How Do Providers Assess Young People for Risk of Sex Trafficking? Observed Indicators, Follow-Up, and Assessment Questions from a Sample of Social Service Providers

Abstract

The extent to which service providers across systems identify and assess potentially sex trafficked youth is understudied. The purpose of this study is to determine whether and how providers observe relevant indicators and assess for sex trafficking risk among minors (ages 12–17), young adults (ages 18–29), and families of minors. A cross-sectional, web-based survey was disseminated to service providers, who represented child welfare, youth justice, and social services (e.g. runaway youth, sexual violence), in a region of a Midwestern state (United States). Participants (N=267) were asked whether they provided direct services to minors (ages 12–17, n=245), adults (ages 18–29, n=148), and/or families/foster families of minors (ages 12–17, n=163), resulting in three respective client groups. Survey items assessed the extent to which providers (1) identified possible sex trafficking indicators across 5 domains; (2) took follow up actions; and (3) asked risk assessment questions. T-tests were conducted to examine differences between those who reported receiving sex trafficking trainings, compared to those who did not. Results suggest that the most commonly identified indicators included depressive symptoms, shame and guilt, lack of social support. Least common indicators included torture, false IDs, hotel involvement. A third of minor-aged providers did not ask sex trafficking risk assessment questions. Providers reported asking fewer clients about online sex trading than in-person forms. There were statistically significant differences among providers who received training. Implications, including provider strategies for assessing online sex trading and organizational protocols to enhance sex trafficking identification, are discussed.

1. Introduction

The U.S. Trafficking Victims Protection Act (TVPA) of 2000 and its successive reauthorizations created protocols for social service providers to identify, assess, and respond to sex trafficking (Wells, 2019). Educational materials and trainings subsequently described sex trafficking indicators or “red flags” that can signal risk or experiences of sex trafficking, as well as screening questions and strategies (Macy & Graham, 2012). Prior pilot studies have begun to identify the extent to which providers, who knowingly encounter sex trafficked youth, observe indicators in practice (Nichols & Cox, 2021; Pate, Anderson, Kulig, Wilkes, & Sullivan, 2021; author reference). However, the extent to which prior findings extend to general provider samples, and whether and how providers follow up (e.g., consult a coworker, ask a screening question, etc.) upon observing sex trafficking indicators remains unknown. Though sex trafficking screening tools have been created and evaluated (Andretta, Woodland, Watkins, & Barnes, 2016; Chisolm-Straker, Sze, Einbond, White, & Stoklosa, 2019; Dank et al., 2017; Jordan Greenbaum et al., 2018; Simich, Goyen, Powell, & Mallozzi, 2014), whether and how providers use such questions in practice remains unclear. Using a cross-sectional, web-based survey of 267 service providers, who represented child welfare, youth justice, and social services (e.g. runaway youth, sexual violence), in a 17-county region of a Midwestern state, this study sought to determine whether and how providers (1) observe sex trafficking indicators/red flags among youth (minors and young adults), (2) follow-up through consultation, documentation, assessment procedures, or organizational referrals, and (3) ask young people about their sex trafficking risk, and to determine differences between providers who report receiving sex trafficking trainings, compared to those who do not.

1.1. Sex Trafficking Indicators and Follow-Up

Sex trafficking indicators consist of “red flags” or warning signs that providers use to identify young people at risk and increase identification of potential sex trafficking victims (Macy & Graham, 2012; Nichols & Cox, 2021). Sex trafficking indicators can help identify vulnerabilities to or signs of victimization. Guided by life course and general strain theories, sex trafficking trajectories are often influenced by early deleterious experiences (e.g., caregiver strain, child abuse) and social embeddedness (e.g., family relationships, peer influences) (Franchino-Olsen, 2019; Reid, 2012; Reid & Piquero, 2016). These elements influence human agency, in which individual choices are made within the constraints of social contexts (e.g., racism, lack of economic opportunities, heterosexism), thereby increasing risk of victimization (Reid, 2012). Therefore, sex trafficking indicators can provide cues of an individual’s vulnerabilities and constraints. For example, providers can observe or assess for physical health indicators or signs of sex trafficking (e.g. medical neglect, heightened history of STD/STI, signs of physical harm/abuse/torture, and/or a history of one or more abortions), while behavioral health indicators (e.g. depressive symptoms, self-harm, anxiety, and/or history of substance use and/or overdose) can assist providers in identifying concerns that may be related to trafficking risk or experiences (Polaris, n.d.). Other indicators that appear in the literature include signs of restricted behavior (e.g. accompanied by an individual who does not let the person speak for themselves and/or exhibit rehearsed or coached speech), system involvement/ risks (e.g. running away, history of involvement with child welfare system, truancy from school), personal/family risk histories (e.g. lack of social support, receive threats to family or friends), and restricted access to personal possessions (e.g. individual does not have access to their own ID) (Homeland Security, 2021; Macy & Graham, 2012). Collectively, providers can use these sex trafficking indicators to identify circumstances that may suggest heightened risk or signal experience of sex trafficking, and follow-up accordingly, via child protection reports, further screening and assessments, or organizational referrals.

Some prior work has sought to understand the relevance of recommended sex trafficking indicators to providers in clinical practice. For example, one study found that of sex trafficking indicators, sexual abuse, sex exchange, runaway behaviors, and explicit photos/videos were most frequently present among 167 substantiated sex trafficking cases in the child welfare system (Pate et al., 2021). Another study of offending youth found that those who were arrested for sex trading related activities (n=102) reported greater adverse childhood experiences, as compared to those arrested for non sex trading activities (Naramore et al., 2017). Small pilot studies of social service providers who indicated that they worked with minors and young adults who were sex trafficked suggested that behavioral health and social support indicators were more commonly seen among sex trafficked young people, rather than signs of restrictive behavior, tattoos/branding, or signs of torture (Nichols & Cox, 2021; author reference). Such indicators reflect other work suggesting that youth who trade sex experience heightened behavioral health and housing concerns. For example, studies using representative samples of high school students that suggest that students who reported experiencing (or being treated for) substance use, depression, and higher rates of suspensions report elevated rates of sex trading (Martin et al., 2020; author reference). Non-representative samples of runaway and homeless youth also show higher rates of self-harm behaviors, and suicide attempts among sex trafficked youth (Frey, Middleton, Gattis, & Fulginiti, 2019; Middleton, Gattis, & Frey & Dominique Roe-Sepowitz, 2018). As such, some of the most relevant sex trafficking indicators may not be those that are often emphasized in awareness materials or educational trainings that reflect very restrictive forms of trafficking (Grace, Bright, Corbett, & Morrissey, 2018; Hoyle, Bosworth, & Dempsey, 2011; Peffley & Nichols, 2018; author reference). However, further work is needed to understand how providers in systems that encounter sex trafficked young people identify such indicators in practice. Furthermore, understanding the extent to which providers document, consult colleagues, ask sex trafficking screening questions, and/or refer to other organizations upon observing sex trafficking indicators remains critically understudied.

