Trafficking and Its Impact on Children with Dr. Michelle Clayton

Released: 8/22/23

Content Warning: This episode contains general discussions of human and sexual trafficking. The conversation is centered around awareness of the signs to increase awareness, but we acknowledge that some may still find this topic distressing and encourage our listeners to take care. More information can be found under “Further Reading and Listening” below.

In this episode of That’s Pediatrics, our hosts talk with Michelle Clayton, MD, MPH, division chief of the Child Advocacy Center at UPMC Children’s Hospital of Pittsburgh.

They discuss:

  • The Child Advocacy Center at UPMC Children’s Hospital of Pittsburgh, a multidisciplinary Center that evaluates children with concerns for physical abuse, sexual abuse, and neglect.
  • The prevalence and different forms of human trafficking and forced labor.
  • Risk factors for trafficking include a history of abuse or neglect, disrupted family connections, running away, gang associations, substance abuse, and dating older adults.
  • The challenge of identifying trafficking due to active efforts to conceal it
  • How medical providers can watch for red flags, listen closely, and approach patients with care.
  • Long-term psychological impacts that trafficking survivors may face, including low self-esteem, mental health concerns, and substance abuse issues.
  • A shift in focus towards therapeutic support for survivors, aiding in criminal prosecution and providing hope for turning lives around.
  • Resources available for survivors, such as the Division of Adolescent and Young Adult Medicine, the Pittsburgh Action Against Rape hotline (PAAR), and Allegheny County Children, Youth and Families.

Meet Our Guest

Michelle Clayton, MD, MPHMichelle Clayton, MD, MPH, FAAP is a board-certified specialist in Child Abuse Pediatrics. She is the Division Chief of Child Advocacy at UPMC Children’s Hospital of Pittsburgh. She completed medical school at the University of Pittsburgh and completed a residency in Pediatrics at Eastern Virginia Medical School (EVMS)/Children’s Hospital of The King’s Daughters (CHKD) in Norfolk, Virginia. Dr. Clayton completed a fellowship in Forensic Pediatrics (now called Child Abuse Pediatrics) at EVMS/CHKD. She is an Associate Professor of Clinical Pediatrics at the University of Pittsburgh. She is a Fellow of the American Academy of Pediatrics (AAP) and is a member of the AAP Section on Child Abuse and Neglect (SCAN). She frequently lectures to medical, investigative, and judicial audiences about child abuse and neglect, and its consequences. Dr. Clayton has received awards from the state of Virginia, as well as a national award, recognizing her work on behalf of abused and neglected children. She has performed thousands of consultations regarding abused and neglected children, and frequently provides expert court testimony.

Meet Our Hosts

Arvind Srinath, MD, MSArvind Srinath, MD, MS, is the Pediatric Gastroenterology Fellowship program director at UPMC Children’s Hospital of Pittsburgh and an associate professor of Pediatrics at the University of Pittsburgh School of Medicine. He received his bachelor’s degree from Johns Hopkins University and his medical degree from the University of Pittsburgh School of Medicine before completing a residency at Johns Hopkins Hospital, a fellowship at UPMC Children’s Hospital of Pittsburgh, and a master’s degree in medical education at the University of Pittsburgh School of Medicine. Dr. Srinath’s areas of interest are curricular development, functional gastrointestinal disorders, and telehealth. Find him on Twitter: @Srinath_Arvind.

Allison WilliamsAllison “Alli” Williams, MD, is a pediatric hospitalist and is certified by the American Board of Pediatrics. She is a member of the Paul C. Gaffney Division of Pediatric Hospitalist Medicine, medical-surgical co-management team director, and assistant professor at the University of Pittsburgh School of Medicine. Dr. Williams received her medical degree from Herbert Wertheim College of Medicine at Florida International University in Miami, Florida, and completed her residency at UPMC Children’s Hospital of Pittsburgh. Her clinical interests include non-RSV bronchiolitis, febrile neonates, and the enhanced of patient care through medical-surgical co-management.


