interpreter or interpreter service(s) to provide linguistically appropriate services to individ-
uals who speak a different language

Recognize the differences between the cultures of law enforcement, the health care profession, trafficked
individuals, and other interprofessional disciplines involved in care

Advocate trafficking response teams that are inclusive and representative of diverse perspectives

Note. CT, child trafficking.
Source: Peck, 2019.

264 Volume 35 � Number 3 Journal of Pediatric Health Care�

TABLE 3. Open-ended conversation approaches

Concern for labor trafficking Concern for sex trafficking

What type of work do you do?
What are your work hours?
How often do you get to see your family?
Does someone prevent you from contacting them?
Can you get another job if you want?
Come you come and go as you please?
How many people live with you?
Are you being paid?
Do you have a safe place to go?
Do you owe money to your employer?
Do you have control over your money and ID/documents?

Do you ever feel pressure to do something you don’t want to?
Have you been physically hurt?
Did someone tell you what to say today?
Has your family been threatened?
Has anyone asked you to have sex with someone else?
Have you ever felt you had to have sex to get what you need, such as
food or to stay in where you live?

Has anyone asked you to dance at a gentleman’s club or take your
clothes off in front of someone?

*Note: Some questions overlap and may be appropriate for concern for both sex and labor trafficking. Principles of trauma-informed care
should be implemented with any clinician-patient interaction. These may present a starting place for conversation to explore potential risk in
the absence of a scientifically-designed screening tool with established validity and reliability.
Source: National Human Trafficking Resource Center, 2019.

provide the information they may choose to act on in the
future. This information may include providing them with
the National Human Trafficking Hotline number (Figure 1).
Avoid judgmental statements that may be abrupt or insensi-
tive, such as, “Why didn’t you ask for help?” or “How could
this have happened?” Be open to unfamiliar narratives.
Although there is currently no universal screening tool

TABLE 4. Recommended calls to action

Evidence-Based, Trauma-Informed, Survivor-Informed, Culturally

Entity Action items

Individual HCPs Seek evidence-based continuing educatio
Memorize the Human Trafficking Hotline p
Learn how to be an effective advocate an
Keep abreast of published scientific literat
Advocate for the implementation of a prot
Advocate for prevention of Adverse Child
Educate children and families about risk f
Volunteer with a local anti-trafficking advo
Serve on a city, state, or federal taskforce

Health Systems/Clinical

Establish an interprofessional workgroup
Designate an organizational taskforce to r
Require annual training for ALL employee
Make trafficking awareness part of orienta
Work collaboratively with local/state/fede
Develop and evaluate the use of order set
Take steps toward becoming a trauma-in
and trustworthiness, choice, collaborati
an exemplar)

Consider scientific development of screen
Create an evidence-based, trauma-inform
Ensure mandatory reporting protocols fol
Implement and evaluate the use of traffick
Include trafficking survivors in interprofess
Consider the potential impacts of vicariou

Academic Institutions Implement evidence-based education in i
Support research agendas including soci
prevention approaches with a public he

Implement trafficking awareness training f
Establish policies and procedures to supp
of trafficking

recommended for routine use, HCPs can use therapeutic
communication to ask open-ended questions (Table 3).

Pediatric HCPs play a pivotal role in raising CT awareness.
Recommended calls to action are summarized in Table 4
with resources contained in Table 5. All pediatric HCPs


n specific to HCPs
hone and text numbers
d clinician for victims presenting in the clinical setting
ure related to child trafficking
ocol within your institution
hood Events (ACEs)
actors for trafficking
cacy group
or committee
to develop and implement an interprofessional protocol
espond in the clinical setting
s, not just clinical personnel
tion or onboarding
ral law enforcement task forces
formed institution (5 primary principles include safety, transparency
on and mutuality, empowerment- consider the Missouri Model as

ing tools with evaluation for reliability and validity
ed and culturally-responsive organizational protocol
low state and federal law
ing-related ICD-10 CM codes
ional teams to promote survivor-informed practices
s trauma and ensure adequate support services are available and

nterprofessional health sciences curricula
al determinants of health, theory-based interventions and upstream
alth paradigm
or ALL employees
ort employees and students who are identified as potential victims

May/June 2021 265

TABLE 5. Resources for individual HCPs, health care organizations, and academic institutions

Organization Resource Website

ACT, National Association of Pediatric
Nurse Practitioners Partners for
Vulnerable Youth

ACT Advocates Train the Trainer program
for healthcare professionals and
speaker’s bureau

Dignity Health Shared Learnings Manual

Dignity Health in partnership with
HEAL Trafficking and Pacific
Survivor Center

PEARR Tool (A Trauma-Informed
Approach to Victim Assistance in
Health Care Settings)

