When Families Become Perpetrators: A Case Series on Familial Trafficking

White CN, Robichaux K, Huang A, Luo C. When Families Become Perpetrators: A Case Series on Familial Trafficking. Journal of family violence. 2024;39(3):435-447.

Abstract: 

Purpose

Human trafficking occurs when a person uses force, fraud, or coercion to obtain an act or service from another person. While trafficking is often depicted as a crime perpetrated by strangers, recent literature has found family members can also be traffickers. Only four peer reviewed studies have specifically examined familial trafficking.

Method

The current study builds upon this sparse literature by reviewing medical charts of patients in a large hospital system who were identified as survivors of familial trafficking between October 2017 and September 2021. Descriptive statistics are reported for all 39 identified patients.

Results

Majority of patients were female (92.3%) and under 36 years old (56.4%; M = 34.2, SD = 11.6). Despite most patients now being adults, all except one were minors at the time the trafficking began. Parents were the most common perpetrator (66.7%) followed by aunt/uncle (12.8%). Nine cases were chosen, given level of detail in patient charts, to be highlighted in a case series to further describe the experiences of these survivors. Cases examined included labor trafficking, parents as perpetrators, intersection of substance use, and males as victims. Force was the most common means of control used and often manifested as physical or sexual abuse that preceded the exploitation. Another reoccurring theme was substance use being a factor when parents were perpetrators.

Conclusion

The findings from this paper can help inform screening techniques by encouraging providers to inquire about familial relationships. Findings may also be helpful for providers working with this population and future research endeavors.

Human trafficking (furthermore referred to as 'trafficking') is a global public health problem with immense physical and mental health consequences (Kiss et al., 2015; Ottisova et al., 2016; Zimmerman et al., 2008). Trafficking, sometimes referred to as "modern slavery," includes "situations of exploitation that a person cannot refuse or leave because of threats, violence, coercion, deception, and/or abuse of power" (International Labour Office et al., 2022, p. 22). Several barriers exist to estimating the prevalence of trafficking; however, the International Labor Organization (International Labour Office et al., 2022) estimated that in 2021, 50 million people globally were "in modern slavery" at any given moment. Modern slavery includes forced labor and forced marriage, and is meant to capture various forms of exploitation (International Labour Office et al., 2022). For example, forced labor can include the commercial sexual exploitation of adults and children. In 2021, the US National Human Trafficking Hotline received 10,360 unique reports of trafficking. Of these reports, 7,499 involved sex trafficking, 1,066 labor trafficking, 400 sex and labor trafficking, and 1,395 were unspecified (Polaris, 2022).

Current research and mainstream media have focused on trafficking as perpetrated by a stranger and typically involves a girl or young woman (Greenbaum, 2020; Koegler et al., 2022). While this can occur, the literature and community agencies are beginning to show that trafficking by a family member is more common than previously understood (Koegler et al., 2020; Raphael, 2019; Sprang & Cole, 2018). Prior studies have found that familial instability increases risk for trafficking (Surtees, 2008). Zimmerman and colleagues (Zimmerman et al., 2008) used post-trafficking survey data from several European countries and found that over 50% of the trafficked women in the sample had experienced physical or sexual abuse (often by father or stepfather), prior to being trafficked. Troubled family life not only increases risk for trafficking by others (Hornor et al., 2020), but can also lead to family members trafficking each other (Greenbaum, 2020).

Familial trafficking may be unique from other forms of trafficking because of the familial ties. For instance, use of force, fraud, or coercion are the hallmark identifiers for classifying abuse as trafficking, but how these elements are utilized and experienced may look different when the abuser is a family member, and the victim is a child. From a developmental perspective, children are often taught to do what their caregivers tell them. Kohlberg's theory of moral development asserts that children in the preconventional level (under 8 years old) adopt a moral code that is shaped by the adults around them. For instance, if a behavior (i.e., sexual acts) leads to a reward (i.e., parental praise), then it must be a good behavior. Children in this level are concerned with obedience and learning to avert punishment. In the second level of development, the conventional level, youth are concerned with maintaining interpersonal relationships and maintaining social order. In this level, family expectations are viewed as valuable, even despite possible negative consequences. Group loyalty can lead to justifying current conditions (i.e., working for a family member without pay). It is not until the final postconventional level that a person is fully aware of individual rights and principals such as human rights (Kohlberg & Hersh, 1977).

Familial Trafficking Literature Review

Regarding prevalence, the percentage of reported familial trafficking cases ranges from 3-44% (Raphael, 2019). Often, reports and studies do not identify traffickers by type (i.e., family, intimate partner, employer, etc.) and/or do not include "familial" as a type of trafficking experienced (Raphael, 2019). According to a retrospective case review from four social service agencies in Florida, the age at which a child first experienced exploitation was connected to who the perpetrator was (Reid et al., 2015). Children exploited by family members were noted to be as young as 4 years old, whereas children exploited by non-family members were as young as 11 years old.

