Compassionate Care—Going the Extra Mile: Sex Trafficking Survivors’ Recommendations for Healthcare Best Practices

Round 1

Reviewer 1 Report

Review of Compassionate Care

This article is super important for bringing the voices of marginalized individuals in recommendations for healthcare providers. The article concludes that healthcare providers need to learn supportive practices, withholding judgement at the same time as asking probing questions to address the needs of traumatized individuals.

There are two main problems that I believe could easily be addressed. First, the first half of the paper seems to be pointing in a different direction than the second half of the paper and these need to be resolved. The first half of the paper seems focused on the issue of identifying trafficked victims, while the second half is on effectively providing resources to victims of violence and exploitation. Second, the focus on red flags and identification sometimes may conflict with a non-judgemental approach, and this needs to be more directly addressed.

The paper could be much stronger in acknowledging the complexities for caregivers of being supportive, enlisting trust, being aware of personal biases and providing for the needs of traumatized individuals. Research on dealing with victims of domestic violence addresses the challenges in learning how to meet an individual where they are. In addition, there is a lot research that should be mentioned about whether the efforts to “rescue” trafficked victims actually work in their benefit or not. Often the label of trafficking is applied to certain racial or ethnic groups, revealing biases and stereotypes. Stereotypes about prostitute agency generally can interfere with enlisting trust. Because trafficking is a crime, there are the complexities of dealing with law enforcement, which can have different goals than those of health care providers.

The first part of the paper focuses on identifying trafficking victims, which can sometimes be very different than meeting their needs or providing resources. It may help focus the paper to have a more nuanced approach to whether or not it is helpful to define patient situations as trafficking. The paper needs to be careful not to conflate prostitution and trafficking. I recognize there is a philosophical debate about choice and sex work, but most of the individuals that healthcare workers are likely to see will see trafficking and sex work as two very different things. Individuals come to sell sex because of choice, coercion and circumstance and can come from a wide variety of backgrounds. Not all individuals who sell sex experience violence, individuals experiencing violence may not sell sex.

As the second half of the paper acknowledges, needs such as housing, food, and healthcare are needs of a wide variety of marginalized individuals, not just those forced against their will to sell sexual services. This paper provides important information for care providers encountering a variety of marginalized groups. Deciding whether or not to identify someone as trafficked often means making judgements on an individual’s ability to choose their situation or identifying someone as controlling them, judgements that may prevent a patient from accessing resources. If the authors want to focus on identifying trafficking, they need a much better operational definition and need to deal directly with these issues. However, I think the strength of the paper is in providing needed resources to any sex working individual in need through compassionate care. This includes recognizing their ability to articulate needs even if it does not include that patient recognizing the source of their problem as a trafficker or deciding to leave the life at that time.

Here are some more specific comments:

p. 1. Define trafficking early on. Here and also in section 1.2, discuss the various definitions used in law enforcement as well as the TVPA definitions of “severe” trafficking. I would also bring up the issues with conflating sex work and trafficking up front to make clear how healthcare providers could best approach this issue. As I explained above, while there is a need to address the trafficking literature, I think the paper could focus on how the needs of a trafficked individual may overlap with the social service and health needs of other individuals they may see.

p. 2 The first paragraph does a great job of explaining the situation faced by runaways, and those whose parents, siblings or boyfriends may be facilitating their involvement in the sex trade. But do know that not all facilitators are using deception or drugs to brainwash a victim, and that runaways and other youth involved in the sex trade may still need housing, resources and the compassion and understanding of care workers. Trafficking is bad, but it is not the source of all the problems faced by these groups.

p. 2 Check the source for the claim that 80-90% of victims of HT have a history of child sexual trauma. I couldn’t find it in that source cited and I’m curious how the data for that was collected.

p. 2 section 1.4, it is also important to point out that stigma and stereotypes also affects sex workers who are not “trafficked” and can prevent them from getting needed services.

p. 2 section 1.7. The intersectional framework is important, but also recognize that victims do not see all third-party facilitators or clients as oppressors. As you point out, the meanings as defined by society at large, and the meanings of members at a micro-level do not always intersect.

p. 4 section 2.1 What is meant by victim-centered stakeholders? Are these service providers? If you can, specify the kinds of organizations from which respondents were recruited -- services directed to trafficking survivors only, or street populations, criminal justice institutions, sexual violence centers? Please be a bit more specific about recruitment.

p. 5 section 2.4. Eligibility criteria included self-identified survivor of sex trafficking. Were all the examples of experiences in the subsequent results sections during the time they were trafficked? Did any of these occur while selling sex without a coercive third-party facilitator? Again, specify the definitions of trafficking being used by the various parties to help the reader understand what is facing victims. Also, are these all individuals who are no longer selling sex or no longer being trafficked? And as for the gender, given the importance of trans populations and males in these marginalized groups, briefly explain if these are cis individuals and/or justify the decision to exclude trans workers.

p. 5 section 3.1. Were the years in victimization years while selling sex regardless of their facilitator or just while under a coercive third party?

p. 9-10 section 3.2.2 and 3.3.1. Please be very careful about the way you frame using number of sexual partners or frequency of visiting as a red flag for trafficking. It would not be good to discourage individuals from getting care by scrutinizing or judging anyone with multiple sex partners. The sexual health of the sex selling population and even those who choose multiple partners is important and the responses of some of the healthcare workers the paper discusses is understandable in this frame. Find a way to combine your later points about compassionate care and rejecting stereotypes with the issues raised by your respondents. This is the kind of delicate balance that I mentioned earlier. The point is to be aware of the needs of individuals.

p. 11 section 3.2.4. Again, be careful in the wording of this section that these tatoos can be a sign of patient need but is not determinative.

p. 11 section 3.2.5. Some of the signs listed in this section could apply to anyone. I think any mother sitting with my teenage daughter at a doctor’s office, given how they sometimes dresses and the general teenage attitude, would be a red flag given this description. That said, your respondents are highlighting things that a compassionate and aware caregiver can pay attention. The point is to provide needed resources. The wording in this and other sections needs to be careful to not encourage stereotyping or judgements at the same time as encouraging caregivers to be attentive to needs.

p. 13 section 3.3.3 and later. These are good points in these sections. The paper could be improved by finding a way to integrate these ideas into earlier sections. As I said above, it might help to shift the focus to assisting individuals rather than identifying trafficked people.

p. 14 middle of the page. What is the “grip of survival”?

Author Response

Please see attachment. Thank you! 

Author Response File: Author Response.pdf

Reviewer 2 Report

This paper highlights the perspective of survivors from human trafficking and the missed opportunities of medical providers/staff to recognize that they were in need of assistance to leave the victimization. This paper provided a thorough overview of the issue as well as clinical and research implications.

Introduction:

Line 44 says, "gaps in the prevention, intervention, and legislation" - maybe add in the words efforts or revise to say "gaps in prevention, intervention, and legislation"

Line 52 - what is the footnote (3) in reference to?

Beginning in line 52, "Moreover, the risks are magnified for homeless and runaway youth, [14] as well as those involved with the child welfare system, [15] kidnapped youth, and children engaged in prostitution sanctioned by parents, older siblings and boyfriends, among other social, economic and behavioral risks [3, 16, 17]. - this sentence is extremely long; might want to break it up. why is boyfriends in italics?

Rephrase the final sentence in the section 1.1 Victims and Risk Factors

Beginning in line 134, separate the run-on sentence into two clear thoughts.

Methods:

Line 150: If only two cities were used for sampling, change multiple cities to state that data collection occurred in two cities.

"According to the San Diego County District Attorney [41]." - This sentence is missing additional information. What is according to the District Attorney?

Maybe reorganize the placement of this sentence, "San Diego places 13th nationally for sex trafficking of minors." - recommend talking about the California ranking first and then doing into details about the city of San Diego

In Table 1 - Latina is italicized, is there a significance for this?

Overall, the results and discussion was very strong sections. This paper will be a great contribution to the field.

Author Response

Please see attachment. Thank you! 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The article is much improved. What is so great about this paper is that it relies on individuals who have experienced being forced to sell sex against their will to say what they wished health care professionals should have done. Ultimately, I see the paper as about how health care professionals can get beyond “whore stigma” in addressing the needs of individuals who may be being forced to sell sex. As the paper explains, human trafficking survivors found health care professionals to be judgmental, judging them as “bad” and responsible for their own troubles and ignoring repeated injuries. That said, I am still concerned about the implications in the Red Flags section as they contrast with the second half of the paper emphasizing non-judgmental compassion in section 3. I feel like the paper overlooks self-efficacy, and in places reproduces a different kind of “whore stigma” that anyone with repeated physical injuries or possibly selling sex is likely a victim and doesn’t know what they want. The paper needs to better address this contradiction.

For example, section 3.2 encourages professionals to be hyper-vigilant of certain people/actions, i.e. frequency in emergency rooms, coming in frequently for condoms, too many STI tests, having a partner that appears controlling and advised them not be afraid to ask questions, understand that victims don’t know what they need or are not willing to disclose, and be willing to intervene. At the same time, Section 3.3.3 and 3.3.4 encourages providers to show empathy, be sympathetic and non-judgmental, not to be “quick to judge based off a certain situation” (p. 15), to ask questions in a caring, compassionate way while withholding judgement. The paper is good in identifying the stigma that sees these as ‘bad’ people, but the consistent use of the term “victim” or “patient-victim” is equally judgmental and disempowering. The way some of the analysis is written seems not sensitive to all the differences and stereotypes about race, sexuality, or gender. I fear that health care providers are not getting many pointers for how to respect people’s choices to sell sex, have bad partners, or access reproductive care and at the same time help those who are in situations where they are forced (as well as others who need similar kinds of help).