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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Allison “Alli” Williams: Welcome to That's Pediatrics. I'm Alli Williams, one of the hospitalists here with UPMC Children's Hospital of Pittsburgh. I'm here with my co-host.

Dr. Arvind Srinath: I'm Arvind Srinath from the Division of Gastroenterology.

Dr. Williams: And we are so excited today to have Dr. Michelle Clayton here with us, who is the Division Chief, the Division of Child Advocacy, and one of our newer physicians within the Child Advocacy Center. Thank you so much for coming today.

Dr. Michelle Clayton: Thank you so much. It's my pleasure to be here.

Dr. Williams: We would love to just start the conversation for all of our listeners who aren't really familiar with the Child Advocacy Center. Can you tell us a little bit more about what it does and why we have it here?

Dr. Clayton: Oh, yeah, that's a great question because I think there's always so many questions about, "Well, what exactly is child advocacy?"

Dr. Williams: Right.

Dr. Clayton: And it's a multidisciplinary specialty. The doctors working with the Division of Child Advocacy, we have a mix of specialists, some of whom are board certified in child abuse pediatrics like myself and Dr. Rachel Berger, and others of whom have a general pediatrics background, but have been trained in the field of child abuse pediatrics, and including Dr. Jennifer Wolford, Dr. Addie Eichman, Dr. Hannah Sahud. And together, along with two additional doctors from the department who we share with the Division of Emergency Medicine, Dr. Carmen Coombs, Dr. Maria Antonucci, and Dr. Matt Valente in the Division of Pediatric Hospital Medicine. Together, we perform evaluations for children with concerns for physical abuse, sexual abuse, and neglect. So we perform a wide array of functions just in the course of evaluating children, both in the inpatient setting, the outpatient setting, and we have connections with a lot of local agencies.

As you might imagine, if you evaluate a child and you know this child was abused, the parent's explanation doesn't make any sense for the injuries that we're seeing in the child, and then you write it up and send it to the police, you work with a lot of different agencies. We work really closely with the agencies that are charged with child protection, children, youth and families, and Child Protective Services. We work closely with police, and we also work with the prosecutorial side of things with the district attorneys. So we have a lot of roles in working in multidisciplinary effort to ensure the safety of children and have a wide variety of people who work with us, not just physicians, but certainly forensic interviewers who are people who are specialized in talking to kids and getting great information from them.

We also have nurse practitioners, physician assistants, and a variety of administrative staff, as well as nursing team members who help us to carry out this goal of helping kids. And we even have one nurse practitioner whom we share with the Division of Adolescent and Young Adult Medicine who helps us with trafficking cases and also helps to cross the bridge between children and adolescents.

Dr. Srinath: Well, Dr. Clayton, first of all, congratulations on your new position.

Dr. Clayton: Thank you.

Dr. Srinath: And leading such a vital division to the health and welfare of our children and families. So first of all, thank you.

Dr. Williams: Absolutely.

Dr. Srinath: Can you tell us a little bit about your career path to where you are today?

Dr. Clayton: Sure.

Dr. Srinath: What brought you to Pittsburgh, and a little bit more about this horribly devastating issue of child sex trafficking, which we hope to get into a little bit more in our discussions today.

Dr. Clayton: Sure, sure. Well, actually, what brought me to Pittsburgh was birth. I was born here.

Dr. Williams: That makes sense then.

Dr. Srinath: That's awesome.

Dr. Clayton: So I'm a native of the area. I grew up in the Homewood section of the city.

Dr. Srinath: Nice.

Dr. Clayton: And went to Harvard for college, came back home and got a master's degree at the Graduate School of Public Health, then started medical school, and fell in love with pediatrics and ultimately ended up after my graduation from medical school going to Eastern Virginia Medical School, which is located in Norfolk, Virginia, for my training at Children's Hospital of The King's Daughters as a general pediatrician. And I meant to be away just for a few years because my family is really closely knit. And I was like, "Well, I'll go there for three years and I'll come right back home."

So here I am 22 years later, finally.