1.2. Sex Trafficking Risk Assessment Questions

Multiple sex trafficking screening and risk assessment guides were developed to help service providers discern their clients’ risk of sex trafficking. Some of these tools have been validated, suggested the utility of asking behaviorally specific questions, as compared to questions that require clients to label their experiences in ways that they may not (e.g. “have you ever been sex trafficked?”) (Contreras, Kallivayalil, & Herman, 2017). For example, one validated tool, the Vera Institute’s Trafficking Victim’s Identification Tool (TVIT) resulted in positive identification of sex trafficking victims (Chisolm-Straker et al., 2019; Simich et al., 2014). This tool included questions such as, “Did anyone ever pressure you to touch another person or have any unwanted physical or sexual contact with another person? Did you ever have sex for things of value (for example money, housing, food, gifts, or favors)?” (Simich et al., 2014, pp. 5–6) Another study using the TVIT (short version) found these questions were strong indicators of sex trafficking, along with an additional question to assess online forms of sex trading (“Did anyone ever take a photo of you that you were uncomfortable with?”) (Williams, Wyatt, & Gaddis, 2018). Assessing for online forms of sex trading (e.g., photos, videos, etc.) may be critically needed in light of growing access to technology and, specifically, social media usage (Chisolm-Straker et al., 2019; Dank et al., 2017; Goldberg & Moore, 2018), as well as the more recent possibility of the COVID-19 pandemic’s role in increasing online activities (Todres & Diaz, 2021). In addition, given the stigmatized nature of sex trading and sex trafficking risk, best practices suggest building rapport with clients and asking risk assessment questions multiple times (Diaz, Clayton, & Simon, 2015; Macy & Graham, 2012).

Sex trafficking screening tools and risk assessment guides are critical to increasing identification, but little is known about whether and how providers who are likely to encounter young people at risk of sex trafficking implement such questions (Dank et al., 2017). It is likely that providers need tailored trainings to address sex trafficking dynamics and assessment strategies. For example, Gonzalez-Pons and colleagues found a statistically significant relationship between providers who believed that sex trafficking required elements of physical force, restraint, bondage, and/or violence (a common sex trafficking misconception) and participants’ inability to identify victims served by their organizations. Sex trafficking training may impact how, when, and who a provider screens for sex trafficking risk, but the extent to which providers receive such trainings, and how this impacts the implementation of sex trafficking screenings and assessments in practice remains understudied.

Understanding the extent to which providers identify sex trafficking indicators in practice, and how they subsequently follow-up and assess young people is an essential step in strengthening sex trafficking identification. Using a sample of child welfare, youth justice, and social service providers in a Midwest region, the purpose of this study is to identify the extent to which social service providers observe sex trafficking indicators, follow-up and ask sex trafficking screening and risk assessment questions, and also explore whether such perceptions and actions differ among those who report receiving sex trafficking trainings compared to those who do not.

2. Material and Methods

2.1. Design

We used a community-based approach to develop this study’s purpose and design in partnership with the regional Department of Health and Human Services Youth and Family Services (YFS) in a 17-county region of a Midwestern state (Jones & Wells, 2007). The region’s YFS was tasked with creating, disseminating, and implementing a regional response protocol for suspected and confirmed sex trafficking cases for the region. We disseminated a cross-sectional, web-based survey to regional service providers who represented systems that encounter sex trafficked minors, young adults, and their families. The survey asked which of three client groups of young people the participant served (e.g., minors, adults, or family/foster family of minors) and then provided a series of quantitative and qualitative questions to assess their observed sex trafficking indicators, follow-up actions, and use and frequency of sex trafficking screening questions per client group. Institutional review board approval was obtained from the University of Wisconsin-Madison.

We use “minor-aged providers” to refer to those who provided services to minors, “adult-aged providers” to refer to those who work with adults, and “family providers” to refer to those who worked with families of minors.

2.2. Participants

Table 1 summarizes the demographics of our sample. Participants (N=267) consisted of those who provided direct services to minors (ages 12–17, n=245), adults (ages 18–29, n=147), and/or families/foster families of minors (ages 12–17, n=159), resulting in three respective, non-mutually exclusive client groups (e.g. some providers worked with just minors while others worked with both minors and adults). Of the full sample (N=267), 40% of providers worked with all three client groups (e.g., minors, adults, and families), 26% worked with minors only, 17% worked with both minors and family providers, and 9% worked with both adults and minors.

Table 1.

Sample Demographics by Provider Group

	Total Sample (n=267)	Minor Providers (n=245)	Adult Providers (n=147)	Family Providers (n=159)
Age
22–29	24% (63)	25% (61)	26% (38)	23% (37)
30–39	28% (74)	29% (71)	22% (32)	30% (47)
40–49	13% (35)	13% (31)	17% (25)	14% (22)
50–59	5% (14)	5% (12)	3% (5)	5% (8)
60–64	1% (4)	1 % (4)	1% (2)	2% (3)
Prefer Not to Answer	29% (77)	27% (66)	31% (45)	26% (42)
Race
White	66% (176)	67% (164)	67% (98)	70% (112)
Black/African American	3% (8)	2% (6)	2% (3)	1% (2)
Native/Indigenous	1% (3)	1% (3)	1% (1)	1% (1)
Asian/Asian American	2% (5)	2% (4)	1% (2)	1% (2)
Latinx/Hispanic	1% (4)	2% (4)	2% (3)	3% (4)
Multiracial	1% (4)	1% (3)	1% (1)	1% (2)
Prefer Not to Answer	26% (67)	25% (61)	26% (39)	23% (36)
Sexual Orientation
Heterosexual	64% (171)	66% (160)	61% (89)	69% (109)
Asexual	3% (8)	3% (8)	2% (3)	2% (4)
Queer*	4% (10)	3% (8)	5% (8)	3% (5)
Prefer Not to Answer	29% (78)	28% (69)	32% (47)	26% (41)
Job Function
Program  Manager/Coordinator	5% (14)	5% (13)	5% (7)	3% (5)
Intake Worker	11 % (29)	11% (28)	10% (15)	13% (21)
Case Manager	24% (65)	25% (62)	25% (36)	29% (46)
Direct Service Provider	16% (43)	14% (34)	10% (15)	11% (17)
Therapist/Counselor	19% (51)	19% (46)	22% (33)	21% (34)
Supervisor	2% (5)	2% (4)	2% (3)	3% (4)
Support Staff	2% (5)	2% (4)	2% (3)	2% (3)
Prefer Not to Answer	21% (55)	22% (54)	24% (35)	18% (29)
Job Sector
Behavioral Health	8% (20)	7% (17)	8% (12)	7% (11)
Counseling/Therapy	17% (45)	17% (41)	19% (28)	20% (32)
Child Welfare	29% (77)	29% (71)	35% (51)	41% (65)
Homeless Youth	1% (3)	1% (3)	1% (2)	1% (1)
IPV/DV/SV/HT+	5% (13)	5% (12)	7% (10)	3% (5)
Youth Justice	13% (36)	14% (35)	3% (4)	7% (11)
Out of Home Care	4% (10)	3% (8)	2% (3)	1% (2)
School Ed Sector	1% (3)	1% (3)	1% (1)	1% (2)
Prefer Not to Answer	22% (60)	23% (55)	24% (36)	19% (30)