I believe these are relatively problems that can be fixed and stem from language that can easily be edited. There is a way to just adjust the wording throughout, and maybe rearrange the order of sections, that I think will solve most of the problem. Think through and indicate the potential for self-efficacy on the part of patients and indicate this throughout. Here are some general suggestions:

Address the dilemmas of identifying and helping individuals in need by drawing on the domestic violence literature and do this early in the paper. There are years of domestic violence research that provides guidelines on how to identify and help individuals in a way that respects self-efficacy. Practitioners in that field have learned to walk with individuals in a supportive way until they are ready to change. It involves not labeling them as victims and giving them choices about how to interpret what is happening to them. Having someone come back to the health care setting over and over can be a good thing, it allows them the opportunity to establish rapport until they are ready to ask for help. Asking for sanctuary or safety is an individual decision. So, it is not a simple task for health care providers to interpret all the red flags the paper mentions. If the research respondents are saying their situation is different, this needs to be elaborated in the finding’s sections more clearly. If there are specific areas where it is similar, say so.

I know there is not as much empirical evidence on recognizing self-efficacy for trafficked individuals as there is on domestic violence, but I do know, for example that the AMA Journal of Ethics from 2017 (one article in this issue is already cited) provides a great deal of insight on the debates and issues with possible approaches. Macias-Konstantopoulos, W.L., 2017. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA journal of ethics, 19(1), pp.80-90.

Relatedly, I encourage you to find a label other than victim or patient-victim for individuals in need.

Reference the screening health care providers may (or may not) already be providing and use respondents to assess what works and what doesn’t. There may be things health care providers are already doing that should be directly addressed in the paper. I know I am always screened for mental health, domestic or sexual violence or other problems when I visit a health care setting. The paper discusses that in one spot. Did other interviewees mention this? Did they get intake forms? Was what they wrote ignored? That is important information for providers. What of the intake process is helpful and not helpful for the individuals you interviewed? How do your respondents think they should gather and use that information?

Information on housing, health care, etc. seems easy to provide without worrying about whether someone is trafficked vs. in an abusive situation. I would highly recommend the authors make more of providers’ abilities to provide that information in a respectful and empowering way regardless of whether they deem someone trafficked or not.

Address anything your interviewees may have said that would be helpful in addressing cultural differences or attend to potential biases against overly sexual women, trans individuals or racial minorities. There is a way to just change a few places the wording that I think will solve most of the problem. Half of the interviewees were not white, yet there is nothing in here dealing with racial and ethnic biases. Interviewees included males, but there were no specifics in the narratives about this relatively unique group.

Highlight the uniqueness of respondents’ situations as relevant to trafficking as opposed to other risks that health care providers should have attended to. There is a spectrum of consent that may or may not affect a sex working individual’s appearance in a hospital. Make clear what it was about the situation the respondents highlighted that was unique to trafficked individuals as opposed to other at risk patients in the context of the concerns I have indicated. See specific comments below.

A few specific suggestions, but these are just a few suggestions on the ways things could be edited. I encourage the authors to think through these issues throughout as they are revising the paper.

The intro takes way too long to get to the uniqueness of this paper. Shortening then section on the evils of trafficking and more quickly set up the problem addressed in this research by acknowledging the dilemmas health care professionals face when dealing with vulnerable individuals who may be trafficked. Your research finds that judgements that sex working patients were just “bad” and responsible for their own hardships and judgements that they are all helpless victims and don’t know what they want can both prevent individuals from getting the help they may need. The majority of individuals selling sex are not trafficked, but those who are need health care professionals to know how to help them.

I suggest in the very first section make clear recommendations are based on interviews with individuals who were trafficked according to the US State Department definition, about what they felt health care professionals can do to help individuals who have experienced severe forms of trafficking. If they weren’t trafficked according to this definition, then make clear what definition you are using in defining respondents as trafficked.

P. 2 line 54 mentions ‘uniqueness’ of trafficked individuals. Yet quotes in the red flags section could be from other vulnerable or abused populations. Distinguish more clearly how health care providers can tell the difference and make that the main point of the section. For example, on page 8, lines 344 to 350, the paper mentions comorbidity of malnutrition, drug dependency and mental health. Perhaps this section should start with this. I wonder if repeated physical trauma is already a red flag for domestic violence. This relates to comments below.

p. 2 line 59. “The U.S. defines” – What particular part of U.S. law, is this the Trafficking Victims Protection Act? The State Department? A certain state’s definition. There is a lot of inconsistency in definitions so I would mention in the narrative what law you are referring to.

p. 2 lines 69-72. This newly added section seems to confuse the issue. Many individuals living on the streets or engaging in survival sex don’t have the freedom to leave and it is not because they are being forced by an individual. The physical injuries as described in the rest of the paper still seem important for a health care provider to notice regardless of whether or not an individual is forcing someone or not. Trafficking survivors can later participate in sex work. There is a spectrum of consent, risk factors, health needs. Address this not just in the intro, but also throughout.

P. 2 lines 80 & 81. The statistic that 84% of people victimized by HT have a history of childhood sexual trauma is problematic. The article cited seems to indicate the situation is more complex. This doesn’t seem central to the paper so I would delete it.

p. 5 lines 237-39. A bit more explanation of the study participants would be helpful. Did all these individuals fit the US State Department definition of HT (the perpetrator entraps an individual and forces the victim into commercial sex acts)? Were all of the participants forced against their will exactly as the law defines it for the entire 5.7 years? As I said above, trafficking survivors can later participate in sex work. Be clear, if you can. I know the situation of many individuals is complex, but how the respondents came to understand the violence they experienced and how health care providers may have helped or not is part of the purpose of your paper. I suspect that their self-efficacy was how they changed their situation.

p. 8 Section 3.2.1. As noted above, the main point of this section needs editing. Physical injuries may be a red flag for trafficking, but they can also indicate domestic violence unrelated to trafficking, or one-time events for someone who sells sex consensually. Research finds that many vulnerable sex workers are reluctant to go to the hospital because the health care provider will either judge them as “bad,” or judge them as victim, and/or judge their partner as a trafficker. Maybe instead, introduce this section by saying that a variety of vulnerable populations experience a range of physical injuries due to domestic abuse, sexual assault, etc. and these individuals need judgement free treatment (as the second half of the article shows). However, the victims of HT told us that they were in the hospital frequently and wished that providers would review medical records to look for frequent injuries. Or better screen for domestic violence. Or whatever that would make their situation “unique.” I don’t’ want to tell the authors what to write, but to help make this first section match the second half, emphasize the points that are unique to individuals held against their will at the time they are interaction with health professionals.

p. 9 line 334-340. If the emphasis is on frequency, the description of the shocking incident that happened to Leaf is less important than what Leaf said about what health care professionals should have done about it. The story of escape from someone taking her to a different location and Leaf jumped out of the car sounds like an incident that could happen to any sex worker, battered spouse, indeed to any individual seeking a ride from a stranger (or not). It sounds like the trafficker mentioned may have been helpful to Leaf in taking her to the ER. This is an example of a situation where “identifying” this individual as trafficked is less important than being non-judgmental in providing services. Or is it different? What made Leaf’s situation different than for example, an angry boyfriend tricking an ex into getting into the car and driving them somewhere they didn’t want to go? Emphasize what makes this unique.

p. 9 Section 3.22. I suggest the same approach in this section. The point is that health care workers can use the very high frequency of visits to reproductive health services and maybe comorbidities as cues to listen more to the patients.

p. 10 lines 380-387. This section makes clear that there are intake forms. I think the point is that respondents didn’t feel like these were attended to. This gets at an earlier concern and indicates that this section needs to be restructured. Make the point about the intake form clear before line 380. Rape or sexual trauma should trigger health care professionals to pay attention and at this level, this is not unique to trafficked individuals. The point is that your respondents said they felt that the staff at the facility should have paid attention to intake forms when they mention rape and abuse, and that these, in combination with frequency, COULD be red flags for trafficking as well, and were in their case. I suggest separating line 387 about humor from the point about the intake form. That said, also make clear what they felt the staff should have done in response to that joke to be non-judgmental and elicit why they were sharing the information.

Author Response

Response to Reviewer 1 Comments-Round 2

To Reviewer 1: 

The authors of this manuscript would like to thank Reviewer 1 for taking the time to review and comment on the changes of the submitted revision for Round 1. The coauthors of this manuscript strongly believe that the updated content addresses the observations Reviewer 1 have brought forth in your second round of reviews.  Based on our understanding of them as well as our rational as to the way we have put together the findings and the aim of this research, we have written and updated our manuscript. The journal had all authors confirm the new authorship and order changes. 

NOTE: Since Reviewer 1 had several points combined in the first section prior to the specific points made at the end, we broke them down and number the recommendations provided to better address them.

Point 1: The article is much improved. What is so great about this paper is that it relies on individuals who have experienced being forced to sell sex against their will to say what they wished health care professionals should have done. Ultimately, I see the paper as about how health care professionals can get beyond “whore stigma” in addressing the needs of individuals who may be being forced to sell sex.