HEAL Trafficking Protocol Toolkit for Developing a
Response to Victims of Human
Trafficking in Health Care Settings
Recent Publications and Reports

Polaris National Human Trafficking Hotline
Shared Hope International State Report Cards for Sex Trafficking


U.S. Department of Health and
Human Services; National Human
Trafficking Training and Technical
Assistance Center; Administration
for Children and Families; Office on
Trafficking in Persons; Office on
Women’s Health

SOAR to Health and Wellness Online
Training Modules:
Trauma-Informed Care; Culturally and
Linguistically Appropriate Services;
SOAR for: Behavioral Health, Public
Health, Health Care, Social Services,
School-Based Professionals

U.S. Department of Homeland

Blue Campaign- A national public
awareness campaign designed to
educate the public, law enforcement
and other industry partners to
recognize and respond to human

Note. ACT, Alliance for Children in Trafficking; HCPs, health care providers; HEAL, Health, Education, Advocacy, Linkage; PEARR, Privacy,
Educate, Ask, Respect and Respond; SOAR, Stop, Observe, Act, Respond.

should seek evidence-based, survivor- and trauma-informed,
culturally responsive continuing education to inform their
clinical practice. Questioning and examining children in a
well-intentioned but poorly informed manner can cause fur-
ther trauma, jeopardize subsequent criminal proceedings, and
risk violating the limits of clinician licensure (Gordon et al.,
2018). Pediatric HCPs should not conduct forensic interviews
if not properly trained to do so.

Pediatric HCPs should support evidence-based, scientifi-
cally rigorous approaches to the development and subse-
quent evaluation of CT preventive efforts. Use a holistic
assessment approach and recognize that all body systems
may be involved. A thorough review of symptoms and a
comprehensive physical and mental health assessment
should be performed to identify risk factors (Richards et al.,
2014). Health care professionals should contribute to critical
efforts to identify situations CLT in addition to situations of
CST (Ronda-Perez & Moen, 2017). Victims of forced labor
should not be underserved with preferential prevention and
intervention efforts diverted or prioritized to vctims of CST.

In the broader context of health care organizations, pedi-
atric HCPs should lead efforts to implement best practices
through policies, protocols, and governance for children
who experience and are at risk for trafficking. Health care

266 Volume 35 � Number 3

organizations should ensure that trafficking awareness is
included in the onboarding process for all new employees
and in annual compliance training. Every health care delivery
environment should develop and implement a clinical proto-
col with input from an interprofessional organizational coali-
tion including clinicians, administrative leadership, staff
support, institutional security personnel, ancillary care serv-
ices, social service disciplines, child life specialists, sexual
assault nurse examiners, and local and federal law enforce-
ment (Dignity Health, n.d.). In particular, the collaboration
between health care and law enforcement professions is an
area needing further development to maximize resources
and optimize patient outcomes. A clinical interprofessional
protocol is critical to employ an evidence-based, trauma-
informed, and culturally responsive approach. Protocols
should address case management, patient referral, and care
coordination. Of utmost critical importance, each protocol
should address mandated reporting obligations for HCPs,
which vary according to state law. Clinicians need clear
direction on how to report suspected cases of child traf-
ficking and the differences in reporting adult cases (Barnert
et al., 2017). Reporting instructions should comply with
federal and state law, including, but not limited to, protec-
tions for reporting confidential patient information and

Journal of Pediatric Health Care�

avoiding violations of the Health Insurance Portability and
Accountability Act. In addition, organizations should be
aware of federal and state efforts and legal implications for
trafficking victims including: criminalization of trafficking
crimes, survivor protections in court, coordination between
state and federal agencies, and business regulations
(National Conference of State Legislatures, 2018). Organi-
zations should ensure that employees know how to contact
the National Human Trafficking Hotline (2019) and the
appropriate guidelines for communication therein, consider-
ing state laws for mandatory reporting and boundaries for
Health Insurance Portability and Accountability Act viola-
tions. Protocols should address discharge planning, patient
safety counseling, and discreet provision of further resour-
ces for those who choose not to self-disclose victimization
and who do not qualify for mandated reporting. Other con-
siderations include safety considerations for victims, families,
and staff; a procedure for handling care refusal or leaving
against medical advice; and potential order sets for evalua-
tion and treatment. HCPs must understand and abide by
their education and mandated scope of practice to avoid
unintentional revictimization, providing poor care, or poten-
tially damaging criminal cases.