To our knowledge, only 4 peer reviewed studies have focused on examining familial trafficking (Koegler et al., 2022; Raphael, 2019; Reid et al., 2015; Sprang & Cole, 2018). In a document analysis study with secondary data from 59 survivors of trafficking in a major US Midwest city, intimate partners were the most frequently reported perpetrators (n = 32), followed by other family members (n = 12; Koegler et al., 2022). Other family members included parents, uncles and aunts, and other extended relatives. In one case, a teen girl reported being awoken in the middle of the night by her stepfather to have sex with a "John," or buyer. In another case of labor trafficking, to help pay off a mother's gambling debt, a child was sent to the US to live with their aunt and uncle. The child was forced to work in restaurants and was never paid for the work (Koegler et al., 2022).

Familial trafficking was also found to happen among adults. The Koegler study analyzed data from an adult woman whose sister and brother-in-law forced her to work 7 days a week for up to 80 hours and only paid her $20-30 per week (Koegler et al., 2022). When she tried to advocate for higher pay, her sister alleged she was paying for the victim's daughter's education, but the child went to public school. This study was integral in expanding the understanding of the continuum of trafficking within the domestic setting, however the study focus was not exclusive to familial trafficking.

In 2019, Raphael published an article profiling the commercial sexual exploitation of children by their parents. Raphael conducted in-depth interviews with four survivors and examined numerous news reports and databases to explore the prevalence and nuances of this phenomenon. The article highlighted the inherent power dynamics (coercion) between parents and their children, and the abuse (force) by parents that often preceded, and continued during, the exploitation. The four cases included three young girls and one boy sexually abused and then sold by their fathers for various reasons, mostly within the context of "organized sexual abuse". The cases mentioned several different opportunities for intervention that were missed by other adults in the children's lives, including the non-offending parent, teachers, hospitality workers, and healthcare providers. Both the Raphael (2019) and Sprang & Cole (2018) studies focused only on sex trafficking among minors, thus missing cases of labor trafficking and familial trafficking among adults.

A non-peer reviewed study examined the prevalence of trafficking among homeless and runaway youth (n = 641) across ten US cities (Murphy, 2016). Although not specific to familial trafficking, the study reported interviewing 9 youth who were sex trafficked by family members. One youth said her mother "gave her" to a man so the family could have a place to sleep (Murphy, 2016). Sixteen of the study participants endorsed being labor trafficked by parents or immediate family members. These youth described being forced to sell drugs by family members who were involved in the illegal drug industry. One participant spoke of selling drugs as the family business and feeling like they had no other choice but to comply (Murphy, 2016).

In addition to these studies, survivors of familial-controlled trafficking have contributed to the literature through books and book chapters (Roche, 2014). In a book chapter on sex trafficking of children in the US, K.D. Roche, details their story of being trafficked for eight years by an uncle and cousin (Jordheim, 2014). Roche's uncle used physical force, and his standing within the family, to coerce them into engaging in sex acts. Roche was made to believe the trafficking was their fault, and when they attempted to disclose the trauma to their mom and aunt, they were met with doubt, denial, and complacency (Roche, 2014). This book chapter and the aforementioned studies highlight the reality that trafficking by family members exists; however, due to sparse literature on the topic, there are unknown nuances of this type of trafficking.

Current Study

The current study will present case examples of familial trafficking experienced by patients identified by a hospital-based anti-human trafficking program within a large southwestern US city. Prior research suggests survivors of trafficking are more likely to be admitted to psychiatric units than non-trafficked individuals (Borschmann et al., 2017; Cary et al., 2016; Oram et al., 2012), making this an ideal setting for identification. Most patients referred to the hospital's anti-trafficking program received inpatient psychiatric care and/or outpatient psychotherapy services. Patients were also referred to the program from the emergency center and medial units. A retrospective chart review of all positively identified patients (n = 396) referred to the program was conducted to determine the prevalence of familial-controlled trafficking across the lifespan. This case series can help guide clinicians in identification and treatment for this unique population, as well as researchers and advocates interested in preventing or mitigating familial trafficking.

Method

Setting & Participants

This study took place at a Level 1 trauma hospital within a fully integrated healthcare system in a large southwestern US city. In October 2017, a group of faculty psychiatrists and psychologists at the hospital created an anti-human trafficking program, in partnership with the city, to address the gap in the identification, care, and treatment of patients who had experienced trafficking. A postdoctoral psychology fellow and clinical social worker were hired to provide direct services to patients such as therapy and case management. Though located on the hospital's inpatient psychiatric unit, where the faculty members practice, the program serves the entire hospital including the emergency center, medical/surgical floors, and outpatient specialty and psychiatry clinics.

