Culturally Sensitive Care for Survivors of Child Trafficking

by Anumitha Aravindan

 Survivors of trafficking are at high risk of poor mental health outcomes due to the immense physical, emotional, sexual, and/or psychological trauma they have endured (Conley et. al. 2023, Stockl et. al. 2024). Of these outcomes, post-traumatic stress disorder (PTSD), anxiety, and depression are common, with one study conducted in England reporting 78% of female and 40% of male survivors having symptoms of one or more of these conditions (Altun et. al. 2017). Another study utilizing electronic health records of children using mental health services observed that 22% of trafficked children had a diagnosis of PTSD, although a higher percentage appeared to have complex post-traumatic stress disorder (CPTSD) symptoms as well (Ottisova 2018). The prolonged traumatization lead many survivors to experience extreme anxiety, or eventually, turn to self-harm or suicide. One study examining clinical records of adult trafficking survivors in London found that 25% of individuals had engaged in self harm while accessing secondary mental health services. When comparing records of all patients who had engaged in self harm, survivors of trafficking were more likely to have been admitted to a psychiatric inpatient facility compared to non-trafficked individuals. With regards to suicidal ideation and attempts, estimates vary, but one study of youth experiencing homelessness in Kentucky and Indiana observed that survivors of sex trafficking, compared to individuals who had not been trafficked, were almost 4 times more likely to have experienced suicidal ideation (Frey et. al. 2019). Another analysis of one hundred thirty-eight sex trafficking survivors seeking care at the PurpLE Clinic in New York City found that one third of all patients indicated having thoughts of being better off dead or hurting themselves (Ravi et. al. 2022). The consistent exploitation of their vulnerabilities, along with a lack of agency, means that many survivors are left without a sense of safety. This may also explain the high rates of re-victimization amongst survivors. One study reports that about 1 in 5 child victims become re-victimized, with the median timeframe between the first and subsequent periods of trafficking being 6 months (Cutbush-Starseed et. al. 2024). Given that trafficking is associated with a multitude of adverse health outcomes, along with high re-victimization rates, it is no surprise that the road to recovery is complex, and by no means linear.

It is important to make several considerations in providing care for survivors of trafficking. Autonomy and informed decision making are highly important. It is imperative that healthcare providers fully explain care plans to patients, and that the patient has agency over healthcare related decisions unless a situation requires a designated proxy. Equally important, however, is culturally competent care, which is defined as care tailored to a patient’s cultural background and beliefs. With regards to survivors of trafficking, cultural differences may heavily influence how survivors perceive their own experiences. This leads to major variability in the manifestation of different mental health problems, which affects how survivors may engage with healthcare providers or with their care plans. One study of a sample of adolescents who had experienced major depressive episodes (MDE) found that despite similar levels of depression symptoms, adolescents who identified as Asian, Latino, or African American were more likely to report interpersonal problems, such as fighting with others, or getting into trouble at school, as reasons for needing mental health treatment, whereas white adolescents were more likely state suicidal thoughts or attempts or depressive feelings as reasons for seeking treatment (Cummings 2014). Multiple studies also show that rates of mental health services amongst people of color also appear to be lower compared to their white counterparts. One study utilizing data from the National Survey on Drug Use and Health from 2008 through 2020 revealed that while the use of mental health treatment increased as a whole, minority groups were less likely to receive treatment compared to white individuals, especially for individuals identifying as African American or Asian (Sheehan et. al. 2024). It is important to recognize that cultural stigma can lead to significant delays in care; however, shifting focus to addressing these delays without considering the patient’s perspective would not only be ineffective, but may make the patient more hesitant to continue care with their current provider. One study amongst undergraduate students accessing university mental health services found that positive perceptions of cultural competency were associated with lower rates of treatment non-adherence (Hooper 2013).

With that being said, there are major disparities with regards to diagnosis and treatment of mental health conditions in ethnic minorities, which can impede patient recovery even if access to care has improved. Multiple studies of patients accessing psychiatric services found that ethnic minorities were far more likely to be diagnosed with conditions such as schizophrenia compared to white patients (Choi et. al. 2012, Maura et. al. 2017). A second study examining ambulatory care services for patients diagnosed with schizophrenia-spectrum disorders (SSDs) found that African American patients were overrepresented in all SSD categories, and more likely to be referred to another physician for care compared to white patients (Bazargan-Hejazi et. al. 2023). This implies detrimental outcomes for survivors of trafficking who may be seeking mental health services. Misdiagnosis and improper utilization of available resources could cause patients to feel more isolated, increasing the chances that they may be lost to follow up, or worse, re-victimized later on.

Language barriers also continue to pose a major problem, some of which cannot be addressed by translation services alone. For example, a study of patients admitted to a psychiatric facility in Switzerland found that individuals with lower language proficiency had higher rates of compulsory admission, medication, as well as seclusion or restraint. Rates of seclusion, restraint, and medication were also higher even for individuals who were admitted voluntarily (Miteva et. al. 2022). A second study examining mental health service uptake among child trafficking services in Cambodia noted several barriers to seeking treatment; these included unfamiliarity with the purpose of counseling services, as well as difficulties with applying Western understanding of psychological symptoms and adapting it to suit the needs of individuals from other cultural backgrounds. Researchers used child exploitation psychosocial assessment tools (CEPAT) specific to the Cambodian population, but researchers noted that there were difficulties in translating numerous words associated with feelings into the Khmer language (Aberdein et. al. 2015).

With regards to caring for survivors of child trafficking, these findings illustrate that cultural competency is essential to understanding how each patient may understand their own experiences, the type of care they may prefer, and resources that would be most effective towards improving their health. It is the provider’s responsibility to balance their own clinical judgement with the patient’s priorities to determine what existing options would be the most beneficial. Providers should also strive to better understand the communities that they serve. For example, having knowledge regarding immigration, refugee, and/or nondiscrimination laws can help healthcare providers better understand barriers that patients from marginalized groups face in obtaining access to support from various entities. These can include law enforcement, child protection agencies, and social services, among others (Rhodes et. al. 2020). Lastly, providers should use any resources necessary to ensure effective communication with their patients, ensuring that the patient understands, agrees with, and is able to contribute to their own care plan. Ultimately, by striving to improve and prioritize culturally sensitive care, physicians and other healthcare providers will be able to better advocate for patients from vulnerable communities.

Citations

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