^*Queer, Gay, Bi, Lesbian

⁺Intimate Partner Violence/Domestic Violence/Sexual Violence/HT

Our sample was majority white, cisgender, heterosexual women, which is consistent with the demographics of service providers in the profession (Salsberg et al., 2017), as well as specifically in this region. Providers represented job sectors such as child welfare, youth justice, behavioral health, homeless and runaway youth services, intimate partner/sexual violence, school education, and out-of-home care (including foster care). We worked with community partners to provide a list of eight types of sex trafficking trainings (e.g. YFS regional training, Ensure Justice conference, fill-in-the-blank option) and asked providers to check any they had attended. About 20–29% of the sample did not complete the demographic questions or indicated that they preferred not to answer, which created some limitations (discussed later). We compared differences between those who completed the demographic information and those who did not and report any statistically significant differences (p<.001) in the relevant sections below.

2.3. ST indicators

Adapted from a pilot study (author reference), the survey first asked multiple open-ended questions to assess sex trafficking indicators for each client group, such as “what if, any red flags, did your [minor-aged or adult] client(s) demonstrate that made you think they were at risk of sex trafficking or had been sex trafficked?” Participants were then asked how often they had identified the following red flags for each respective client group in the past 12 months on a 5-point Likert scale (Never, rarely, occasionally, often, always). A total of 46 indicators were presented for minors and families of minors, and 45 for adults. The indicator omitted from the adult group was “travel in and out of area without permission of parent/guardian.” Indicators included 10 client presentation indicators (e.g. tattoos, inappropriate clothing, accompanied by a person who does not let the person speak for themselves), eight behavioral health indicators (e.g. depression/depressive symptoms), seven physical health concerns (e.g. multiple abortions), 11–12 indicators of client reporting instability or system involvement (e.g. involvement in CPS, history of running away, current or prior truancy), and 9 social support/abuse indicators (e.g. child sexual or physical abuse, lack of social support). It is important to note that these indicators may suggest a potential for sex trafficking risk as well as several other non-trafficking related concerns, e.g., high risk sexual activity, sexual violence, or general behavioral health issues.

2.4. Follow Up Actions

Participants who work with minors or adults were then asked after they had identified the red flags, how often did take the following options on a 5-point Likert scale (never, occasionally, often, always): “I was not sure what to do/didn’t do anything”, “I made a mental note”, “I documented the red flags in the client’s chart”, “I consulted a coworker/supervisor”, “I consulted law enforcement”, “I made a report to child protection”, “I asked a sex trafficking assessment question”, “I referred to another organization”. If the participant answered occasionally, often, or always to the questions, they were then prompted to specify which red flags most often made them choose this option (open-ended responses).

2.5. Sex Trafficking Screening and Risk Assessment Questions

The following set of questions were asked before the indicator and follow-up questions described above to reduce social desirability bias, as participants may have thought that they should have asked more questions upon observing sex trafficking indicators than they did in practice. For minor and adult client groups, participants were asked “For how many of your clients have you asked the following questions (or similar) in the last 12 months?” Participants were given a list of 11 sex trafficking screening and risk assessment questions (e.g. Has someone used force, fraud, or coercion to have sexual contact with you?) and asked to indicate number of clients asked on a 5-point Likert scale (none of my clients, some, a few, most, or all). We also provided an optional open-ended space for providers to indicate whether they asked any other questions that were not listed to assess risk (in the last 12 months). Participants were also asked how regularly do they ask minor-aged or adult clients sex trafficking screening questions (Every time we meet, usually a few times, usually once, N/A) and at what point in the relationship (e.g. 1^st meeting, 2^nd meeting, 3^rd or 4^th meeting, 5^th meeting or after).

2.6. Sampling & Data Collection

The authors collaborated with multiple stakeholders at YFS to comprehensively sample participants. First, discussions with the team resulted in a comprehensive list of individual direct service providers (and their email addresses) from youth justice, child welfare, and regional social service organizations. Social service organizations included those that address issues of foster care, sexual violence, intimate partner violence, human trafficking, and homeless youth. Next, we compared this list of providers and their organizations to a 2018 content analysis (author reference), in which the research team scanned organizational websites for all regional organizations that, based on their work and age range, could encounter sex trafficking in practice. We identified a few gaps between the community-based list of providers and the content analysis that mostly consisted of providers who addressed substance use, housing, and youth mentoring and obtained additional email addresses of their direct service providers.

Of the 820 emails we sent in total, 42 were returned, seven failed to send, three were duplicates, 9 did not meet inclusion criteria. Of the remaining 766 potential participants, 267 of them completed the survey, yielding a 35% response rate. The email invited them to complete the online survey to understand how direct service providers who encounter minors, young adults, and their families or foster families conducted client assessments, specifically about clients who may be involved in the sex trade. Participants answered screening questions to confirm that they had been identified as a direct service provider, social worker, or behavioral/mental health provider in the region who worked with young people ages 12 to 29 and/or the families of minors. The authors included contact information for the community partner as well as the research team to increase the likelihood of participants believing the survey was legitimate (as many of the state workers had just had a training on email scams). Upon completion, participants were directed to a separate survey to consent to receive a $15 electronic gift card for their participation.

2.7. Analysis

Qualitative responses were independently coded by two members of the research team. The coding schematic (codes, categories, and quotes) was continuously discussed until finalized and then checked by a third member of the research team. We found no discrepancies in coding that were not related to wording of labels (e.g. “addressing for safety” vs. “safety planning”). Quantitative data were entered into SPSS for cleaning and analysis.