Participants

From October 2017 to September 2021, the program received 559 referrals for services, of which 396 individuals screened positive for a history of sex and/or labor trafficking. The current study's sample included a subset of patients who experienced familial trafficking (N = 39). Nine of the 39 patient cases are presented as a case series to explore the nuances of trafficking by family members, including patients who were trafficked for labor, by a parent, to support a family member's substance use, and who identified as male. These 9 cases were chosen due to them having enough details in the chart to report.

Hospital Procedures for Anti-Human Trafficking Program Referral

Referrals to the program may originate from providers within the healthcare system (e.g., psychiatrists, nurses, social workers, etc.) or from community partners (e.g., anti-trafficking organizations, law enforcement, self-referrals, etc.). Within the healthcare system, providers can refer patients following a suspicion or disclosure of trafficking and the fellow and/or social worker can meet with the patient to conduct a human trafficking screener based on best practices determined by the National Human Trafficking Training and Technical Assistance Center (NHTTAC), Polaris, and the Rapid Appraisal for Trafficking (Chisolm-Straker et al., 2021). Once trafficking status is determined, program personnel work with patients to address emergent social and psychological needs and provide linkage to community-based services for ongoing case management, as needed.

Study Procedures

For the current study, a retrospective chart review in the healthcare system's electronic medical record was conducted of all 396 positively identified patients to identify those with experiences of familial-based trafficking. Two of the study authors met to create a codebook including variable information and where information was located within the medical records. These two authors then trained the two additional authors on how to use the codebook and extract data from the medical records system. All authors met periodically to resolve any disputes in coding. To standardize the data, information was extracted beginning at the point of first encounter or referral to the anti-trafficking program because some patients had been seen in the healthcare system for decades prior to being identified by the program while others were new to the hospital system. None of the validated screening tools above explicitly inquire about familial involvement, and program personnel did not add a question into their screening protocol to explore this topic until after the study began. Therefore, knowledge of patients' experiences with familial trafficking came from either the provider free-text notes or the patient positively answering the question when asked by program personnel. Of the 396 charts reviewed, 39 charts were notable for familial involvement in trafficking. Specific vulnerabilities of these patients, and the psychological consequences of enduring this type of trafficking, as well as demographic information was recorded from the charts. Nine cases out of the 39 were chosen based on level of detail provided in the chart to be highlighted for a more in-depth analysis of familial trafficking experiences. The institutional review boards of the hospital and medical univeristy approved the use of de-identified archival data for research purposes and therefore did not require informed consent.

Patient Demographic Variables

All patient demographic data (e.g., gender, age, presenting problem, diagnosis, housing status) was extrapolated from patient medical records from inpatient and outpatient encounters within the hospital system. For patients who were admitted to the hospital, this information was found in the history and physical portion of the initial interview, or the discharge summary. For patients who were only seen in the outpatient clinic, this information was found in their psychiatry and psychology notes. Providers utilize varying techniques to collect this information such as directly asking the patient or relying on prior chart notes. This process is often unstructured, and it is not always clear exactly who first collected the information. For example, gender may be asked by the registration staff when the patient first enters the hospital or the triage nurse. Then when a patient sees the psychiatrist on the unit, the psychiatrist may use the gender information from the previous staff and record this in the history and physical interview note rather than asking the patient again. This process of using unstructured clinical interviews with a combination of open and closed ended questions is common standard of care in hospital settings (Asp et al., 2020; Miller, 2002; White & Ugueto, 2022).

Presenting problem is assigned by the emergency center physician who initially encounters the patient. This documentation is based on provider observation, information provided by the patient, or information provided by whoever is accompanying the patient (e.g., EMS, police, family, friend, etc.) This designation is often more of a description than an actual diagnosis, as diagnoses are reserved for the initial psychiatric evaluation and subsequent evaluations leading up to discharge. Presenting problem descriptions included, but were not limited to, "patient was brought [into the emergency center] by police due to increasing paranoia and erratic behavior," or "patient attempted to claw her left eye out." Several descriptions had overlapping aspects. For example, patient presented with "suicidal ideation and endorsing recent suicide attempt by overdose" was categorized as "suicidal ideation/suicide attempt/self-harm" instead of just "suicidal ideation." For the purpose of this study, and in an effort to retain the integrity of the data, presenting problems were categorized to best represent the fullness of the original description.

Case Series Data

All case series data was extracted from patient medical records from inpatient and outpatient encounters within the hospital system. Provider notes were reviewed beginning at the first note where patient was identified as a survivor of trafficking and connected with the hospital anti-human trafficking program. This was done to standardize the data due to extreme variability in how long patients had contact with the hospital system. Additionally, providers often retain information from prior notes regarding patient details decreasing the chance critical information was missed. Providers vary in the level of detail they include in patient charts. This detail can range from simply noting "patient was positively identified as being trafficked by their parent as a child", to a full summary of the patient's trafficking experience. Cases with enough details in the chart were selected to be highlighted in the case series and categorized by theme.