Although there is no diagnostic standard for trafficking,
International Classification of Diseases, 10th Revision, Clini-
cal Modification (i.e., ICD-10-CM) codes (Figure 2) were
approved in October 2018, offering options for adult or
child confirmed or suspected labor or sex trafficking. It is
important for clinicians to use these codes to provide a bet-
ter understanding of the scope of this problem (OTIP,
2018). When these codes are used in an electronic medical
record, consider confidential use to protect victims from
potential retribution for seeking health care. It is important
to note that there is insufficient evidence to support univer-

FIGURE 2. International Classification of Dis-
eases, 10th Revision, Clinical Modification codes
for trafficking. Source: Office on Trafficking in
Persons, 2018.

sal adoption of a standardized screening tool for CST and
CLT (Peck, 2019). Care should be taken to construct tools
with a strong scientific approach and implement rigorous
efforts to assess reliability and validity.

Academic institutions should prioritize and support schol-
arly efforts to research clinician response to CTwith emphasis
on scientific inquiry inclusive of individual, relationship, com-
munity, and societal impacts on social determinants of health
(i.e., a public health paradigm construct) and theory-based
interventions. Care should be given to thoughtful construc-
tion of prevention and intervention efforts, with consideration
and implementation of rigorous scientific studies with statisti-
cal outcomes measurement. Inclusion of child victimization
should be examined scientifically, comparing unique experien-
ces and holistic impacts of child vs. adult victims (Le, 2018).

Pediatric nurse practitioners and other pediatric HCPs are ide-
ally positioned to lead efforts for trauma-informed, culturally
responsive, and evidence-based care of children who have
experienced or are at risk for experiencing trafficking (Peck,
2019). Adopting incremental and evidence-based clinical prac-
tice changes amplifies the impact of pediatric HCPs as effec-
tive leaders with a cohesive and collective response to child
trafficking. By recognizing previously unidentified victims and
employing upstream prevention approaches, pediatric HCPs
can positively impact health outcomes for children.

Supplementary material associated with this article can be
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  • White Paper: Recognizing Child Trafficking as a Critical Emerging Health Threat
      • References

Position Paper, also known as a White Paper, is a tool to educate and inform the public on a specific health issue. This authoritative document takes a specific position or recommends a specific approach to solving an identified problem. Choose a White Paper  (THE WHITE PAPER IS ATTACHED AS A PDF USE THE TOPIC THAT I PROVIDED)

In this discussion, evaluate the White Paper and consider the quality and source of the message should include:  

· an overview of the White Paper selected and how it relates to a health care policy effort of interest to the master’s prepared nurse (IMPORTANT YOU MUST TALK ABOUT THIS IN THE PAPER) – include its’ source and purpose 

· how the chosen White Paper can advance current health systems, practice, and/or organizations to improve health outcomes

· the selected White Papers’ impact on economic, legal, and/or regulatory processes

Please remember all your written work must follow APA 7th Edition format. AT LEAST TWO REFERENCE THE ONE I GAVE YOU AND RESEARCH FOR ANOTHER ONE TO SUPPORT THE TOPIC

The paper must be done with the document attached which is the WHITE PAPER OF MY CHOICE



Position Paper

The chosen White Paper for completing this discussion is “How Mental Health Care Should Change as A Consequence of the COVID-19 Pandemic” by Carmen Moreno et al., published in 2020. The Position Paper was prepared by a group of international clinicians, advanced mental healthcare professionals, and mental healthcare users to create awareness about the mental health challenges posed by the COVID-19 pandemic (Moreno et al., 2020). The paper argues that today’s interconnectedness influenced society’s vulnerability to this infection, but this still provides the infrastructure necessary to improve mental healthcare delivery (Moreno et al., 2020). Hence, the COVID-19 pandemic response strategy provides the opportunity to enhance mental healthcare services (Moreno et al., 2020). The selected White Paper relates to the health care policy effort of interest, the bill introduced to Congress by Patty Murray, Senator for Washington, S. 3799: PREVENT Pandemics Act, advocating for the establishment of a better protocol for preventing and responding to future pandemics (, 2022). It touches on the mental health burden that came with the pandemic and provided insightful recommendations. 

The chosen White Paper can advance current health systems, practice, and organizations to improve health outcomes because it sees opportunity in chaos. It equips stakeholders with vital knowledge for addressing the potential mental health challenges of outbreaks like the COVID-19 pandemic. Moreno et al. (2020) inform that these challenges face the general public, COVID-19 patients, persons with pre-existing mental problems, and healthcare workers (Moreno et al., 2020). It then goes on to narrate the mental health service responses that have been deployed during the pandemic, make recommendations for sustainable mental health delivery, and assess mental health outcomes in clinical practice (Moreno et al., 2020). Hence, one can also argue that the selected Position Paper can the economic, legal, and regulatory processes by supporting public funding for treating and caring for affected people and shaping legal and regulatory frameworks and demands for emergency and disaster preparedness. 


References (2022). S. 3799: PREVENT Pandemics Act: Overview. Retrieved from

Moreno, C. et al. (2020). How mental health care should change as a consequence of the COVID-19 pandemic. The LANCET Psychiatry, 7(9), 813-824.

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