2.7.1. Sex Trafficking Training Groupings and Analysis.

To examine differences among those who reported receiving sex trafficking specific trainings compared to those who did not, we created three, non-mutually exclusive training variables: (1) sex trafficking training (general), (2) sex trafficking indicator training, and (3) sex trafficking screening/assessment training. We determined which trainings qualified for each of the training variables through a collaborative process with anti-trafficking regional hub director, who had attended or was familiar with almost all the trainings listed by the participants. For the 3 trainings that were listed in the fill-in-the-blank option that were unknown to the team, we included them in the first (general) training variable only.

Within each provider group (e.g. minors, adults, families), we compared the means for those who received each of the three sex trafficking trainings to those who did not. For aim 1 (sex trafficking indicators), we ranked indicators according to their means from most (#1) to least (#46 for minors/families of minors, #45 for adults) commonly observed within each provider group (e.g. minors, adults, families). For follow-up actions and screening/risk assessment questions, we obtained the means for each item and conducted independent t-tests between providers who received sex trafficking trainings, compared to those who did not, within the minor-aged and adult provider groups. We compared results between each training group and the no training group, and have noted differences, as applicable in the results.

3. Results

3.1. ST Indicators and Follow-Up

Tables 2 and 3 show the rankings of the most and least commonly identified indicators according to means and differences in each group according to whether they received sex trafficking indicator training (variable 2). The most commonly identified indicators across provider groups included behavioral health indicators (e.g. depressive symptoms, shame and guilt), history of child protective services, weak ties/lack of social support, history of abuse and self-harm. Least commonly identified indicators showed more variation between groups but generally included signs of torture, false IDs, and hotel involvement. Rankings listed as “N/A” indicate that the indicator did not rank as most or least common. Those who did not report their gender had higher means of observing tattoos/branding, reports of hotel use, signs of torture; those with missing information regarding their highest degree also reported higher means for signs of torture (p<.001). Participants self-reported receipts of trainings that address sex trafficking generally (training variable 1) or specifically focus on sex trafficking indicators (training variable 2) did not make substantial differences in perceptions of most or least commonly reported indicators. These results do not elucidate how useful these indicators were in identifying sex trafficking victims but rather how common they were in practice.

Table 2.

Most Common Indicators Commonly Identified Among Social Service Providers with and without Sex Trafficking Training (Likert-type Scale 1–5, 1=no clients 5=all clients)

	Indicator Means
	MP with Training (n=140)	MP without Training (n=90)	AP with Training (n=79)	AP without Training (n=54)	FP with Training (n=91)	FP without Training (n=53)
Variables	Ranking (M)
Depression or depressive symptoms	1 (3.7)	1 (3.6)	1 (3.7)	1 (3.3)	1 (2.9)	1 (2.7)
Anxiety and general sense of fear	2 (3.6)	2 (3.4)	3 (3.5)	1 (3.3)	1 (2.9)	2 (2.6)
Exhibit feelings of shame, guilt, and/or low self esteem	2 (3.6)	3 (3.3)	3 (3.5)	2 (3.2)	2 (2.7)	3 (2.5)
History of or current involvement with the child welfare system/child protective services	3 (3.5)	4 (3.2)	5 (3.3)	4 (2.9)	1 (2.9)	4 (2.3)
Weak family ties/lack of social support	4 (3.4)	5 (3.1)	2 (3.6)	3 (3.0)	3 (2.6)	3 (2.5)
History of child physical or sexual abuse	4 (3.4)	4 (3.2)	4 (3.4)	3 (3.0)	3 (2.6)	3 (2.5)
Physical self-harming behaviors (e.g., cutting), suicidal ideation, and/or history of attempted suicide	5 (3.3)	4 (3.2)	N/A	5 (2.7)	4 (2.4)	5 (2.2)
History of running away	6 (3.1)	N/A	N/A	N/A	N/A	N/A
Report history of suspensions, truancy, or having dropped out of school	6 (3.1)	6 (2.9)	N/A	N/A	4 (2.4)	N/A
Exhibit a low level of interpersonal trust/credibility (afraid to talk to anyone outside of one’s circle)	7 (3.0)	N/A	N/A	N/A	N/A	N/A
Report experiences of bullying by peers	N/A	6 (2.9)	N/A	N/A	5 (2.3)	5 (2.2)
History of substance use and/or overdose	N/A	7 (2.7)	3 (3.5)	4 (2.9)	4 (2.4)	5 (2.2)
Unstable housing/homelessness and/or constantly changes residences	N/A	N/A	6 (3.2)	3 (3.0)	N/A	6 (2.1)
Previous drug-related and/or loitering charges	N/A	N/A	7 (3.0)	6 (2.6)	N/A	N/A
Unable to meet their basic/survival needs	N/A	N/A	8 (2.9)	N/A	N/A	N/A

Notes: MP = Minor Provider, AP = Adult Provider, FP = Family Provider

Rankings: 1 indicates most frequent (highest means); N/A indicates the indicator was not ranked in the top 8 indicators.

Table 3.

Least Common Indicators Commonly Identified Among Social Service Providers with and without Sex Trafficking Training (Likert Scale, 1=no clients 5=all clients)

	Indicator Means
	MP with Training (n=140)	MP without Training (n=90)	AP with Training (n=79)	AP without Training (n=54)	FP with Training (n=91)	FP without Training (n=53)
Variable	Ranking (M)
Are unable to provide key personal information like their address or current location	41 (1.8)	N/A	N/A	N/A	43 (1.4)	44 (1.4)
Report gang involvement/affiliation	42 (1.7)	44 (1.5)	41 (1.7)	44 (1.5)	N/A	45 (1.3)
Deceptively recruited to work	43 (1.6)	45 (1.4)	42 (1.6)	44 (1.5)	44 (1.3)	45 (1.3)
Report use of hotels for sexual encounters	44 (1.5)	45 (1.4)	N/A	43 (1.6)	43 (1.4)	N/A
Have tattoos/branding representing some sort of ownership or membership (such as tattoos that say, “Daddy,” “Property of...,” “In the life,” etc.)	44 (1.5)	46 (1.3)	43 (1.5)	44 (1.5)	45 (1.2)	46 (1.2)
Involvement in commercial sex industry	44 (1.5)	46 (1.3)	43 (1.5)	46 (1.4)	46 (1.1)	45 (1.3)
History of one or more pregnancies and/or abortions	45 (1.4)	45 (1.4)	41 (1.7)	43 (1.6)	N/A	44 (1.4)
Signs of torture (e.g. ligature marks, burns, etc.)	46 (1.3)	46 (1.3)	45 (1.3)	45 (1.4)	46 (1.1)	46 (1.2)
Have falsified documents/identification, possess multiple names, and/or does not have access to their own ID	46 (1.3)	46 (1.3)	44 (1.4)	45 (1.4)	45 (1.2)	46 (1.2)
Previous prostitution or solicitation charges	46 (1.3)	46 (1.3)	42 (1.6)	43 (1.6)	45 (1.2)	45 (1.3)
Heightened history of STD’s/STI’s	N/A	44 (1.5)	N/A	N/A	43 (1.4)	N/A
Use language common in the commercial sex industry (ex. in the life, stroll, pimp, etc.)	N/A	N/A	41 (1.7)	43 (1.6)	44 (1.3)	45 (1.3)
Have explicit photos/profiles on internet	N/A	N/A	42 (1.6)	N/A	N/A	N/A
Are accompanied by an individual who does not let the person speak for themselves, refuses to let the person have privacy, or who interpret for them	N/A	N/A	N/A	43 (1.6)	N/A	N/A