Results

Descriptive Statistics on All Identified Patients

Table 1 displays demographic information for all 39 patients who were identified as experiencing familial trafficking. Majority of patients were female (92.3%) and under 36 years old (56.4%; M = 34.2, SD = 11.6). Most patients were African American//Black (43.6%) or White (30.8%), and were born in the U.S. (84.6%). Despite most of the patients now being adults, all except one were minors at the time the trafficking began. Parents were the most common perpetrator (66.7%) followed by aunt/uncle (12.8%). Suicidal ideation, suicide attempt, or self-harm was the most common reason patients presented at the emergency center or outpatient clinic. Trauma and stressor related disorders were the most common diagnoses given to patients (33.3%). Majority of patients reported living in their own home (61.5%) followed by living in a shelter or on the street (25.6%).

Case Studies

Information such as patient names and certain demographic details that could lead to patient identification have been altered to protect patient identity. The cases highlight various themes including labor trafficking, parents as perpetrators, intersection of substance abuse, and males as victims.

Labor Trafficking

Case A. Ms. A is 52-year-old Latina female who presented voluntarily to the hospital's emergency center for worsening depression, anxiety, and passive suicidal ideations. Although she was actively engaged in outpatient psychiatric treatment to address recurrent Major Depressive Disorder and Generalized Anxiety Disorder, Ms. A endorsed unremitting symptoms such as loss of interest in activities, loss of appetite, an extreme sense of hopelessness, and emotional detachment from her loved ones. When queried about the onset of these symptoms, Ms. A noted a public argument she had with someone at work that left her feeling worthless and ashamed. She noted similar feelings in childhood when her father would yell at her as a child.

Ms. A disclosed being removed from school prior to age 13 and moving to the United States "for work." Once she arrived, she was never enrolled in school and was made to work 90 h a week in a restaurant for less than $80 per week. Ms. A's father would send the money she earned back to their home country to support her other siblings. Ms. A described being upset by this because she enjoyed school and wanted to continue her education. Given the disruption of her educational development and exorbitant labor hours, Ms. A was determined to have experienced labor trafficking for 8 years, beginning when she was a minor. Despite the remote history of exploitation, Ms. A was offered linkage to an outpatient trauma clinic for therapy and a community-based case management agency to assist with ongoing needs. After a two-day hospital admission, Ms. A was given a diagnosis of Depression and discharged back to her own home.

Case B. Ms. B is a 20-year-old Latina female who was referred to the hospital's outpatient clinic for an initial psychiatric evaluation and therapy by a local anti-trafficking organization. During the first session, Ms. B endorsed significant issues with trust, experiencing hypervigilance in her community, intense shifts in mood, and a recurrence of non-suicidal self-injury (NSSI) by cutting. She believed these symptoms were exacerbated by a recent sexual assault. Ms. B noted increased intrusive thoughts of past abuse, difficulty sleeping, consistently feeling afraid, and detachment from peers. When completing the PTSD Checklist for DSM-5, Ms. B identified her index trauma as sexual and physical abuse by a male extended family member as a younger child.

After her mother traveled to the United States, Ms. B was removed from school and began living with the extended family member in her home country. At the age of 12 she was forced to sell products at various venues and engage in domestic work, and was subjected to ongoing physical and sexual abuse by the extended family member, especially when she did not earn enough money. Despite several past suicide attempts and current NSSI, Ms. B expressed a strong desire to address trauma symptoms and learn distress tolerance skills in therapy. As Ms. B was already connected to a community-based organization for case management, she was offered ongoing therapy sessions through the hospital based anti-trafficking program and connected with a hospital social worker for support in accessing and remaining engaged in medical and mental health care. After her initial appointment she was given a diagnosis of Trauma and Stressor Related Disorder, with no evidence of substance abuse. At the time of the encounter, she was living in her own home with a trusted family member.

Parents as Perpetrators

Case C. Ms. C is a 45-year-old African American female who was referred to the hospital's outpatient psychiatry clinic for medication management and therapy by a local anti-trafficking organization. During the initial therapy session, Ms. C endorsed worsening depression in the context of current housing instability, a significant history of trauma, and subsequent interpersonal difficulties and limited coping skills. Ms. C reported experiencing physical abuse and neglect by mother who struggled with alcohol and substance use, and sexual abuse by an older sibling beginning around age 6. Ms. C recalled 3 specific instances of being "sold" by others. Her older sibling sexually abused and sold her to his friends beginning around age 6. As a young teenager, she sought community in a gang and was later made to dance in a strip club. Ms. C identified her mother as an additional perpetrator, stating that she sold her as a teenager to a man who later impregnated her. She described her upbringing as fraught with violence and instability, which resulted in running away, involvement with Child Protective Services, and subsequent foster care placements. Throughout the years, she received intermittent psychiatric treatment receiving diagnoses of PTSD, depression, and Borderline Personality Disorder. While she had not consistently taken psychiatric medications to mitigate symptoms of PTSD and depression, she was interested in beginning a new regimen and beginning trauma exposure therapy. Due to provider changes, Ms. C was transferred to a new provider and at termination was given a diagnosis of PTSD.