As the paper explains, human trafficking survivors found health care professionals to be judgmental, judging them as “bad” and responsible for their own troubles and ignoring repeated injuries. That said, I am still concerned about the implications in the Red Flags section as they contrast with the second half of the paper emphasizing non-judgmental compassion in section 3. I feel like the paper overlooks self-efficacy, and in places reproduces a different kind of “whore stigma” that anyone with repeated physical injuries or possibly selling sex is likely a victim and doesn’t know what they want. The paper needs to better address this contradiction.

For example, section 3.2 encourages professionals to be hyper-vigilant of certain people/actions, i.e. frequency in emergency rooms, coming in frequently for condoms, too many STI tests, having a partner that appears controlling and advised them not be afraid to ask questions, understand that victims don’t know what they need or are not willing to disclose, and be willing to intervene. At the same time, Section 3.3.3 and 3.3.4 encourages providers to show empathy, be sympathetic and non-judgmental, not to be “quick to judge based off a certain situation” (p. 15), to ask questions in a caring, compassionate way while withholding judgement.

Response to Point 1:

We agree that it is a huge challenge to identify potential HT-patients; yet we contend it is doable. This study’s aim was to bring the voices of survivors to the table based on their past experience with healthcare providers as Reviewer one has pointed out. It seems to us that not being judgmental of what they do, it is different from being diligent as to what to look for in order to identify potential HT-patients. Although there may not be specifics about how each healthcare provider applies these recommendations in their everyday practices, this exploratory study brings forth some key components that seek to inform these very protocols and practices in the context of delivering care in their clinics, hospitals, and so forth.

Thus, the subsection in Findings 3.2 of “Red Flags” is assessing “potential red flags.” (subheading was updated). As stated, we have shared, no one “red flag” alone will point to HT victimization; but rather a holistic assessment is needed. Therefore, this section is about the “observational” assessment that could lead to potential identification of HT-victims. We have addressed this point by stating the following,

3.2.5. Other Signs & Caution

Study participants pointed to other potential signs as indicators of sex trafficking victimization. For example, inconsistencies with the reasons for their injuries, being too distracted, constantly looking at cell phone messages, looking around, anxious, nervous or skittish. Caution must be exercised regarding not stereotyping or judging patients as these potential red-flags can overlap with other patients who are not victims of sex trafficking. If a potential HT-patient is accompanied with an older controlling person, study participants pointed out to consider it as a red flag. Nonetheless, the key additional components of this accompanying person would include characteristics of a personality that is domineering, forceful, controls the interaction between the patient and the healthcare provider, does not want to leave the room, is much older than the patient, fills out her forms, and is holding on to the patient-victim’s identification card. Although, no one isolated sign is indicative of suspicion, having a combination of different signs adds to the probability of sex trafficking. It is also important to know that at times, according to some participants, the suspect could appear to be a nice person, but still is controlling in the context of the decision-making process.” [page 12].

Therefore, we believe there is no contradiction between identifying and treating the patient with respect and compassion. These are both needed in order to begin building rapport and instilling hope in the HT-patient according to participants’ voices.

Point 2: The paper is good in identifying the stigma that sees these as ‘bad’ people, but the consistent use of the term “victim” or “patient-victim” is equally judgmental and disempowering. The way some of the analysis is written seems not sensitive to all the differences and stereotypes about race, sexuality, or gender.

We have addressed the language and changed “patient-victim” to “HT-patient” throughout the paper.  

Point 3A: I fear that health care providers are not getting many pointers for how to respect people’s choices to sell sex, have bad partners, or access reproductive care and at the same time help those who are in situations where they are forced (as well as others who need similar kinds of help).

Response to Point 3A:

Maybe the “missing link” it is in the definition of human trafficking. It should be clear that Human Trafficking oppression is not a choice, and that the focus of this paper is not about individuals who “opt” to sell their bodies. Rather, it is about participants who experienced extreme oppression when they were under the victimization of traffickers. This study’s aim seeks to provide pointers to healthcare providers by incorporating the reflections and recommendations of HT survivors regarding how to improve their delivery of care to potential HT-patients. It is important to remember that this study is an exploratory concurrent study that utilizes qualitative methodology to seeks the answers of the research question. As stated in Section 2.1 (page 4).

2.1. Sampling of Participants

This qualitative exploratory study utilized an a priori sampling approach widely used in public health to gain a greater understanding about participants’ perspectives and experiences of a given subject [43]…..

We agree with Reviewer 1 that these approaches can also be applicable to other subgroups who may also need compassionate care. Nonetheless, being a victim of human trafficking is not based on conscious choice.  We believe in dignity and respect for all human beings, those are the bases of public health. No one should be living under the beatings of an abusive partner even if they “believe “it is their choice. Based on the HT literature and other social and behavioral sciences literature, we understand that victims of oppressive situations, are facing circumstances due to risk factors—including for example, prior abuse and a distorted sense of who they are and what they “deserved” in life. Therefore, interactions between such at-risk populations including DV are optimal opportunities to instill hope through respect, compassion and showing care.  This study, therefore, does not seek to provide specifics to providers in dealing with those who “choose” to sell their bodies. Yet, adopting these recommendations will continue to provide respect, compassion and dignity to whoever comes into the healthcare setting.

Additionally, literature points to the fact that HT is not a choice and that this crime is based on oppression. We have established this in the section 1.1 Victims and Risk Factors

The U.S. defines HT as a crime where the perpetrator entraps an individual and forces the victim into commercial sex acts (sex trafficking) or forced labor services (labor trafficking) [1]. HT victims usually experience force, fraud or coercion in the process of becoming trafficked. When the HT crime is committed against a minor, the absence of force, fraud or coercion does not disregard trafficking as a crime, and it is considered “severe” form of trafficking [1, 13].  When an individual is entrapped into the subjection involving “involuntary servitude, peonage, debt bondage, or slavery,” it is also considered a severe form of trafficking [1]. Thus, HT perpetrators use strategic deception, confinement, reidentification, and exposure to violence, danger, and drugs to brainwash and manipulate the child, adolescent, or adult who is sex trafficked [14]. Women and children are the most vulnerable. HT victims are different than other vulnerable populations in that they are forced to these crimes and oppression. Other vulnerable populations such as those who maybe living on the streets and engage in survival sex for example, do not follow under the same category as trafficked victims. Trafficked victims, whether in the U.S. or abroad, do not have the freedom to simply leave their perpetrators [1, 13].

In the context of the U.S., vulnerability risks among these groups are at the individual, familial, communal, and societal levels [3]. Moreover, the risks are magnified for homeless and runaway youth. In addition, those involved with the child welfare system, kidnapped youth, and children engaged in prostitution forced by parents, older siblings and “boyfriends” are subjected to perpetrators [15-17]. Other social, economic, and behavioral risks influence the vulnerability risks of HT [3, 17, 18]. In other words, being physically, emotionally, and/or sexually abused contributes to victims’ vulnerability [3, 6, 13, 14, 17, 18]. While there are various studies with a range of findings, one study has uncovered that up to 84% of people who have been victimized by HT, have a history of childhood sexual trauma [19, 20]. In all, addressing the wide range of risk factors could lead to reducing the vulnerability of many vulnerable subgroups, not only of those who become victims of HT. [page 2].

Point 3B: I believe these are relatively problems that can be fixed and stem from language that can easily be edited. There is a way to just adjust the wording throughout, and maybe rearrange the order of sections, that I think will solve most of the problem. Think through and indicate the potential for self-efficacy on the part of patients and indicate this throughout. Here are some general suggestions.

Response to Point 3B:

If we review the definition of “self-efficacy” and the literature behind this concept, we find that HT-patients most likely will not have a strong sense of “self-efficacy.” Therefore, this is where this study’s findings have the potential to build “self-efficacy” in the healthcare provider. If the healthcare provider can place her/his personal biases aside (as stated by participants in this study) and treat their patients with compassion, care, and respect, there may be a greater opportunity for HT-patients to begin realizing their own “self-efficacy” as they are offered other choices, including support and resources to exiting their situation. HT is such an oppressive state that even if the HT-patient has an emerging sense of “self-efficacy,” it is almost impossible to exercise it due to their restrictive life situation and likely low self-esteem. Those who have successfully exited their HT victimization have done so because they were offered a new window of opportunities: Someone showed care, respect, and assisted them in their ability to exit. Lastly, this is not a paper focused on the “self-efficacy” of the HT-patient. Again, our focus is on bringing the voices of survivors of HT to the table so healthcare can reflect about the significance of their perspectives, and hopefully incorporate into their practices salient aspects derived from their recommendations.

Please see article:

Judge, Timothy A.; Erez, Amir; Bono, Joyce E.; Thoresen, Carl J. (2002). "Are measures of self-esteem, neuroticism, locus of control, and generalized self-efficacy indicators of a common core construct?". Journal of Personality and Social Psychology. 83 (3): 693–710. doi:10.1037/0022-3514.83.3.693. PMID 12219863.

Point 4: Address the dilemmas of identifying and helping individuals in need by drawing on the domestic violence literature and do this early in the paper. There are years of domestic violence research that provides guidelines on how to identify and help individuals in a way that respects self- efficacy. Practitioners in that field have learned to walk with individuals in a supportive way until they are ready to change. It involves not labeling them as victims and giving them choices about how to interpret what is happening to them. Having someone come back to the health care setting over and over can be a good thing, it allows them the opportunity to establish rapport until they are ready to ask for help. Asking for sanctuary or safety is an individual decision. So, it is not a simple task for health care providers to interpret all the red flags the paper mentions. If the research respondents are saying their situation is different, this needs to be elaborated in the finding’s sections more clearly. If there are specific areas where it is similar, say so.