Notes: MP = Minor Provider, AP = Adult Provider, FP = Family Provider

Rankings: There were 46 indicators for minors/families of minors and 45 for adults. Indicators 41–46 (41–45 for adult providers) represents the least frequent (lowest means), with no. 46 (or no. 45) as the lowest; N/A indicates the indicator was not ranked in the bottom 6 indicators.

3.2. Follow-Up Actions

Table 4 shows the actions that providers took upon identifying sex trafficking indicators in practice as well as differences between providers who received sex trafficking indicator training (training variable 2), compared to those who did not. Providers reported documenting red flags in a chart and consulting a coworker/supervisor more often than making a mental note for later, reporting clients to child protection, asking sex trafficking assessment questions, or referring to other organizations. Both minor-aged and adult providers who received sex trafficking indicator training had significantly higher means of asking sex trafficking risk assessment questions and referring clients to other organizations, compared to those who did not receive sex trafficking indicator training. There were no significant differences

Table 4.

Follow-Up Actions upon Identifying Red Flags among Minor-aged (n=229) and Adult (n=132) Providers: T-test Results of Providers with/without Sex Trafficking Indicator Training (Likert Scale 1–4, 1=never 4=always)

Response	Overall M (SD)	Training M (SD)	No Training M (SD)	t
I was not sure what to do/didn’t do anything.
Minor Provider+	1.4	1.4(.7)	1.3(.5)	−1.31
Adult Provider^	1.5	1.5(.7)	1.6(.8)	.56
I made a mental note for later.
Minor Provider	2.3	2.4(1.1)	2.3(1.0)	−.53
Adult Provider	2.1	2.1(1.1)	2.1(1.1)	−.11
I documented the red flags in the client’s chart.
Minor Provider	3.2	3.2(1.0)	3.1(1.0)	−.75
Adult Provider	2.8	3.0(1.1)	2.7(1.2)	−1.38
I consulted a coworker/supervisor.
Minor Provider	3.2	3.3(.8)	3.1(.94)	−1.75
Adult Provider	2.6	2.7(1.1)	2.6(1.1)	−.83
I consulted law enforcement.
Minor Provider	2.0	2.0(1.1)	2.0(1.0)	.09
Adult Provider	1.5	1.5(.8)	1.5(.8)	.05
I made a report to child protection.
Minor Provider	2.5	2.4(1.2)	2.5(1.1)	.80
Adult Provider	1.6	1.6(1.0)	1.6(.9)	−.09
I asked a sex trafficking assessment question.
Minor Provider	2.1	2.5(1.1)	1.9(1.1)	−3.95*
Adult Provider	1.9	2.2(1.1)	1.7(1.0)	−2.55***
I referred to another organization.
Minor Provider	1.9	2.1(1.1)	1.7(1.0)	−2.62**
Adult Provider	1.8	2.0(1.0)	1.6(.9)	−2.02***

Notes:

^*p<.001

^**p<.01

^***p<.05

⁺Among minor-aged providers (n=229), 95 received sex trafficking indicator training (variable 2). and 134 did not.

^{^}Among adult-aged providers (n=132), 57 received sex trafficking indicator training (variable 2), and 75 did not.

Training variable signifies sex trafficking training that addressed sex trafficking indicators (training variable 2).

T-tests comparing providers who received the sex trafficking general training (training variable 1), compared to those who did not receive any sex trafficking training, produced similar results. In addition, minor-aged and adult providers who received general sex trafficking training had statistically significant higher means of documenting red flags in the chart [minors (t=−.2.21, p=.023); adults (t=−2.45, p=.012)]. Minor-aged providers also had statistically significant higher means of consulting a coworker/supervisor (t=−2.36, p=.02). Unlike training variable 2 results, however, adult providers who received general sex trafficking training (training variable 1) did not have statistically significant higher means of asking risk assessment questions. Qualitatively, providers suggested that certain indicators of sex trafficking, such as disclosure of sex trading activities particularly among minors or relationships with a suspicious older person, prompted a range of responses including feeling unsure or making mental notes. It is also important to note the use of outdated language to describe sex trading activity, such as “prostitution,” which was mentioned six times among minors and twice among adults.

3.3. Sex Trafficking Screening and Risk Assessment Questions

Table 5 shows frequencies and timing of providers’ use of sex trafficking risk assessment questions. Approximately 34% of minor-aged providers and 60% of adult providers reported that they do not ever ask their clients sex trafficking screening questions.

Table 5.

Frequency and Timing of Sex Trafficking Risk Assessment Questions among Minor-aged (n=245) and Adult (n=147) Providers^*

	Minor Provider	Adult Provider
First Meeting Only	12.4% (33)	10.9% (29)
Second Meeting Only	9.0% (24)	6.0% (16)
Third/Fourth Meetings Only	13.9% (37)	7.9% (21)
Fifth Meeting or After Only	11.2% (30)	5.2% (14)
Multiple Sessions (two or more)	19.5% (52)	10.5% (28)
Did Not Ask	34.0% (91)	59.5% (159)

^*Participants answered the question about their respective client group: In the last 12 months, at what point in your relationship with a [minor-aged/adult client] have you asked sex trafficking risk questions?

Table 6 shows providers use of sex trafficking screening and risk assessment questions with their respective client groups. Minor-aged and adult providers reported generally asking no, a few, or some clients recommended sex trafficking assessment questions. Providers generally asked fewer recommended screening questions about online forms of sex trading than in-person forms. Minor-aged providers who received sex trafficking risk assessment trainings (training variable 3) had statistically significant higher means in asking nine recommended screening questions (see Table 7), as well as “Have you been (sex) trafficked?”, which is not recommended because it requires clients to label their experiences in ways that they may not. There were only two statistically significant difference between adult providers who received sex trafficking assessment training, compared to those who did not, for the questions, “Has someone used force, fraud, or coercion to have sexual contact with you?” and “Did anyone ever force you to do something sexually that you didn’t feel comfortable doing?”. When comparing participants who did and did not report demographic data, those who reported their highest educational degree were more likely to ask, “did anyone ever force you to engage in sexual acts with friends, family members, or business associates?” (p<.001).