Case D. Ms. D is a 38-year-old Caucasian female who presented voluntarily to the hospital's emergency center for ongoing suicidal ideations and a recent suicide attempt by way of overdosing on prescribed medication. Ms. D endorsed a lengthy medical history consisting of treatment for spinal injuries and abscesses and seizures, which left her unable to work. The financial stress resulted in an exacerbation of depressive symptoms, the loss of her home, and relapsing on substances. When queried about substance use, Ms. D indicated she began using opioids at an early age to manage pain following a car accident.

In describing her childhood, Ms. D mentioned several incidents of verbal and physical abuse by mother, which she attributes to her mother's substance use at the time. After a few days in the inpatient psychiatric unit, Ms. D disclosed that as a child she was sold by her mother to various men to fund her mother's drug use. The exploitation reportedly stopped once Ms. D left for college but would resume when she returned home on break. Ms. D indicated the trafficking completely stopped when she got married. Once stabilized in the hospital, Ms. D was connected to an outpatient psychiatrist for management of an opioid use disorder, and to a community-based social service provider for shelter and case management support. Her primary diagnoses following the 7-day hospital stay were Major Depressive Disorder and Opioid Use Disorder. About a year later, after being housed, Ms. D returned for outpatient therapy as interactions with her mother continued to feel "tense." She had trouble reconciling the desire to have a positive relationship with her mother, and the desire to have the prior abuse acknowledged.

Case E . Ms. E is a 20-year-old Latina female who voluntarily presented to the hospital's emergency center for suicidal ideation with a plan to walk in front of oncoming traffic or overdose on drugs. During the initial psychiatric evaluation, Ms. E was observed to be disorganized and unable to provide a linear timeline of the events that preceded the admission. Ms. E became tearful when describing a history of childhood sexual abuse and endorsed persistent feelings of unworthiness and uncleanliness.

Initially during admission, due to her delusions and visual hallucinations, the treatment team was unable to clarify what the patient experienced in childhood. After a few days, Ms. E's psychosis mostly cleared, and she was able to elaborate on her prior statements. Originally from Central America, Ms. E moved to the United States with her mother at a young age, while her father joined several years later. Ms. E described her mother as a "prostitute" and repeatedly asked "who does that to their child?" She reported her mother worked at a local bar and would often bring her along as a minor. The patient reported her mother would drink with customers and engage in sexual acts. Initially, Ms. E was only expected to talk with customers, but was later encouraged by her mother to engage in sexual acts. Ms. E reported several unwanted sexual encounters one of which resulted in a pregnancy while still a minor. Although unaware when the exploitation began, Ms. E later learned her mother's work in a bar was a result of her mom being trafficked as well. The two later applied for a T-Visa. Upon discharge, Ms. E was provided with hospital- and community-based resources and follow-up appointments and returned home to live with her father. Following a 6-day hospital stay, Ms. E was given the diagnosis of Unspecified Mood Disorder.

Intersection of Substances

Case F. Ms. F is a 28-year-old Latina woman who was voluntarily admitted to the hospital's inpatient psychiatric unit from the emergency center after a suicide attempt. During the initial interview with Ms. F, she indicated she did not really want to die and still had a lot to live for. She believed substance use likely played a role in her decision to attempt suicide, which she acknowledged was an impulsive decision. When asked about potential triggers for substance use and suicide attempts, she cited her mother, with whom she had a poor relationship. In further meetings with a staff psychologist, Ms. F disclosed a history of childhood sexual abuse by an extended family member, and later physical abuse by mother. Beginning around age 15, Ms. F's mother used threats and physical violence to force her into dancing at an adult entertainment venue. This exploitation lasted for 3 years. Ms. F revealed her mother used her earnings to buy cocaine.

Ms. F identified these traumatic events as directly connected to the state of her mental health and expressed a desire to build her coping resources and process these events through outpatient therapy. After being stabilized on medications, she was discharged to her own home with her partner. Ms. F spent 4 days in the hospital and was discharged with a diagnosis of Substance Induced Mood Disorder.

Case G. Ms. G is a 57-year-old Caucasian woman with a history of methamphetamine and cannabis use disorder who was brought into the emergency center by her spouse and involuntarily admitted to the inpatient psychiatric unit for agitation, suicidal ideation, and evidence of self-harm. When asked about the context for her suicidal ideation, she revealed that she was angry with her family. Ms. G said she thought her spouse would feel bad because she cut herself, but instead he sent her to the hospital and encouraged her to get a specific diagnosis for social security benefits. She noted her spouse was physically and sexually abusive, and on several occasions, he forced her to engage in prostitution and he would take the money.