Dr. Williams: Just a couple.

Dr. Srinath: Circle back.

Michelle Clayton: That's right. So I made my way back home last summer when I took a position with the Division of Child Advocacy. Rachel Berger stepped down as the division chief, and so I thought that was a wonderful opportunity to be able to continue in the field of child advocacy that I absolutely love and be able to come home because the overwhelming majority of my family's here, parents, siblings, aunts, uncles, cousins, everybody except for me and my kids.

Dr. Williams: Oh my goodness.

Dr. Srinath: Awesome.

Dr. Williams: So we're thrilled you're back, even if it's 22 years later. We're thrilled that you have this new position as well. And you had mentioned, when you were talking about all the wonderful things that the Child Advocacy Center does, is you had mentioned the word trafficking.

Dr. Clayton: Yes.

Dr. Williams: And this is something that I think we should talk a little bit more about today because I think myself included, a lot of us feel like this is something we hear about and don't see. So could you talk a little bit about the trafficking, what type of trafficking we're seeing and more information about that for the U.S. and maybe even the Pittsburgh area locally?

Dr. Clayton: Absolutely. I think that there's this huge misperception about human trafficking, what it is, what areas are affected. And the truth that a lot of people find really astonishing is that it happens all the time. It happens under our noses. It happens right here in our region. And what I want to do is just talk generically about trafficking, but also talk about kind of what it is, but also talk about the different forms that it takes on and how we're affected by it in the United States. I remember at the center where I was before I came here, I heard about trafficking and thought the very same thing that most people think like, "Oh, well, that's for other people, not for us. And certainly not here."

Dr. Srinath: Exactly.

Dr. Clayton: And we had some training about trafficking, and to my absolute astonishment, I realized that most of the people who've been trafficked, like most of the people in the United States that have been trafficked, are natives of the United States. They're not brought from another country. They didn't cross a border. The overwhelming majority of people who've been subjected to human trafficking are U.S. citizens.

Dr. Williams: That's shocking.

Dr. Clayton: It is shocking. It is. Estimates of the number of people involved in trafficking worldwide in a 2021 study show that, at any given moment, over 27 million people are being trafficked worldwide.

Dr. Williams: Oh my gosh.

Dr. Srinath: 27 million?

Dr. Clayton: 27 million, yes. And a lot of people think about sex trafficking, but forced labor is also a very highly prevalent way in which people are trafficked. When you think about who gets trafficked, most people think women in terms of sex trafficking. And it is true that the majority of people who are being trafficked sexually or sexually exploited are women, although there certainly are men who are trafficked as well. And when it comes to forced labor, the majority of people who are trafficked are men, especially in the construction trade, which is another astonishing fact that people really don't think about. But women are also trafficked for labor, including domestic work, housekeeping, childcare. The amount of forced labor and the amount of sex trafficking that happens right under our noses is astonishing. Because I think the common perception of someone who's being sexually trafficked is a woman who's being forced by a pimp to bring in money. That certainly happens, but it's by far not the only way in which sex trafficking occurs.

Dr. Srinath: So for the listeners, I can't imagine how scary this is. Just us hearing about this, scary, devastating, horrible, immoral, so many words come to mind, which just I think we can't even put together in terms of thought processes, hearing what you're talking about even so far. For families out there, what are risk factors for this?

Dr. Clayton: It's a great, great question. And I think that in order to recognize what the risk factors are, we have to broaden our perception about what trafficking is and what it constitutes. So it's this kind of traditional notion of pimp prostituting a woman or prostituting a person and forcing them to turn over all their money is not the only way in which people get trafficked. Instead, sometimes you can have a group of people trafficking a person and forcing them to engage in sexual activity and taking the money, like a gang, for example. There's familial trafficking, horrible as it is, and horrible as it sounds. Someone's family members can allow others to engage in sexual activity with that person or child in exchange for not just money, but also rent, food, drugs.

Dr. Srinath: Oh, gosh.