Table 6.

Use of Screening and Assessment Questions among Minor-aged (n=245) and Adult (n=147) Providers: T-tests Results with/without Sex Trafficking Risk Assessment Training (Likert Scale, 1=no clients, 5=all clients)

Questions	General M	Training M(SD)	No Training M(SD)	t
Have you been (sex) trafficked?
Minor Provider*	1.8	1.9(1.1)	1.7(.9)	−2.00***
Adult Provider^	1.9	2.0(1.2)	1.9(1.2)	−.68
Has someone used force, fraud, or coercion to have sexual contact with you?
Minor Provider	2.2	2.4(1.2)	2.1(1.1)	−1.89
Adult Provider	2.2	2.5(1.4)	2.0(1.3)	−2.00***
Did anyone you worked for or lived with trick or force you into doing anything you did not want to do?
Minor Provider	2.1	2.3(1.3)	2.0(1.0)	−2.27***
Adult Provider	2.1	2.3(1.3)	2.0(1.2)	−1.33
Did anyone ever pressure you to touch another person or have any unwanted physical or sexual contact with another person?
Minor Provider	2.3	2.5(1.3)	2.2(1.1)	−2.13***
Adult Provider	2.1	2.3(1.4)	2.0(1.3)	−1.39
Did you ever have sex for things of value (for example: drugs, money, housing, food, gifts, or favors)?
Minor Provider	2.0	2.3(1.2)	1.8(.9)	−3.80*
Adult Provider	2.0	2.1(1.2)	1.9(1.2)	−.86
Did anyone ever force you to do something sexually that you didn’t feel comfortable doing?
Minor Provider	2.5	2.8(1.2)	2.3(1.1)	−3.50*
Adult Provider	2.4	2.7(1.5)	2.2(1.2)	−2.18***
Did anyone ever put your photo on the Internet to find clients to trade sex with?
Minor Provider	1.5	1.6(1.0)	1.4(.8)	−2.04***
Adult Provider	1.6	1.7(1.0)	1.6(1.0)	−.58
Have you ever put your own photo on the Internet to find clients to trade sex with?
Minor Provider	1.5	1.7(1.1)	1.4(.8)	−2.96**
Adult Provider	1.6	1.7(1.0)	1.5(1.0)	−1.16
Did anyone ever force you to engage in sexual acts with family, friends, or business associates for money or favors?
Minor Provider	1.9	2.1(1.2)	1.7(.9)	−2.93**
Adult Provider	2.0	2.2(1.3)	1.9(1.2)	−1.41
Did anyone ever encourage or pressure you to do sexual acts or have sex, including taking sexual photos or videos?
Minor Provider	2.1	2.3(1.2)	2.0(.9)	−2.69**
Adult Provider	2.0	2.2(1.4)	1.8(1.1)	−2.00
Did anyone ever force you to trade sex for money, shelter, food or anything else through online websites, escort services, street prostitution, informal arrangements, brothels, fake massage businesses, or strip clubs?
Minor Provider	1.7	2.0(1.3)	1.6(.9)	−2.80**
Adult Provider	1.8	2.0(1.2)	1.8(1.1)	−1.11

Notes:

^*p<.001

^**p<.01

^***p<.05

⁺Among minor-aged providers (n=245), 91 received sex trafficking assessment training (variable 3), and 154 did not.

^{^}Among adult-aged providers (n=147), 54 received sex trafficking assessment training (variable 3), and 93 did not.

Training variable signifies sex trafficking training that addressed sex trafficking risk assessment questions and strategies (training variable 3).

Table 7.

Other Sex Trafficking Questions Used by Providers in the Last 12 Months (Qualitative Themes)

Theme	Characteristics	Sample Quote
Providers’ Questions for Minor-aged Clients (17 years old or younger)
Material Items	Gifts, hair, new clothing, cell phones	“Has anyone, stranger, or someone you just met, given you any gifts recently and what was the reason for these gifts?” “If no job where they are getting their hair, nails, new clothing or cell phones from and who’s paying the bill”
Safety	Current safety, safety plan, threats to safety	“Do you currently feel safe? If not, we will set up a safety plan”
Trading Sex	For goods, money, or favors	“Has anyone ever promised goods or money in exchange for sexual contact?”
Sex Trafficking	Screening questions, discussing with client, providing education	“Do you understand that sex-trafficking does not mean being kidnapped and sold into the sex industry?* And then if they do or don’t know I explain to them that is can mean selling or trading sexual acts that are or may not be consensually doing in exchange for housing, food, clothing, shelter and so on is human/sexual trafficking.”
Forced Sexual Activity	Forced by family members, sexual activity in relationships	“Any family members assist in forcing you to engage in unwanted sexual activity?” “Whether within your own interpersonal relationship or not, have you ever felt forced to engage in sexual activity for ‘favors’?”
Friends’ Sex Trading	Inquiry about friends’ sex trading	“Do any of your friends trade sex for money?”
Providers’ Questions for Adult Clients (18 years old or older)
Safety	Current safety, safety planning, threats to safety	“Has anyone threatened your safety or the safety of your family in exchange for sexual acts/behaviors?”
Abuse/Trauma	Physical, sexual, other, open-ended questions about abuse, experiences of abuse/trauma	“Have you ever experienced trauma, sexual, physical, or otherwise?”
Sex Trafficking	History of, knowledge of	“Do you understand what sex trafficking is? Do you know anyone who has been associated with sex trafficking?”
Providers’ Questions for Family Members (including biological, adoptive, or foster families) of your minor-aged clients’ (17 years of younger)
Material Items	Multiple phones, cash/money	“I’ve encouraged foster parents to watch for cash, things of value that cannot be easily explained* how youth would have* gotten this and taught them about what types of things to be aware of as a red flag”

^*indicates changes to misspelled words

T-tests comparing providers who received general sex trafficking training (training variable 1), compared to those who received no training, only produced one statistically significant finding. Minor-aged providers who received general trafficking training had statistically significant higher means of asking clients, “Did you ever have sex for things of value?” [t=(−2.2), p=.03].

Table 7 shows coded themes, characteristics, and sample questions that providers indicated were used in practice but not included in the list of questions provided. Some themes were similar to sample questions we provided, e.g. questions that focused on sex trading. However, other responses that were not listed in the survey indicated that some providers are asking additional questions, such as those that ask clients about the definition of sex trafficking and explain it to their clients, assess safety, or ask about material items.