She also noted that she had been a victim of sexual abuse as a child. Ms. G confirmed she was first molested by family members as a young child. Her brother then sexually exploited her by "selling" her to his friends and her sisters' boyfriends for a profit. Ms. G's brother would use the money for drugs. Following these disclosures, Ms. G endorsed homicidal ideation towards her spouse and felt that returning home would not be in her best interest. After meeting with the social worker and anti-trafficking team, Ms. G was discharged to the home of a safe friend. Her primary diagnoses following a 9-day hospital stay was Unspecified Mood Disorder and Methamphetamine and Synthetic Cannabis Use Disorder.

Males as Victims

Case H. Mr. H is a 22-year-old biracial male who was brought to the hospital by EMS following an altercation with his stepfather, during which he endorsed suicidal and homicidal ideations. Mr. H was accompanied by his mother who provided collateral related to previous inpatient and outpatient psychiatric treatment. She reported her son has been previously diagnosed with a psychotic disorder, mood disorder, attention-deficit/hyperactivity disorder, and oppositional defiant disorder, and has had a difficult time finding medication to manage the symptoms appropriately. Mr. H's mother confirmed he could return home once stabilized, but she preferred he find stable housing elsewhere if possible. Mr. H later reported recently moving in with his mother and not liking how his stepfather treated her. He endorsed feeling angry or numb for most of his life but reported anger was the prevailing emotion.

During the initial clinical interview, Mr. H related his anger to a long history of sexual abuse beginning with non-parental caregivers at age 4. For roughly 6 months, around the age of 16, he lived with his biological father who struggled with substance abuse. He recalled being forced by his father to engage in sexual intercourse with other adults so he could support his father's drug use. After two weeks in the hospital, Mr. H's auditory hallucinations had mostly resolved and he no longer endorsed homicidal ideations toward his parent; however, he declined to return home and accepted shelter placement. He was given a long-acting injectable and returned for weekly therapy until he was accepted into a long-term residential program for transitional-aged youth struggling with mental health, homelessness, and trauma. His primary diagnoses following an 8-day hospital stay were Schizoaffective Disorder in addition to Cannabis Use Disorder.

Case I. Mr. I is a 24-year-old Caucasian male who was referred to the hospital's outpatient psychiatry clinic for medication management and therapy by an extended family member. The referral source indicated Mr. I was sexually exploited by his sibling and has struggled with substance use since around age 14. After establishing rapport with the therapist, Mr. I noted extensive physical and sexual abuse in childhood and a significant family history of substance abuse. Despite engagement in multiple inpatient and outpatient treatment programs, Mr. I continued to use substances to cope with the home environment he felt unable to leave. He described a period in his early 20s where his sibling received drugs in exchange for Mr. I's sexual acts with others.

Mr. I identified his sibling as "[his] trafficker," and upon confrontation was physically assaulted by the sibling and threatened with death. Since leaving his home state, Mr. I was threatened by others involved and subsequently relapsed on substances. He experienced a resurgence of paranoid delusions, symptoms of mania, and hypersexuality. After several years of intermittent engagement with outpatient providers, Mr. I terminated services. At termination, Mr. I's primary diagnosis was Post-Traumatic Stress Disorder, in addition to Methamphetamine Use Disorder, severe.

Discussion

The current study presented case examples of human trafficking committed by family members. We found that perpetrators varied however they were most often a parent or sibling. Other highlighted factors included the intersection of familial trafficking and substance abuse, labor trafficking, and male victims. This study and previous literature (e.g. Koegler et al., 2022) found victims were exploited by those within their own family and often as minors. While force, fraud, and coercion do not need to be proven in cases of child sex trafficking, acknowledging these elements and how they may be utilized or experienced can be important in understanding survivors' experiences. Force was the most common means of control used and often manifested as physical or sexual abuse that preceded the exploitation. For instance, Ms. F's mother would physically assault her to get her to comply with dancing at an adult entertainment venue. Both physical and sexual abuse was used to get Ms. B to initially comply with the labor trafficking but was also used as a form of punishment when she did not meet quota.

The inherent power dynamics between parent and child or older and younger siblings may produce a coercive environment. The idea of disappointing or angering a parent or sibling may be enough to compel a child into doing something they do not understand or would not want to otherwise do. Ms. E accompanied her mother to work and was in an environment where sex work was taking place. Initially, she was only expected to drink with customers, but that eventually shifted to her mom encouraging her to also engage in sex acts. Ms. E may have worried about disappointing her mother or felt compelled to do the work because it was what her mother also did. While fraud, the third means of trafficking, was not explicitly endorsed by patients in our case series, another one of the 39 familial trafficked patients did report being lied to by her aunt about what her interactions with men would involve. Unfortunately, the patient's chart did not include further details about the fraud. Despite fraud not being documented in majority of the patient charts, an argument could be made that the relationship among family members was fraudulent because of the assumption that this trusted family member would not hurt or exploit them.