Dr. Clayton: Right. And there's also a kind of survival aspect. A lot of children and adolescents, especially those who are in abusive situations, may run away, but then engage in sexual activity for survival to get a roof over their head, to get food for drugs or for anything they may need. And so if we broaden our perception about what trafficking is, and if we think about the federal definition of it, it's using sexual activity in exchange for anything of value, not just money, but also shelter, clothing, food, whatever.

Dr. Williams: Survival items.

Dr. Clayton: Exactly. And so when we think about it with that broader lens, we begin to recognize there's a whole lot of things that actually are sex trafficking that we may never have considered before. For example, a child who has to perform sexual favors to get lunch money, or a child who has to go see the landlord every time the rent is due, and they go all by themselves.

Dr. Srinath: Oh, gosh.

Dr. Clayton: If we think about these things, the problem becomes truly staggering to contemplate.

Dr. Williams: And a lot of our listeners are pediatricians or future pediatricians and members of our community. And so to think about it more specifically from a pediatric outlook, you had mentioned 27 million people worldwide. Are there any numbers, adults versus pediatric population?

Dr. Clayton: It's really difficult to come at these numbers, like you're saying. Estimates about exactly how many women and children enter into sex trafficking every year vary wildly. Some organizations believe as few as 10,000 each year. Others, the estimate's more like over 300,000 per year.

Dr. Srinath: Oh, wow.

Dr. Williams: Wow.

Dr. Clayton: So part of the problem being able to come up with decent estimates or pie in the sky vision of accurate numbers is because, well, this is a covert activity. Efforts at concealment have become more sophisticated all the time, particularly with the use of electronic means of advertising a person's services, soliciting clients. But oh, I just realized you had asked about kind of ways that people can think about or situations that could make people think about trafficking. And I did forget to answer the question.

Dr. Srinath: That's okay, this is such a-

Dr. Clayton: And it relates directly to how do we figure out what's going on? So I have to say that it's difficult to get clarity on the numbers of people. All we know is that it's far too many, and it's something that's usually pretty elusive because of the active efforts at concealing it. So that's one of the challenges to identification, that active effort to conceal it. But there are a lot of places where trafficking tends to occur, particularly sex trafficking such as hotels and motels, massage parlors, truck stops, even sporting events. I believe the last time the Superbowl happened in Atlanta, there was this huge article talking about how many people were flown in to be trafficked.

Dr. Srinath: Oh, no.

Dr. Williams: Oh my gosh.

Dr. Clayton: Right. There's been a lot of studies about who becomes trafficked and how old are they at the time? Most are between 12 and 15, although some are younger. And of the adults who were involved in sex trades, many of them became engaged in it before they turned 18. Identifying people who've been trafficked is something that really can help to change the course of their lives. If parents notice that they have a child who suddenly has these new things or these expensive things that no one in the family bought them or gifted them, that should heighten their concern about the possibility of trafficking.

A common misperception about people who've been trafficked is that they are snatched from their home and they just disappear. But actually many victims... Or I shouldn't call them victims, because people who are being trafficked have a lot of resistance to being called a victim. And the trend is moving away from calling them a victim. Although, we tend to think them of them as being victimized, that's not how they often regard themselves. And if we come at them with that, "Oh, you poor thing, you've been victimized.", perspective, that can truly alienate them and make it difficult for them to engage in any offers or efforts to help them.

Dr. Srinath: So is it almost like a Stockholm syndrome mentality? Is that what you're getting at in terms of how they perceive?

Dr. Clayton: Right. I mean, it's all about their perception. Exactly. If they're being actively trafficked by one person, they may see that person as their boyfriend, their lover, someone who actively helps them out and protects them. And it's because of the way they've been groomed to engage in this activity, absolutely. Or they may have a lot of resistance to, say, family members being characterized as someone who's caused them a lot of harm if they were trafficked by their family. If they're trafficked by friends, they may have a lot of resistance to someone talking negatively about the person who trafficked them or the people who trafficked them. So there's a lot in terms of the perception that necessitates a really careful approach.

Dr. Williams: So how do we deal with that approach then, right?