Response to Point 4:

Same response as in Point 3B. Self-efficacy is about exercising choices based on your ideas of what you can do in the future. There has been research conducted regarding the association between self-efficacy and self-esteem. The more self-esteem someone possesses, the higher their self-efficacy is. Literature points to the fact that HT-patients (and other oppressed groups such the ones mentioned by Reviewer 1) do not possess high self-esteem; therefore, their self-efficacy will be very low.

Most likely, the HT-patient will not be asking for help, and when they do, then the healthcare provider must be ready to assist by providing suitable resources as discussed in a section of this manuscript—3.3.3

At the same time, asking questions to simply find information without providing concrete guidance or resources suitable for the HT-patient could potentially be more detrimental when trying to build rapport and trust. It is essential that healthcare providers who identify potential key red flags seek the advice of those already trained to serve this population. Understanding their trauma is an important first step to assist HT-patient as well as acquiring skills to interacting with them. Being empathic and caring is essential as is the ability to withhold judgment. Alexandra, a survivor from San Diego area shared,

My recommendation would be to ask questions very carefully. Many [patient-victim] may not be comfortable with talking about their situation. Try to be more careful. Try to be more caring, you know? Give them more information on where they can get help… The doctor that I was talking to asked me, ‘Well, why are you in this situation? Why are you on the streets?’… Some people see prostitution like it’s disgusting to them. So, they could ask the question more like ‘what happened in your life that led you to this situation?’ They [HCP] could ask questions in a different way, you know? Making sure they [HCP] don’t ask them in a way that they wouldn’t want to be questioned, you know?

Just as asking questions in a caring, compassionate and respectful way while withholding judgment is important, so is the ability of the healthcare provider in seeking to build rapport, trust, and a willingness to intervene in the lives of HT-patients as they may interact with during their daily practices.

And Discussion

….. If a protocol or plan is not in place, there are limited opportunities to assist sex trafficking patient-victims further. It is understandable that resources for patients who have been identified as victims of HT can be challenging to find; especially in this current strained healthcare system of the U.S. This is why a collaborative model to assist and address the needs of HT-patients is essential in anti-trafficking efforts as earlier stated [6, 10, 25, 28]. [page 20].

We agree with Reviewer 1 in that the tasks for healthcare providers to identify all the different red flags can be challenging. However, this should not be done in isolation not by the healthcare provider alone. New collaborative models have begun to emerge in the healthcare setting that seeks to best serve HT-patients. These models call for a collaborative format in which there is a team that engages in the process in case the healthcare provider has identified potential “red flags”.

For more on “collaborative models” to provide suitable resources to HT-Patients, please see:

Richie-Zavaleta, A.C.; Baranik, S.; Mersch, S.; et al. From Victimization to restoration: multi-disciplinary collaborative approaches to care and support victims and survivors of human trafficking. JHT. 2020; 1-17. doi:10.1080/23322705.2020.1730132

Chambers, R. (2019) Caring for human trafficking victims: A description and rationale for the Medical Safe Haven model in family medicine residency clinics. The International Journal of Psychiatry in Medicine, 54(4-5), 344-351. https://0-doi-org.brum.beds.ac.uk/10.1177/0091217419860358

Chang, K., & Hayashi, A. (2017). The role of community health centers in addressing human trafficking. In M. Chisolm-Straker, & H. Stoklosa, Human trafficking is a public health issue (pp. 347-362). Cham, Switzerland: Springer International Publishing AG.

Point 5: I know there is not as much empirical evidence on recognizing self-efficacy for trafficked individuals as there is on domestic violence, but I do know, for example that the AMA Journal of Ethics from 2017 (one article in this issue is already cited) provides a great deal of insight on the debates and issues with possible approaches. Macias-Konstantopoulos, W.L., 2017. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA journal of ethics, 19(1), pp.80-90.

Response to Point 5:

We agree with Reviewer 1 and with some of the recommendations of the article noted in the comments. Thus, these recommendations, along with the findings of this study, are shared throughout the sections of this manuscript and summarized in the Discussion:

…”In terms of supportive practices that healthcare settings and providers need to explore and potentially adopt, this study points to key recommendations specific to attitudes related to the personal treatment of the HT-patient, creating a safe and comfortable environment, and practicing a type of care that adds to extant frameworks including trauma-informed and victim-centered care—a Compassionate Care. Additionally, withholding judgment about the HT-patient demonstrating respect when taking a medical history and/or asking probing questions, and being aware of one’s personal biases must be reflected in the institutions’ culture as well as in the health care providers’ daily practices. Moreover, these practices always warrant being subsumed within both trauma-informed and victim-centered approaches to care as well as being part of healthcare providers’ medical ethos [25, 27, 39, 51, 52]. Nonetheless, this study introduces the concept of Compassionate Care in the context of caring for HT-patients. To the authors’ understanding, this concept has yet to be identified as a finding in previous literature in the context of HT. Compassionate Care outside the HT literature is defined as a type of care mainly provided by healthcare professionals characterized by recognizing, understanding and empathizing with the patient’s concerns suffering or pain. Yet, it does not stop there. The ability to empathize with the patient moves the healthcare provider to positive actions that typically lead to ameliorate the situation of their patient. This Compassionate Care approach to care seems to offer the potential for additional positive outcomes in the context of the provider-patient relationship as well as patients’ health outcomes both of which are needed outcomes among HT-patients treated in the healthcare setting [52]. This approach and applied skill to the care of patient-victims of trafficking has the potential to facilitate a breakthrough in their interaction, assessment of needs, and provision of suitable resources for paving a successful exiting of their oppression. A Compassionate Care approach could also be applied to other vulnerable HT-patients

For example, since Compassionate Care shows that the provider is willing to go the extra mile to ensure the HT-patient knows the provider cares for her, it could encourage HT-patients to see healthcare and the healthcare setting as a potential advocate and safe haven respectively. If the HT-patient could begin to trust the healthcare provider, there might be a window of opportunity to instill hope in the patient-victim’s mind. This hope could lead the victim to be encouraged about receiving support, and to leave her perpetrator. The recommendations of survivors are not only intended to better identify HT-patients in the healthcare setting, but also to identify key elements necessary to build trust between patient and provider. Without Compassionate-Care, the identification of and opportunity to assist victims of sex trafficking in the healthcare setting is limited. 

Once the healthcare provider has gained efficacy in learning how to identify red flags, the type of resources, information provided to HT-patients and who follows with assisting the HT-patient after the healthcare provider has identified potential victimization of trafficking are just as essential as the framework of care in use. This study highlights the importance of having a well-developed plan and knowledge of suitable local and national resources and partners needed in support of this population. If the HT-patient is ready to leave her trafficker, the healthcare provider and the healthcare team must be ready to respond to her immediate needs. In cases where HT-patients of sex trafficking are willing to share their status and ready to leave their current situation, this study found a great need for a plan that ensures immediate protection and integrated support. If a protocol or plan is not in place, there are limited opportunities to assist sex trafficking HT-victims further. It is understandable that resources for patients who have been identified as victims of HT can be challenging to find; especially in this current strained healthcare system of the U.S. This is why a collaborative model to assist and address the needs of HT-patients is essential in anti-trafficking efforts as earlier stated [6, 10, 25, 28].

Additionally, types of information displayed, and its formatting are essential as well. Having posters displayed at the healthcare setting for everyone to see seems to not only show there is institutional awareness of the problem, while simultaneously encouraging the HT-patient to trust the particular setting. Having resource-rich information disseminated to the HT-patient that is hidden from perpetrators is also important for her safety and the future opportunities for the HT-patient to return to the same medical setting. These recommendations point to the imperative of priority-ranking the eradication of the victimization through the implementation of creative ways to address their condition. They live in constant danger under the oppression of their traffickers. The ultimate goal, therefore, is to keep her safe, build rapport and trust in the context of patient-provider interaction, and to offer opportunities for future intervention so she can exit her victimization successfully.

Lastly, if a trauma-informed, victim-centered and compassionate care framework can be implemented, it would be fitting that healthcare settings would set up a peer-to-peer counseling system. Through this system, identified victims could be further assisted by peers whom they could find trustworthy given their similar victimization experience. This would not only reflect a victim-centered approach to care, but it will also allow for the integration of fellow survivors in the future intervention of other HT-patients. This approach to care seems to result in a two-fold outcome. Firstly, it seeks to facilitate a greater prospect for building trust and rapport with the HT-patient. Secondly, it could also empower other survivors as they assist in the process of intervention.  Showing HT-patients that the healthcare provider is someone who cares and is willing to go the extra mile by listening to the HT-patient with empathy offers the potential to build rapport, trust and provide a more integrated process through the framework of Compassionate Care. These are vital components for assisting and supporting such a population in healthcare settings, including similar interactions with other frontline personnel.”

Point 6: Relatedly, I encourage you to find a label other than victim or HT-patient for individuals in need.

Response to Point 6:

Please see Response to Point 2. Same.