4. Discussion

Our study shows important insights into how service providers who are employed in systems that encounter sex trafficked young people observe sex trafficking indicators, the circumstances under which they follow-up, and the extent to which they ask sex trafficking screening and risk assessment questions. Our data cannot elucidate whether young people are presenting with such indicators in practice and being missed by providers (e.g. not recognizing tattoos/branding), or whether the least commonly identified indicators are not actually relevant sex trafficking indicators. However, our findings do add to a growing body of work suggesting that some of the indicators highlighted in trainings (e.g. tattoos/branding, signs of torture) are less relevant to providers in these settings (Nichols & Cox, 2021; Pate et al., 2021; author reference). This study also suggests that providers are identifying sex trafficking indicators in practice, yet do not necessarily take relevant follow-up actions, such as assessing the young person for sex trafficking. Providers are less likely to ask questions that assess online forms of sex trading (e.g. posting photos or videos of themselves online), which is an important gap in the wake of general technological availability for young people (Goldberg & Moore, 2018), as well as the COVID-19 pandemic that may have increased online activity (Todres & Diaz, 2021). Trainings that address sex trafficking risk assessments, rather than just the basics, may be important, although more work is needed to evaluate their impact and to establish best practices.

4.1. ST Indicators

Our study builds on prior work suggesting that providers are more likely to identify indicators that are consistent with some of the most rigorous evidence examining potential risk factors and signs of sex trafficking (e.g. behavioral health issues, weak social support, truancy, substance use). These sex trafficking indicators pose a central challenge for providers: on the one hand, many of the common indicators are not specific to sex trafficking, suggesting that they could occur frequently but be less useful. For example, a youth who uses substances may be sex trafficked or experiencing other concerns, such as depression or experimentation. Given that 29% of our sample represented child welfare, it was expected that child protection history and abuse were viewed as some of the most reported indicators. On the other hand, some indicators may occur less frequently but be more useful, e.g., homelessness or unstable housing may be seen less often (depending on provider role) but be a stronger predictor of trafficking. Regardless, governmental and community trainings’ often still emphasize indicators that are consistently some of the least commonly observed indicators in our study (e.g. tattoos, signs of torture, falsified documents, reports of hotels for sexual encounters, etc.) (Dank et al., 2017; Nichols, 2016; Nichols & Cox, 2021; Peffley & Nichols, 2018), which is problematic. Though it is possible that these indicators reflect a non-trafficking situation for youth, presence of these indicators should prompt further assessment of a possible sex trafficking situation. While it is possible that these indicators are relevant but not assessed for or easily observed (i.e., if a sign of torture or tattoo is located beneath key articles of clothing or requires disclosure from the client, such as history of pregnancies or abortions), growing evidence suggests that the least commonly identified indicators found in our study are not as relevant to providers in these systems. This could be because some of them suggest very restrictive forms of sex trafficking (e.g. kidnapping). Most known sex trafficking cases in the U.S. have been shown to either involve emotional abuse or trauma bonds (e.g. a “boyfriend pimp” whom the client loves), or survival sex dynamics, which would not have the presence of a trafficker at all (Goldberg & Moore, 2018; Nichols, 2016). As such, many of the least commonly identified sex trafficking indicators may not be as relevant to providers encountering the latter types of cases in these systems.

Importantly, providers’ reported receipt of trainings that address sex trafficking dynamics broadly and/or sex trafficking indicators specifically made no or minimal differences in provider rankings. While it is possible that trainings are insufficient in teaching providers to identify sex trafficking indicators in practice, it is likely that at least some of these trainings highlight sex trafficking indicators that are not relevant to providers by emphasizing presentations that are reflective of extreme forms of trafficking (e.g. signs of torture). Prior literature suggests that many trainings use sensationalistic images of typically young, white cisgender girls and women who are trafficked through brutal force and/or abduction by older men (Grace, Bright, Corbett, & Morrissey, 2018; Hoyle, Bosworth, & Dempsey, 2011; Peffley & Nichols, 2018; author reference). For example, the Southwest Michigan Human Trafficking Task Force used mannequins exhibiting rope burns and possessive tattoos in trainings provided to practitioners (Wrege, 2017). As such, providers like our study’s participants may be less likely to encounter trafficked young people who experience branding, torture, falsified documents or being unaware of their location and not able to speak for themselves, and should be trained accordingly. Sex trafficking indicators, such as weak social support or interpersonal trust, behavioral health concerns (e.g. depression, anxiety, shame, self-harming or suicidal ideation), truancy or suspensions, in schools among minors should be emphasized and prompt providers to conduct additional screening and assessment. This may why some organizations like Polaris Project most recently suggest focusing less on indicator lists and more on youths’ behavioral changes, “It’s not knowing the signs-it’s knowing the story” (“Recognizing Human Trafficking | Polaris,” n.d.), which may be helpful for providers who maintain longer term relationships with youth. Future research should aim to understand whether providers do not observe some of the least commonly identified indicators because they do not assess for ones that may be hidden behind clothing or require disclosure, or because they do assess and young people are not presenting with or disclosing such indicators in these settings.

4.2. Follow-up Actions

To our knowledge, this is the first study to examine whether and how providers take subsequent actions to document, consult others, or assess clients after observing sex trafficking indicators in practice. Importantly, providers who received indicator trainings were significantly more likely to report asking minors and adults sex trafficking risk assessment questions and refer minors and adult clients to another organization. This is a promising finding, as it is possible that receiving such trainings facilitate providers’ follow-up actions when confronted with a client exhibiting sex trafficking indicators. It is also possible that other factors are influencing these findings; providers who are more likely to receive seek out sex trafficking training may also be more likely to seek out information in other ways or know that they should be assessing and referring and therefore be more subject to social desirability bias.

Our qualitative data revealed some interesting potential “stuck points” in which providers felt unsure of what to do, made mental notes, or documented in client charts but did not ask sex trafficking risk assessment questions or report to child protective services. For example, providers reported feeling unsure or making mental notes about reports of sex trading activity among minor-aged clients. This is problematic, as any reports of sex trading activity among minors should be automatically identified as sex trafficking by the federal definition, and subsequently prompt child protection involvement and assessment. Future research should further explore the reasons why providers felt unsure and probe about any concern they may have about further harm to clients in referring to other systems. The few providers who described sex trading as “prostitution,” particularly among minors, also suggests a potential cause for concern. Similarly, consulting law enforcement for adults who present with housing instability and sex trading should also be avoided. Another salient theme that providers reported was the presence of material items, such as cell phones or unexplained gifts, which sometimes prompted assessments but also resulted in providers feeling unsure or making mental notes. Some providers also used such material items as talking points to assess for how they received or paid for these items; the effectiveness of this strategy should be explored. In addition, these data revealed that providers may have some difficulty assessing between sexual activity, e.g. “sexual encounters among teens” or “sexual acting out,” and sex trafficking risk behaviors. It is possible that young people disclose (possibly age appropriate) sexual activity, but, without further risk assessments, providers do not know whether there is also a trafficking risk. Future research should use documentation records to explore whether and how providers document, consult, assess and refer clients who are at risk of sex trafficking.