Labor trafficking is particularly interesting when viewed in the context of the family because in some cultures it is not uncommon for children to work to help the family (Bencomo, 2005; The World Bank Group, 2013). There are also cases where minors obtain jobs on their own to help contribute to the household income due to socioeconomic challenges (Becker & Coursen-Neff, 2016; Teens Taking Jobs to Help Parents Struggling in the Pandemic , 2021). While we are adamantly against punishing people for being in poverty, in accordance with the United Nations' The Convention on the Rights of the Child (Convention on the Rights of the Child , 1989), our team determined that if a child's work responsibilities negatively impacted their education (i.e. missed school for work or completely removed from school) or healthy development (i.e. medical neglect) and included elements of force, fraud, or coercion, then regardless of family financial need, this likely constituted labor trafficking.

For instance, Ms. A was removed from school and made to work exorbitant hours for pay well below the legal minimum wage. Although Ms. A was upset about being removed from school, she was aware the money was being used to help her siblings back in her home country. The practice of helping younger siblings, may make minors more susceptible to labor trafficking due to their sense of duty to the family. For this reason, a trafficker may not have to use force, fraud, or coercion in the traditional sense to exploit minors. For example, simply saying "do this so you can help your family" may be enough to coerce a minor into this type of exploitive situation. Ms. B was similarly forced to leave school as a minor to work, with force (physical and sexual abuse) as the exploitive tactic used to keep her compliant. These cases highlight how vulnerable minors are and how they can be exploited by family members and made to work in either poor conditions, for unfair pay, or in a way that is detrimental to their development (i.e. being removed from school).

Another common theme from the highlighted cases was substance use among trafficking perpetrators which is in line with prior research (e.g. Sprang & Cole, 2018). Mr. I reported being exploited by his sibling for the sibling to obtain drugs. Similarly, Mr. H was also made to engage in sexual acts to support his father's addiction. The intersection between parents as perpetrators and the presence of substance use during exploitation was seen several times in the data. Of the 26 patients who identified their mother, father, or both as perpetrator(s), 7 explicitly described their parent(s) receiving drugs, or money for drugs, in exchange for the abuse. Though we do not have data on what compelled our patient's parents to exploit them, parental substance use has been previously noted as a motivator for parents commercially exploiting their children (Raphael, 2019).

It is possible these parents' substance use was a result of their own adverse experiences in childhood and this contributed to them passing on trauma and maladaptive coping to their children. This act of passing on trauma or its effects is referred to as intergenerational trauma (Bradfield, 2011). The previous generation's trauma can impact the current generation's interpersonal functioning and how they approach the world. It can also result in actual experiences of trauma for the next generation including domestic violence, sexual assault, etc. (Isobel et al., 2019). In the case of Ms. E, her mother had her own experiences of trafficking and sexual exploitation, which appeared to have impacted her ability to parent and subsequent decision to introduce Ms. E into the commercial sex industry as a minor. Of note, we have no evidence whether Ms. E's mother volitionally trafficked her or was compelled to by her own traffickers. In addition to passing on experiences of trauma, intergenerational trauma can lead to the continuation of maladaptive coping such as substance use.

Five out of nine of the highlighted patient cases had their own substance use disorder as either a primary or secondary diagnosis. It is unknown whether the substance use started prior to or as a result of the trafficking. The intersection of substance use and trafficking is documented (Gerassi, 2018; Hopper, 2017). Survivors may experience forced substance use during their trafficking experience (Meshelmiah et al., 2018) and develop a dependency that requires treatment. For others, substance use may be introduced after the fact to cope with the trauma experienced (Ravi et al., 2017). Both Ms. F and Ms. G endorsed extensive trauma in childhood beginning with sexual abuse by family members, and later trafficking by different family members. Both patients presented to the hospital with current substance use and suicidal ideations. Though Ms. F identified substance use as a contributing factor to her recent suicide attempt, Ms. G did not explicitly acknowledge a link between the two. Given the relationship between trauma and substance use (Torchalla et al., 2012), it is important to expand survivor access to competent treatment facilities that address the addiction in a trauma-informed way and to provide resources for trafficking survivors. Doing so helps to avoid re-traumatization and sets survivors up for success following completion of treatment (Hopper, 2017; Meshelmiah et al., 2018).

Finally, Case H and Case I shed light on a population that is often overlooked in the human trafficking literature and media conversations about trafficking- males as victims. Although only 3 out of our 39 familial trafficking cases included males as victims, this provides support for the argument that boys and men should not be left out of the conversation and are also in need of support. Historically, services for this population have been repeatedly underfunded compared to those geared towards women and girls (Jones, 2010). This lack of attention for males further stigmatizes their experiences of trafficking and can lead to underreporting and therefore fewer males receiving the help they need (Barron & Frost, 2018; Trounson & Pfeifer, 2020). It is imperative for providers and community organizations working with survivors to understand the unique experiences of males trafficked by family members.