Point 7: Reference the screening health care providers may (or may not) already be providing and use respondents to assess what works and what doesn’t. There may be things health care providers are already doing that should be directly addressed in the paper. I know I am always screened for mental health, domestic or sexual violence or other problems when I visit a health care setting. The paper discusses that in one spot. Did other interviewees mention this? Did they get intake forms? Was what they wrote ignored? That is important information for providers. What of the intake process is helpful and not helpful for the individuals you interviewed? How do your respondents think they should gather and use that information?

Response to Point 7:

We agree, that those are great questions. In this study, participants did not talk about the intake form, however. Nonetheless, we have suggested “Future Recommendations” by stating the following,

“Future research could also gather more recommendations from survivors in other non-clinic-based health settings such as within the mental health and behavioral health care systems.  In the current study, only one survivor spoke about a mental health system, but survivors do interact with social workers in other systems who could serve as first responders as well. Furthermore, findings from this study indicate a need to increase the systematic ways to track HT-patients in the HCS into a national database. A national database would assist given the migratory nature of some trafficking rings where victims of HT are moved from state to state. Overall, more research is needed to inform best practices for the early identification and detection of human trafficking; specifically, when applying the framework of Compassionate Care to this vulnerable population.” [page 21].

Point 8: Information on housing, health care, etc. seems easy to provide without worrying about whether someone is trafficked vs. in an abusive situation. I would highly recommend the authors make more of providers’ abilities to provide that information in a respectful and empowering way regardless of whether they deem someone trafficked or not.

Response to Point 8:

We have updated the manuscript content to the following,

This Compassionate Care approach to care seems to offer the potential for additional positive outcomes in the context of the provider-patient relationship as well as patients’ health outcomes both of which are needed outcomes among patient-victims of HT treated in the healthcare setting [52]. This approach and applied skill to the care of patient-victims of trafficking has the potential to facilitate a breakthrough in their interaction, assessment of needs, and provision of suitable resources for paving a successful exiting of their oppression. A Compassionate Care approach could also be applied to other vulnerable patient-victims that frequent healthcare settings. In other words, it is not limited to HT-patients, but any other vulnerable population that visits the healthcare setting and whose needs may overlap with HT-patients.  [page 19-20].

Point 9: Address anything your interviewees may have said that would be helpful in addressing cultural differences or attend to potential biases against overly sexual women, trans individuals or racial minorities. There is a way to just change a few places the wording that I think will solve most of the problem. Half of the interviewees were not white, yet there is nothing in here dealing with racial and ethnic biases. Interviewees included males, but there were no specifics in the narratives about this relatively unique group.

Response to Point 9:

We completely agree with the Reviewer 1 that issues of race, and gender differences are important in the context of treating HT-patients in the healthcare setting. However, as stated before, this study was not designed to answer those particular questions individually, and the participants did not address these issues during the interviews. Nonetheless, the applied theory of Intersectionality acknowledges not only the issues of gender and race but sexism, xenophobia, racism and so forth. It is through these lens that these findings must be interpreted and applied. We added the definition of health also. This definition provides a context of a holistic approach to care. HT-patients do not only have physical needs, but many other ones. Therefore, readers must understand that the voices of HT-survivors in this study must think of both this theory and a holistic approach to better understand their recommendations. Thus, in section 1.6 Theory, we have revisited and updated the text to be clearer. It now reads as follows,

...”Therefore, seeking to understand the experiences of survivors of sex trafficking can awaken the sense of awareness and openness to the wisdom derived from their lived experience. The ability to integrate their important recommendations for better healthcare practices and assessments when serving potential HT-patients in healthcare settings can help in the formulation of much needed holistic healthcare protocols and practices.  Moreover, Intersectionality theory is relevant to our understanding of the importance of their noted recommendations in that their experiences were contextualized by a range of interconnections of oppression including but not limited to racism, sexism, misogyny, xenophobia, classism, heterosexism, economic discrimination, inequities, and so on. Thus, the recommendations presented in this study are a result of these junctions.  Most importantly, the voices of these survivors of HT can inform daily practices for healthcare professionals and other frontline personnel in order to create a care that is grounded in the proposed framework here presented—Compassionate Care, along with the other principles of trauma-informed care [6-7, 9, 42].   

Lastly, the definition of health established by the World Health Organization’s constitution is an essential blueprint when addressing the needs of vulnerable populations such as HT-patients and others who need specific care beyond the presented acute physical and chronic needs. This definition and holistic approach to care must be applied when interpreting the findings of this study as well. It is important to adhere to a holistic approach when identifying and addressing the needs of HT-patients because their needs are multiple and required a multi-level approach that goes beyond the physical care [7]. This definition states that health is not only the absence of infirmity, but “is a state of complete physical, mental and social well-being” [43]. Consequently, the Intersectionality theory along with the definition of WHO for health are both important components to consider when understanding the voices of participants of this study. 

Point 10: Highlight the uniqueness of respondents’ situations as relevant to trafficking as opposed to other risks that health care providers should have attended to. There is a spectrum of consent that may or may not affect a sex working individual’s appearance in a hospital. Make clear what it was about the situation the respondents highlighted that was unique to trafficked individuals as opposed to other at-risk patients in the context of the concerns I have indicated. See specific comments below.  The intro takes way too long to get to the uniqueness of this paper. Shortening then section on the evils of trafficking and more quickly set up the problem addressed in this research by acknowledging the dilemmas health care professionals face when dealing with vulnerable individuals who may be trafficked. Your research finds that judgements that sex working patients were just “bad” and responsible for their own hardships and judgements that they are all helpless victims and don’t know what they want can both prevent individuals from getting the help they may need.

Response to Point 10:

We believe that the “evils of trafficking” are important to develop so readers can gain a deeper understanding of what HT-patients experience. Not having a deeper understanding of this “evil” will continue to leave HT-patients ignored and unidentified.

Point 11: The majority of individuals selling sex are not trafficked, but those who are need health care professionals to know how to help them.

Response to Point 11:

Indeed! Therefore, this study is about those who experienced human trafficking victimization and their interactions with healthcare providers during this period. The aim of this study was to methodologically gather their recommendations to enhance the practices of healthcare providers not only in the identification of such victims, but also in how they are treated relationally. This study is not about those who are not HT-patients.

Point 12: I suggest in the very first section make clear recommendations are based on interviews with individuals who were trafficked according to the US State Department definition, about what they felt health care professionals can do to help individuals who have experienced severe forms of trafficking. If they weren’t trafficked according to this definition, then make clear what definition you are using in defining respondents as trafficked.

Response to Point 12:

Based on Reviewer 1 we have addressed this comment stating the following,

Unfortunately, in the U.S. and around the globe, a range of vulnerable subgroups exist in society; nonetheless, this research focuses on sex trafficking survivors’ recommendations to healthcare providers regarding best practices. Given the complexities, yet similarities, of sex trafficking with other vulnerable groups; the framework of care here presented—Compassionate Care—could potentially assist healthcare providers to not only to identify, support and assist patient-victims of sex trafficking, but any other vulnerable victim they may interact with in their daily practices. Yet, it is imperative to understand that although HT victimization may overlap with other type of victimizations; for example, domestic violence, HT-patients require specific assessment and treatment in order to meet their medical needs. Failing to recognize their victimization leads to inadequately providing them with the right resources to support their transition into survivors [4-7, 9]. What it is worse, if the healthcare setting is not equipped to support such population after identification, this could place the patient-victim in a greater danger…..[pages 1-2].

Also, we had addressed this participant criteria by describing and adding a sentence to the end of the section 2.4

2.4. Eligibility Criteria

The eligibility criteria consisted of the following qualifications: a) self-identified survivor of sex trafficking within the U.S.; b) visited healthcare settings during their trafficking experience; c) were 18 years of age or older; d) were able to read, write and speak English; and e) left their victimization at least six-months prior to their participation in the study. The definition of survivor used in this study meant that all study participants were no longer being forced to commercial sexual exploitation in the context of the U.S. law definition of sex trafficking and were emotionally ready to participate in the study.  [page 5].

Point 13: P. 2 line 54 mentions ‘uniqueness’ of trafficked individuals. Yet quotes in the red flags section could be from other vulnerable or abused populations. Distinguish more clearly how health care providers can tell the difference and make that the main point of the section. For example, on page 8, lines 344 to 350, the paper mentions comorbidity of malnutrition, drug dependency and mental health. Perhaps this section should start with this. I wonder if repeated physical trauma is already a red flag for domestic violence. This relates to comments below.

Response to Point 13:

We believe we have addressed this point by stating the following,  

“Unfortunately, in the U.S. and around the globe, a range of vulnerable subgroups exist in society; nonetheless, this research focuses on sex trafficking survivors’ recommendations to healthcare providers regarding best practices. Given the complexities, yet similarities, of sex trafficking with other vulnerable groups; the framework of care here presented—Compassionate Care—could potentially assist healthcare providers to not only to identify, support and assist patient-victims of sex trafficking, but any other vulnerable victim they may interact with in their daily practices. Yet, it is imperative to understand that although HT victimization may overlap with other type of victimizations; for example, domestic violence, patient-victims of HT require specific assessment and treatment in order to meet their medical needs. Failing to recognize their uniqueness leads to inadequately providing them with the right resources to support their transition from victimization to survivors [4-7, 9]. What it is worse, if the healthcare setting is not equipped to support such population after identification, this could place the HT-patient in a greater danger…” [page 2]

Point 14: p. 2 line 59. “The U.S. defines” – What particular part of U.S. law, is this the Trafficking Victims Protection Act? The State Department? A certain state’s definition. There is a lot of inconsistency in definitions so I would mention in the narrative what law you are referring to.