4.3. Sex Trafficking Assessment Questions

Our findings suggest that about third of providers who work with minors and over half of providers who work with adults in these settings do not ask sex trafficking risk assessment questions, which could be underestimated due to social desirability bias. Providers in these systems should be screening and (re-)assessing for sex trafficking risk (rather than only asking a screening question in the first meeting), as they build rapport with clients over time. Therefore, trainings and organizational protocols should encourage assessment strategies that include multiple assessments over time, not just in the first meeting with clients (Diaz et al., 2015; Macy & Graham, 2012). Since approximately half of providers who answered the protocol question indicated that they either did not have or were unsure if they had a protocol to identify and respond to sex trafficking, the extent to which such protocols can impact providers’ actions and use of assessment questions remains an important area of future scholarly inquiry.

Providers reported using recommended questions as well as some creative and sometimes problematic strategies to assess for sex trafficking. Although most providers did not report asking the question “have you been (sex) trafficked?,” one salient theme in the qualitative data suggested that providers reported asking if the client was familiar with sex trafficking and explaining how their sex trading fits that definition. This is an interesting finding, as it is not recommended to ask young people if they have been sex trafficked because young people do not necessarily identify with the term (Contreras, Kallivayalil, & Herman, 2017; author reference). Young people may also feel belittle or talked to down to, if providers are trying to explain to them the definition of sex trafficking rather than just discussing sex trading behaviors and associated risks (Campbell & Georgescu, 2000). Although the means for providers who reported asking clients recommended sex trafficking risk assessment questions (Dank et al., 2017; Simich et al., 2014) were generally low, providers who reported attending trainings that addressed sex trafficking assessment strategies produced significantly higher means. This is a promising finding, as trainings that address whether and how to assess minors for trafficking, not just general sex trafficking training, could result in improved assessment strategies. However, our study also suggests that these trainings should stress the importance of avoiding “have you been (sex) trafficked?”, as providers (including those who reported training) may still be asking that question. In addition, there were only two significant differences among adult providers, which is cause for concern. Possible explanations for this finding could be that sex trafficking assessment trainings are more focused on minors than adults, or that there are clearer guidelines for what to do if a minor discloses rather than an adult, which could result in more assessments. Future research should further explore these questions.

It is also important to note that providers generally reported (across groups) asking fewer clients questions about online forms of sex trading as compared to in-person forms. In fact, questions that assessed whether clients had ever posted photos on the internet had some of the lowest scores of all the sex trafficking risk assessment questions. This finding could also explain why illicit profiles was not ranked higher among perceived sex trafficking indicators, suggesting a gap and opportunity for provider training. Providers should ask clients not just whether clients were encouraged, pressured, or forced to post sexual videos or photos but also if they are posting themselves, as such questions could serve as an opening to assess risk by discussing survival sex exchanges (particularly for minors). In addition, clients may be less willing to disclose that someone else was involved (as a pimp or trafficker), which is consistent with recommended questions about clients’ in-person sex trading behaviors. Finally, it is worth noting that another salient, qualitative theme was asking whether friends were involved in sex trading, which could be an important way to indirectly assess for online and in-person forms of sex trading. Prior studies addressing sexual risk assessments among young people suggest that asking about friends’ behaviors, rather than their own, may be a key strategy to facilitate discussion (Fedina, Williamson, & Perdue, 2019; Goldberg & Moore, 2018). Such conversations should be accompanied with statements that normalize the many reasons young people trade sex (i.e. to survive, bring in money, because someone else pressured or forced them to), before asking whether a young person’s friends are engaging in such behaviors. Future research should assess whether and how such strategies may help young people feel more comfortable discussing online and in-person sex trading behaviors and potentially facilitate disclosures, and whether organizational protocols can enhance these efforts.

4.4. Limitations

This study should be taken within the context of its limitations. First, though effort was made to indicate that our study sought to understand how providers conduct assessments broadly, we needed to state that the purpose of the study was to examine how providers assess clients who may be involved in the sex trade. It is possible that our sample does not represent providers who believe that they do not work with this population, as they may have been more likely to disregard the invitation. Second, our data are missing key demographic information for approximately a quarter of our sample, which made it difficult to draw identity-based comparisons, and depended on self-report measures. Efforts were made to address possible social desirability bias by offering multiple options for similar behaviors, such as “I made a mental note” compared to “I didn’t know what to do/did not do anything.” However, future studies should assess social service provider actions using observational designs and case record analysis. Third, it is not clear if our findings on the least common indicators are because service providers encounter them less frequently, or if they encounter them more frequently but do not perceive of them as indicators and so fail to include them in their assessments. Similarly, our study also did not ascertain the extent to which the perceived sex trafficking indicators are reflective of young people who experience sex trafficking, it does provide insights into social service providers’ processes of identify and assessing people who are potentially at risk of sex trafficking. Fourth, although we determined our sex trafficking training variables through a collaborative process with our knowledgeable community providers who were familiar with the trainings we listed in the survey, it is possible that some were miscoded. However, we do not know details about when the training occurred or the frequency of training, which is important area of further inquiry. Finally, even though a 35% response rate is consistent with online surveys among providers (Dykema, Jones, Piché, & Stevenson, 2013), our sample may not be representative. As such, findings from this study may not be generalizable and future research should expand this study to other areas within and outside of the Midwest region in the US.

5. Conclusion

Our study provides empirical evidence for how providers assess for sex trafficking risks and its associations with prior training about sex trafficking. Findings suggest some important implications for the development and implementation of tailored training, ongoing support, and organizational protocols to support providers in the incredibly difficult work of identifying (potentially) sex trafficked youth. Despite decades-long efforts to increase identification, there are still critical gaps in the screening and assessment practices as well as important opportunities for tailored trainings to strengthen sex trafficking identification. As appropriate with provider role, it is essential that providers assess for both online and in-person sex trading behaviors and have clear protocols to address youths’ needs.

Highlights:

• Providers encounter more commonly identified sex trafficking indicators than the sex trafficking specific ones that are often highlighted in community settings.

• Providers who work in these systems may not be consistently assessing for sex trafficking, despite consistently identifying sex trafficking indicators.

• Sex trafficking specific trainings may make some differences in providers’ actions, though more work is needed to understand their impact.