This case series not only adds to the sparse literature on familial trafficking, but it also has clinical implications. While more healthcare providers are becoming aware of human trafficking, few healthcare facilities have screening and response procedures related to trafficking (Munro-Kramer et al., 2022). The current study provides further evidence that survivors of trafficking are utilizing healthcare resources, supporting the claim that healthcare facilities are ideal places to screen for trafficking. There are several existing screening tools that could be implemented in healthcare settings such as the Rapid Appraisal for Trafficking (RAFT) for emergency departments (Chisolm-Straker et al., 2021) or the Quick Youth Indicators (QYIT) for Trafficking, which can be used in any setting that interfaces with youth who have runaway or are experiencing homelessness (Chisolm-Straker et al., 2019). While the RAFT, QYIT, and other screening tools have been found to be valid with trafficking populations, they often do not specifically ask about familial involvement. Asking broad questions about trafficking or exploitation relies heavily on the child, or respondent, to understand exactly what exploitation is and who can be responsible for perpetrating it. While it is not a healthcare provider's responsibility to investigate the crime, and they should never ask questions purely out of curiosity, it is their responsibility to conduct comprehensive screenings to inform treatment and assess for patient safety. Failing to ask about familial relationships may lead to false negatives in trafficking screenings. For instance, a child may not associate the labor they feel compelled to do as a formal job because their "boss" is their parent. Developmentally, a child may not have the resources or knowledge to understand the labor as being exploitative. Regardless of when the trafficking occurred, survivors may not volunteer information about their family's involvement for fear of negative repercussions. By directly asking about family relationships, this may open the door for patients to disclose this unique form of trafficking. As with all abuse screenings, patients should always be informed of providers' mandated reporting requirement and providers should stay up to date on their state's mandated reporting laws. In particular, providers should know the difference between the legal requirement for child abuse disclosed by a child vs. childhood abuse disclosed by a now adult (e.g. Texas Family Code, 2021), such as was the case with majority of the current study's sample.

Given that data for the current study was obtained via retrospective chart review from records originally intended for clinical care, future research could use more traditional research methods to obtain more standardized data (i.e. research surveys or interviews). For instance, despite the sample of patients who experienced familial trafficking being primarily African American, we were unfortunately only able to highlight one case of an African American patient in the case series due to the lack of information in patient charts. Traditional research methods would allow for greater equity in the amount and detail of data collected across the sample. While we are unsure of why there was such a discrepancy in level of detail in patient charts, patient disclosure willingness, patient length of stay in the hospital, provider time, provider knowledge of trafficking, and provider bias could have all played a role. Prior research has suggested some medical providers have a bias against US racial/ethnic minorities which results in providers not taking their medical complaints seriously (Maina et al., 2018). Another possibility is African American patients in the study sample may have had prior negative experiences with providers not taking them seriously or being stigmatizing, and therefore were less likely to disclose details of the trafficking to our staff.

Future research should also explore whether there are differences between hospital vs. community samples in terms of prevalence and experience of familial trafficking. Finally, the current study and future research can inform policy regarding trafficking. Policy makers should consider how force, fraud, and coercion are defined within a family context. As discussed above, this may look different between family members than between strangers or acquaintances. Children in particular may feel compelled to comply with requests from family member without the types of force or coercion you typically see with other types of trafficking. The inherent power dynamics within families requires thoughtful consideration.

Although this study is valuable in highlighting a lesser-known form of trafficking, it is not without limitations such as inconsistent screening efforts by providers and identification based on patient self-report. The healthcare system represented in this study requires all hospital staff to complete a brief mandatory education course on human trafficking; however, not all departments or units have implemented screening and response measures. To our knowledge, the hospital's inpatient psychiatric unit is the only unit to have embedded a screening tool into the clinical interview, although it does not explicitly inquire about familial trafficking. Therefore, it is possible patients with familial trafficking experiences were missed if providers did not ask follow-up questions. Another limitation of the study is that the data collected is self-reported. As the program does not require law enforcement cooperation or evidence of prior reporting, all identification is based on patient self-report. It is possible patients have been missed or incorrectly categorized as some may not remember the totality of their experiences, who was involved at the time, or if the abuse was exploitive or commercialized. The final limitation is the unstandardized nature of medical chart documentation. Different providers and units may provide greater detail than others, making it easier to identify those with family involvement in trafficking. Documentation also effected which cases we were able to highlight because some providers simply did not provide enough information in the notes.

Conclusion

Research on familial trafficking is extremely limited. The findings from this study provide additional information about the existence of familial controlled trafficking, as well as the long-term effects on mental health. This form of trafficking is nuanced due to the unique relationship between the survivor and the perpetrator. The findings from this paper can help inform screening techniques by encouraging providers to inquire about familial relationships, particularly among children. Findings may also be helpful for providers working with populations who may be at risk for exploitation. Future research could further investigate motivators for familial trafficking as well as improved identification techniques across the lifespan and in various setting. Subsequent research should compare the psychological impact of familial versus non-familial trafficking to inform intervention efforts.

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