Response to Point 14:

TVPA is a federal law. We updated the first sentence in the manuscript to state the following,

Two thousand twenty marks the 20th year anniversary of the Trafficking Victims Protection Act of 2000 (2000); first federal law that defined human trafficking in the 21^st century [1].

1. Trafficking Victims Protection Act (TVPA). 2000. Victims of trafficking and violence protection act of 2000. (22 USC 7102 §103), U.S. Congress.

https://www.govinfo.gov/content/pkg/PLAW-106publ386/pdf/PLAW-106publ386.pdf

Additionally,  the paragraph includes the definition of HT under federal law. It does not only explains the complexities of trafficked minors, but both labor and sex trafficking. The manuscript states,

The U.S. defines HT as a crime where the perpetrator entraps an individual and forces the victim into commercial sex acts (sex trafficking) or forced labor services (labor trafficking) [1]. HT victims usually experience force, fraud or coercion in the process of becoming trafficked. When the HT crime is committed against a minor, the absence of force, fraud or coercion does not disregard trafficking as a crime, and it is considered “severe” form of trafficking [1, 13].  When an individual is entrapped into the subjection involving “involuntary servitude, peonage, debt bondage, or slavery,” it is also considered a severe form of trafficking [1]. HT perpetrators use strategic deception, confinement, reidentification, and exposure to violence, danger, and drugs to brainwash and manipulate the child, adolescent, or adult who is sex trafficked [14]. Individuals who fall prey under trafficking are different than other vulnerable populations in that they are forced to commercial sex acts and forced labor [1]. Trafficked victims, whether in the U.S. or abroad, do not have the freedom to simply leave their perpetrators [1, 13].

Point 15: p. 2 lines 69-72. This newly added section seems to confuse the issue. Many individuals living on the streets or engaging in survival sex don’t have the freedom to leave and it is not because they are being forced by an individual. The physical injuries as described in the rest of the paper still seem important for a health care provider to notice regardless of whether or not an individual is forcing someone or not. Trafficking survivors can later participate in sex work. There is a spectrum of consent, risk factors, health needs. Address this not just in the intro, but also throughout.

Response to Point 15:

We agree, it seemed confusing. The updated version, reads as follows,

Yet, there continues to be gaps in the efforts of prevention, intervention, and legislation at multiple levels within the U.S. and abroad; especially among adult victims [7, 10- 12]. This research focuses on sex trafficking survivors’ recommendations to healthcare providers regarding best practices. Given the complexities in the victimization and identification of HT-patients; the framework of care here presented—Compassionate Care—could potentially assist healthcare providers to identify, support and assist HT-patients.  Although HT-patients may overlap with other vulnerable populations in the healthcare setting, it is imperative to understand that HT-patients require specific assessment and treatment in order to meet their medical needs. Failing to recognize their victimization leads to inadequately providing them with the right resources to support their transition to survivorship [4-7, 9]. What it is worse, if the healthcare setting is not equipped to support such population after identification, this could place the patient-victim in a greater danger.  [page 2].

The second point made; we believe has been addressed in the Discussion section.

See page 20 when we state,

This approach and applied skill to the care of patient-victims of trafficking has the potential to facilitate a breakthrough in their interaction, assessment of needs, and provision of suitable resources for paving a successful exiting of their oppression. A Compassionate Care approach could also be applied to other vulnerable patient-victims that frequent healthcare settings. In other words, it is not limited to HT-patients, but any other vulnerable population that visits the healthcare setting and whose needs may overlap with HT-patients. 

Point 16: P. 2 lines 80 & 81. The statistic that 84% of people victimized by HT have a history of childhood sexual trauma is problematic. The article cited seems to indicate the situation is more complex. This doesn’t seem central to the paper so I would delete it.

Response to Point 16:

We believe this adds to the understanding of risk-factors and it fits in the paragraph. We believed we had addressed your previous concern in Round 1. This seems to fit the context of understanding the complexities of risk-factors. However, the wording was changed so it is clearer,

Literature also points to the fact that a majority of those who have been victimized by HT, have a history of childhood sexual trauma [19, 20]. In all, addressing the wide range of risk factors could lead to reducing the vulnerability of many vulnerable subgroups, not only of those who become victims of HT.

Point 17: p. 5 lines 237-39. A bit more explanation of the study participants would be helpful. Did all these individuals fit the US State Department definition of HT (the perpetrator entraps an individual and forces the victim into commercial sex acts)? Were all of the participants forced against their will exactly as the law defines it for the entire 5.7 years? As I said above, trafficking survivors can later participate in sex work. Be clear, if you can. I know the situation of many individuals is complex, but how the respondents came to understand the violence they experienced and how health care providers may have helped or not is part of the purpose of your paper. I suspect that their self-efficacy was how they changed their situation.

Response to Point 17:

Yes, to all Reviewer 1 questions—yes- sex trafficking US definition

Yes, all were forced

Yes, average 5.7 years

We added a description to the criteria and now states as follows,

2.4. Eligibility Criteria

The eligibility criteria consisted of the following qualifications: a) self-identified survivor of sex trafficking within the U.S.; b) visited healthcare settings during their trafficking experience; c) were 18 years of age or older; d) were able to read, write and speak English; and e) left their victimization at least six-months prior to their participation in the study. The definition of survivor used in this study meant that all study participants were no longer being forced to commercial sexual exploitation in the context of the U.S. law definition of sex trafficking and were emotionally ready to participate in the study.  [page 5].

This study did not investigate the way they exit their situation.

Point 18: p. 8 Section 3.2.1. As noted above, the main point of this section needs editing. Physical injuries may be a red flag for trafficking, but they can also indicate domestic violence unrelated to trafficking, or one-time events for someone who sells sex consensually. Research finds that many vulnerable sex workers are reluctant to go to the hospital because the health care provider will either judge them as “bad,” or judge them as victim, and/or judge their partner as a trafficker. Maybe instead, introduce this section by saying that a variety of vulnerable populations experience a range of physical injuries due to domestic abuse, sexual assault, etc. and these individuals need judgement free treatment (as the second half of the article shows). However, the victims of HT told us that they were in the hospital frequently and wished that providers would review medical records to look for frequent injuries. Or better screen for domestic violence. Or whatever that would make their situation “unique.” I don’t’ want to tell the authors what to write, but to help make this first section match the second half, emphasize the points that are unique to individuals held against their will at the time they are interaction with health professionals.

Response to Point 18:

It seems that the issue here is language. We have changed the wording from “Key Red Flags” to “Potential Red Flags among HT-Patients”. We have included those changes throughout the paper. It is understandable that in the context of “unique” the word “key” could be misleading in that it zeros in the assumption of “very important.” Yet, the point here is not to have a 1, 2, 3 list of “red flags” but it’s more about noticing potential red flags [nuances]. We believe changing this word places the “red flag” section in a more “fluid” context rather than concrete.

3.2. Potential Red Flags among HT-Patients

In terms of the start of this section, the first paragraph was edited as follows,

3.2.1. Physical Injuries, Medical Records, and Other Comorbidities

Participants in the study shared their multiple physical injuries and the reasons why they visited the healthcare settings. These physical injuries experienced included, but were not limited to broken bones—jaws, legs, arms ribs, eye sockets and so forth. Other injuries resulted from assaults such as being hit, punched, thrown from one side of the room to another, rapped, or car accidents, to mention some. Yet, at other times, their lives were endangered when they tried to escape an abusive sex buyer. However, escaping at times results in major accidents and injuries. Study participants also spoke of their violent traffickers, trafficker assistants or sex buyers perpetrating intentional harm to them such as hitting or throwing them out of cars. Redd’s experiences typify the physical trauma experienced by many. Additionally, her medical record adds to the evidence of her trafficking trauma by providing an extensive medical record of her previous multiple injuries. Redd stated,

She [HCP] went back on my medical records and she was like ‘you’ve been here for a broken arm. You have been here for a lot of stuff…’ I had told them that I was hit by a car, but I really had been thrown out of the car. [In another occasion] he [trafficker] broke my arm. That was different. When hit me in the head with the pole, I [also] went to the [same] hospital. She pulled all my medical records! So she was like ‘you sure have a lot of accidents’ (sarcastic tone). I was like, ‘well, I am clumsy’.

Several participants spoke about coming to the same healthcare clinic and the importance of reviewing medical records. Although this can be challenging due to the change of information HT-patients may provide at different points of entry. Yet, even so, looking at records was a highlighted recommendation by study participants. Valery recommends healthcare providers review their medical record, if possible, to see if there are any patterns of repeated injuries. She stated,

The provider should really look at the medical records. Always look at the medical records period. If it’s something similar every time, that’s a red flag. They [HCPs] [Page 8].

Point 19: p. 9 line 334-340. If the emphasis is on frequency, the description of the shocking incident that happened to Leaf is less important than what Leaf said about what health care professionals should have done about it. The story of escape from someone taking her to a different location and Leaf jumped out of the car sounds like an incident that could happen to any sex worker, battered spouse, indeed to any individual seeking a ride from a stranger (or not). It sounds like the trafficker mentioned may have been helpful to Leaf in taking her to the ER. This is an example of a situation where “identifying” this individual as trafficked is less important than being non-judgmental in providing services. Or is it different? What made Leaf’s situation different than for example, an angry boyfriend tricking an ex into getting into the car and driving them somewhere they didn’t want to go? Emphasize what makes this unique.

Response to Point 19:

This study seeks to gather the recommendations of survivors of HT to deepen the understanding of their experiences so that HCP can have a more compassionate view of their patients and walk away from what Reviewer 1 characterized as “whore stigma.” We agree these experiences could be similar to those who are not HT-patients. This is why identifying an HT-patient can be very difficult if the different “clues” are not integrated into a whole context of several red flags. Study responses shared their recommendations in the context of their HT experience. Although what happened to Leaf could have also had happened to someone else, it does not take away her experience as a human trafficking victim who was constantly abused by her trafficker and sex buyers.  

The process of identification should not rest on the shoulders of one provider, as shared above, but on a team of experts (including survivors who are working in hospitals) to assist HT-patients and others who may resemble similar overlapping characteristics as we have suggested here in the discussion. Maybe those who are being abused by an abusive partner are being “groomed” to become HT victims? The fact of the matter is that we do not know. Yet, what a great opportunity it would be if the healthcare provider can identify this patient, build rapport and provide some suitable services for this person to escape her situation. Ultimately, the medical provider has the obligation to seek every patient’s wellbeing. If we refer to the definition of WHO’s for health, we will find that wellbeing is not limited to physical health, but all aspects of health. Thus, the uniqueness of HT-patients at the end of the day doesn’t matter as much as how patients--who could be HT-patients (or not)--are treated in the healthcare setting. This is what this study’s participants seem to be conveying by sharing their stories and their recommendations by asking healthcare providers to adopt a Compassionate Care approach.

We have also added the WHO’s definition of health under 1.6. Theory and Framework by stating the following,

Therefore, seeking to understand the experiences of survivors of sex trafficking can awaken our sense of awareness and openness to receive their important recommendations for better healthcare practices and assessments of potential HT-victims when they enter the different healthcare settings. Therefore, the Intersectionality theory assist to understand the study participants’ recommendations in that their experiences were contextualized by potential interconnections of oppression including but not limited to racism, sexism, misogyny, xenophobia, classism, heterosexism, economic discrimination, inequities, and so on. Moreover, these recommendations presented in this study are a result of these junctions and have the potential to inform daily practices for healthcare professionals and other frontline personnel [42].   

Lastly, the definition of health established by the World Health Organization’s constitution is an essential one when addressing the needs of vulnerable populations such HT-patients and others who need specific care beyond their physical acute and chronic needs. This definition and holistic approach to care must also be applied when interpreting the findings of this study as well. It is important to adhere to a holistic approach in identifying and addressing the needs of HT-patients because their needs are multiple. This definition states that health is not only the absence of infirmity, but “is a state of complete physical, mental and social well-being” [43].

Point 20: p. 9 Section 3.22. I suggest the same approach in this section. The point is that health care workers can use the very high frequency of visits to reproductive health services and maybe comorbidities as cues to listen more to the patients.

Response to Point 20:

Some rewording was done in this section 3.2.2

Again, the repetitive pattern of visits with different patients could point to their trafficking and exploitation and this could potentially lead to the identification of HT-patients if this and other red flags are strongly pointing to the victimization of HT. Ann shared,…

And

Moreover, medical records at community-care clinics that offer free services could point to patterns of sexually risky behaviors, as well as repetitive screenings, can signify potential red flags of sex trafficking victimization.

Point 21: p. 10 lines 380-387. This section makes clear that there are intake forms. I think the point is that respondents didn’t feel like these were attended to. This gets at an earlier concern and indicates that this section needs to be restructured. Make the point about the intake form clear before line 380. Rape or sexual trauma should trigger health care professionals to pay attention and at this level, this is not unique to trafficked individuals. The point is that your respondents said they felt that the staff at the facility should have paid attention to intake forms when they mention rape and abuse, and that these, in combination with frequency, COULD be red flags for trafficking as well, and were in their case. I suggest separating line 387 about humor from the point about the intake form. That said, also make clear what they felt the staff should have done in response to that joke to be non-judgmental and elicit why they were sharing the information.

Response to Point 21:

Based on suggestions, this subsection [page 10] was updated to the following,

Although repeated screenings, multiple sex partners, rape, abortion or any other signs of sexual trauma could be an indication of trafficking; HT-patients, at times, may share the truth in a humorous manner. Whether they do it or not, the important take away of these participants’ experiences is to pay attention to the content shared during the intake phase of the medical visit. Sharing in an inconspicuous manner may be a way of revealing their trauma without being blunt

And,

Moreover, medical records at community-care clinics or other type of healthcare settings—E.D., mental health clinics, urgent care clinics and other providers that offer free services could point to patterns of sexually risky behaviors as well as repetitive screenings can signify potential red flags of sex trafficking victimization when combined with other above discussed indicators. Lastly, taking seriously what it is shared during the intake phase of the medical visit can add important information to the identification of HT-patients.

We thank Reviewer 1 again for her/his insights and feedback. These comments and observations have led to a more clearer manuscript.

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

This article is so much improved since the first version I reviewed. I SO appreciate the care and hard work taken by the authors in revising this paper. I know this is tedious, but it has paid off.  I just have a few editing suggestions.  Some are pretty bold on my part, but I hope that’s okay.

Make sure the newly edited sections are carefully proofread. There were some issues that could be cleared up with a good proofreading.

Much of the literature has begun to appreciate that the vast majority of human trafficking is labor trafficking, but the bulk of attention has been on sex trafficking.  This paper focuses on recommendations by survivors of sex trafficking.  So please go through and make very, very clear where you are talking about all human trafficking and where you are specifically talking about sex trafficking.  For example, line 61, trafficking of a minor only refers to sex trafficking, not labor trafficking. So please go through the entire document, but especially the first few pages to correct this.

In that vein, I suggest, just to be clear, that you not abbreviate human trafficking but rather abbreviate sex trafficking. Do not use HT-patients, but rather ST-patients.  That way you are clear that labor trafficking victims may have different circumstances that probably need attention by health care providers, but you are providing advice from sex trafficking victims.  

P. 1 line 37, 38 Good in clarifying that the TVPA was important, but that it was not the first trafficking law. To make this even more clear, please edit those first two sentences to read:

“Two thousand twenty marks the 20th year anniversary of the Trafficking Victims Protection Act of 2000 (2000); the most significant federal law defining and setting penalties for human trafficking in the 21^st century.”  And delete the sentence “For the first time through the creation of tis law, human trafficking (HT) was defined and penalized by the United States (U.S.) government.”

I realize this is highly unusual for a reviewer, but if you will indulge me, I want to suggest some specific wording changes in one section.  Perhaps this will help communicate the precision that I have been encouraging in framing your important research, especially in articulating the differences between the needs of sex workers who do so by choice and circumstance and those who experience coercion.  So please consider changing the wording of section 1.1 Victims and Risk Factors to something like this:

“Human trafficking continues to be an egregious crime committed against the most vulnerable of victims.  The TVPA defines human trafficking as the exploitation of a person for sex or labor using "force, fraud, or coercion [1]. Severe trafficking involves the “recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” [1]. But it also includes as severe trafficking anyone under age 18 who commits a commercial sex act.

"In practice, sex trafficking victims are subject to strategic deception, confinement, reidentification, and exposure to violence, danger, and drugs to manipulate them [14], factors that make their situation unique. Trafficked victims, whether in the U.S. or abroad, do not have the freedom to simply leave their perpetrators [1, 13]. 

"At the same time, a number of other vulnerable and marginalized groups appear in healthcare settings and have needs that are quite similar to those experiencing sex trafficking.  Homeless and runaway youth, those involved with the child welfare system, kidnapped youth, and others may be forced or “encouraged” by parents, older siblings and “boyfriends” to engage in prostitution [15-17].  Being physically, emotionally, and/or sexually abused contributes to victims’ vulnerability [3, 6, 13, 14, 17, 18]. Many of these individuals may not always be forced by an individual, but have few choices given their circumstances. Other social, economic, and behavioral risks influence the vulnerability marginalized populations.

"In other words, individuals who engage in prostitution do so because of choice, circumstance, and coercion, and the framework of care we present -- Compassionate Care -- can do a great deal to direct all of these individuals to needed services. The needs of individuals who sell sex by choice or circumstance may be best served by meeting food, housing and healthcare needs first, and encouraging them exit the sex industry only if they desire.  But the needs of those who do not have the ability to choose are quite different, and they have specific assessment and treatment needs. As our research will show, healthcare providers must very carefully assess individuals to provide the right kind of care to the right individuals.”

Given that this research is directed to healthcare providers, in p. 3, Section 1.3 Points of Entry, I strongly suggest taking out references that seem addressed to law enforcement in that first paragraph.  If healthcare providers aim initially toward turning victims over to law enforcement, it may scare victims away. If law enforcement cannot find a trafficker, they are likely to arrest the individual for prostitution.  So, for example, in the first paragraph, delete the first sentence on line 97, delete “along with law enforcement” on line 99.  And on line 106 add, (c) prepare victims and pass information on to law enforcement investigators where appropriate.”

P.2 line 32, change “recognize their own need for assistance” to “recognize their needs.” This seems to give them a bit more agency, which is what Compassionate Care is about.

P.6 line 251 in the context of the U.S. law definition. Given widely varying definitions of trafficking across states, do you mean federal law, ie TVPA?  Or individual state laws?  Were their traffickers sentenced under US law? Or was it a definition used to make them eligible for those programs?  If so what was that law?  If it was the same as the TVPA or a TVPA derived law, just say that.

The rest is just fine.  

Author Response

Response to Reviewer 1 Comments-Round 3

To Reviewer 1: 

The authors of this manuscript would like to thank Reviewer 1 for taking the time to review and comment on these last changes of the submitted revision for Round 2. The coauthors of this manuscript strongly believe that the updated content and edits address the observations Reviewer 1 has brought forth in her third round of reviews.  Based on our understanding of them as well as our rationale, we have edited the manuscript accordingly.

The journal had all authors confirm the new authorship and order changes. 

Point 1: Much of the literature has begun to appreciate that the vast majority of human trafficking is labor trafficking, but the bulk of attention has been on sex trafficking. This paper focuses on recommendations by survivors of sex trafficking. So please go through and make very, very clear where you are talking about all human trafficking and where you are specifically talking about sex trafficking. For example, line 61, trafficking of a minor only refers to sex trafficking, not labor trafficking. So please go through the entire document, but especially the first few pages to correct this.

Response to Point 1:

Point 2: In that vein, I suggest, just to be clear, that you not abbreviate human trafficking but rather abbreviate sex trafficking. Do not use HT-patients, but rather ST-patients. That way you are clear that labor trafficking victims may have different circumstances that probably need attention by health care providers, but you are providing advice from sex trafficking victims.

Response to Point 2:

HT was changed to ST when appropriate throughout the manuscript.

Point 3: P. 1 line 37, 38 Good in clarifying that the TVPA was important, but that it was not the first trafficking law. To make this even more clear, please edit those first two sentences to read:

“Two thousand twenty marks the 20th year anniversary of the Trafficking Victims Protection Act of 2000 (2000); the most significant federal law defining and setting penalties for human trafficking in the 21st century.” And delete the sentence “For the first time through the creation of tis law, human trafficking (HT) was defined and penalized by the United States (U.S.) government.”

Response to Point 3:

The beginning of the manuscript was updated to reflect the following:

The Trafficking Victims Protection Act (TVPA) was enacted in 2000 as one of the most significant federal law of the 21^st century. This law defined and criminalized human trafficking with the goal of eradicating the crime and protecting its victims [1].

Point 4:

I realize this is highly unusual for a reviewer, but if you will indulge me, I want to suggest some specific wording changes in one section. Perhaps this will help communicate the precision that I have been encouraging in framing your important research, especially in articulating the differences between the needs of sex workers who do so by choice and circumstance and those who experience coercion. So please consider changing the wording of section

1.1 Victims and Risk Factors to something like this:

“Human trafficking continues to be an egregious crime committed against the most vulnerable of victims. The TVPA defines human trafficking as the exploitation of a person for sex or labor using "force, fraud, or coercion [1]. Severe trafficking involves the “recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” [1]. But it also includes as severe trafficking anyone under age 18 who commits a commercial sex act.

Response to Point 4:

As we re-read several times the definition as it is stated in the TVPA, we edited these sentences  as follows:

Human trafficking continues to be an egregious crime committed against the most vulnerable of victims, particularly women and children [13]. Within human trafficking there are different types of exploitation. TVPA defines sex trafficking when there is “recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act” [1]. When this type of crime is committed against a minor, the absence of force, fraud or coercion does not disregard trafficking as a crime, and it is considered a severeform of trafficking [1, 13].  Other severe forms of trafficking occur when a person is entrapped into “involuntary servitude, peonage, debt bondage, or slavery”[1].

Point 5:

"In practice, sex trafficking victims are subject to strategic deception, confinement, reidentification, and exposure to violence, danger, and drugs to manipulate them [14], factors that make their situation unique. Trafficked victims, whether in the U.S. or abroad, do not have the freedom to simply leave their perpetrators [1, 13].

Response to Point 5:

Done. Revised as suggested.

Point 6:

"At the same time, a number of other vulnerable and marginalized groups appear in healthcare settings and have needs that are quite similar to those experiencing sex trafficking. Homeless and runaway youth, those involved with the child welfare system, kidnapped youth, and others may be forced or “encouraged” by parents, older siblings and “boyfriends” to engage in prostitution [15-17]. Being physically, emotionally, and/or sexually abused contributes to victims’ vulnerability [3, 6, 13, 14, 17, 18]. Many of these individuals may not always be forced by an individual, but have few choices given their circumstances. Other social, economic, and behavioral risks influence the vulnerability marginalized populations.

"In other words, individuals who engage in prostitution do so because of choice, circumstance, and coercion, and the framework of care we present -- Compassionate Care -- can do a great deal to direct all of these individuals to needed services. The needs of individuals who sell sex by choice or circumstance may be best served by meeting food, housing and healthcare needs first, and encouraging them exit the sex industry only if they desire. But the needs of those who do not have the ability to choose are quite different, and they have specific assessment and treatment needs. As our research will show, healthcare providers must very carefully assess individuals to provide the right kind of care to the right individuals.”

Response to Point 6:

It seems that our point is misunderstood in this part of manuscript. These couple of sentences are meant to describe who is more likely to become a victim of sex trafficking. Although we understand that these different subpopulations, if analyzed outside the context of sex trafficking, can be seen as they engage in prostitution as a way to survive, that is not the point here. The point here is to provide some background information as to “who” is at higher risk to  become a victim of sex trafficking based on previous literature. Nonetheless, we appreciate that Reviewer 1 pointed out the need for clarity. Thus, for more clarity, we have moved and edited our second level subheading to 1.1 Marginalized Groups with Higher Risks for Sex Trafficking . The updated section now reads as follows:

1.1. Marginalized Groups with Higher Risks for Sex Trafficking 

In society, there are several marginalized groups who are at a higher risk of becoming trafficked. Their vulnerabilities originate from a diversity of needs—physical, emotional, social, and financial among others. Additionally, experiences of past trauma and abuse also contribute to becoming a trafficked victim. The literature has identified several characteristics among survivors that speak to the susceptibilities of becoming an easier target for sex traffickers. These characteristics include: a) homelessness or runaway;  b) experiences of abuse or trauma—physical, emotional or sexual; c) being part of juvenile correction or child welfare systems; d) between the ages of 12 and 14; and e) member of a non-conformant gender group – LGTBQ [3, 6, 13-20]. In all, addressing the wide range of risk factors could lead to also reducing the number of victims of human trafficking.

Point 7:

Given that this research is directed to healthcare providers, in p. 3, Section 1.3 Points of Entry, I strongly suggest taking out references that seem addressed to law enforcement in that first paragraph. If healthcare providers aim initially toward turning victims over to law enforcement, it may scare victims away. If law enforcement cannot find a trafficker, they are likely to arrest the individual for prostitution. So, for example, in the first paragraph, delete the first sentence on line 97, delete “along with law enforcement” on line 99. And on line 106 add, (c) prepare victims and pass information on to law enforcement investigators where appropriate.”

Response to Point 7:

We appreciate the comment and the suggestion. Although we have not deleted the suggested sentences (we believe—based on literature—that a collaborative model must include trained law enforcement for the safety of all people involved—providers and victims, as well as  to address the gravity of the crime). However, we have modified the text to make this point clear in the manuscript. Now it reads as follows:

1.3. Points of Entry—Opportunities for Intervention

 To appropriately address human trafficking—both sex and labor, it is vital that medical providers, social services professionals and trained law enforcement agents, follow effective frameworks and safe protocols to perform appropriate measures in order to assist in the transition from victimization to survivorship when the opportunity arrives [14]. The literature speaks of collaborative models that work best in addressing ST-patients’ needs in the context of healthcare settings. Both coordination of services as well as needed resources to move beyond victimization are essential [6, 10, 25, 28].  In the context of healthcare settings, frontline staff, clinicians, and social workers can take first steps to: (a) identify human trafficking victims and perpetrators; (b) stabilize and control the human trafficking situation; (c) prepare victims and pass information on to trained investigators, and; (d) refer victims to specialized service providers [24]. Therefore, multidisciplinary teams can provide more efficacious outcomes from victimization, survivorship to restoration [14].

Point 8:

P.2 line 32, change “recognize their own need for assistance” to “recognize their needs.” This seems to give them a bit more agency, which is what Compassionate Care is about.

Response to Point 8:

This part was updated and it no longer contains the mentioned sentence. It reads as follows:

This research focuses on sex trafficking (ST) survivors’ recommendations to healthcare providers regarding best practices. Given the complexities in the victimization and identification of ST-patients; the framework of care here presented—Compassionate Care—could potentially assist healthcare providers to identify, support and assist ST-patients.  Although ST-patients may overlap with other vulnerable populations in the healthcare setting, it is imperative to understand that ST-patients require specific assessment and treatment in order to meet their medical needs. Failing to recognize their victimization leads to inadequately providing them with the right resources to support their transition to survivorship [4-7, 9]. What is worse, if the healthcare setting is not equipped to support such a population after identification, this could place the ST-patient in a greater danger. 

Point 9:

P.6 line 251 in the context of the U.S. law definition. Given widely varying definitions of trafficking across states, do you mean federal law, ie TVPA? Or individual state laws? Were their traffickers sentenced under US law? Or was it a definition used to make them eligible for those programs? If so what was that law? If it was the same as the TVPA or a TVPA derived law, just say that.

Response to Point 9:

Done. Revised as suggested.

Thank you for your time and recommendations. 

Author Response File: Author Response.docx