Dr. Clayton: Yes.

Dr. Srinath: Yes.

Dr. Williams: Because I was just thinking like, oh my goodness, if I see someone as a hospitalist that I'm worried about something that doesn't really sit well with me when I'm getting a history on this patient, how do we as the providers keep our eyes to the sky, our ears to the ground? Whatever the saying is, because I'm terrible with sayings. But how do we approach this if we're worried about something like this with our patients?

Dr. Srinath: And what makes us even worried, to be honest?

Dr. Williams: Yeah, red flags maybe.

Dr. Srinath: What should pediatricians be looking for to be like, "Guess what? Something's up." Outside of the example you mentioned.

Dr. Williams: Exactly.

Dr. Srinath: I'm sorry. I didn't mean to-

Dr. Williams: No, same thing.

Dr. Srinath: But I think we're thinking in tandem here.

Dr. Clayton: Yes. Yes, absolutely. Certainly if there's a history of abuse or neglect, that should help us to recognize that that's a child who's vulnerable. Often children who've been in the foster care system, children who've already been exploited are certainly at higher risk to be exploited again by someone else. And so that alone should certainly make medical providers be aware of the possibility and should prompt a person to listen closely and watch carefully as far as that situation, because certainly those things alone puts a child at high risk. One child put it as having been in the foster care system, she said, "Well, I was used to having a paycheck attached to me. How was this different?"

Dr. Srinath: Wow.

Dr. Williams: Wow.

Dr. Clayton: And certainly if there's a child who has really disrupted or abnormal family connections or limited connection with their family, again, that's a child who's really vulnerable, who may have to do things to survive that other kids may not have to worry about. So certainly a situation to watch closely and think about carefully regarding the likelihood or the possibility of trafficking. If there's a history of running away, again, a child on the streets may have to do things to get a roof over their head or be coerced into doing things to keep food in their belly and clothes on their back.

A child who typically dates or has relationships with older adults, and so often we think about a young girl with an older male, but it can definitely go the same way around. It could be a male with an older female. It could be a young girl with an older female, a young male with an older male. This cuts both ways. If they have any kind of ongoing relationships or typically date older adults, there could absolutely be a trafficking component to that. If there's a gang association, some gangs may require sexual activity as initiation to the gang, for example. That can be forced participation as someone being assaulted or forced participation as someone who is doing the assaulting.

Dr. Srinath: That's horrible.

Dr. Clayton: And so those are definitely things to keep in mind. And if someone comes in repeatedly with sexually transmitted infections, if they have inappropriate or sexual activity online with other people, particularly again with someone who's older than them, these are all things to keep in mind. And I did want to point out that children who are LGBTQIA+ certainly are very, very high risk for many things. First, risk for being rejected by their family. Risk for running away. Risk for being abused as their family discovers their sexual orientation or their gender orientation. Identifies as LGBTQIA+ absolutely is at high risk for being trafficked. And a child who's got substance abuse issues or ongoing substance use, especially if that's chronically increasing over time, they may find other ways to get money, or that vulnerability can be used to exploit them. So there are a lot of different things to keep in mind as we approach patients and families. And the goal is to really expand our perspective and include trafficking in the differential as we encounter patients and families. Anything that strikes us as unusual, anything that makes us concerned, we should listen to that little voice.

Dr. Srinath: Can you just touch upon the psychological impact long term on folks who have been subjected to trafficking?

Dr. Clayton: Absolutely. Absolutely. There's a whole host of problems that can pursue a person after having been trafficked, including low self-esteem, and then a host of mental health concerns and including depression, suicidality, certainly substance use or abuse can be either exacerbated or even initiated during a time of trafficking. And so there's a whole lot of challenges. First, in helping a person understand that they were trafficked. That really may not be the way that they perceive themselves. And then once they can recognize that, then they can move on to a position of strength in terms of recognizing that they don't want that for themselves and moving beyond the elements, which led them to it.

So there are some people who have been trafficked who remain in the same situation and really have a hard time getting away from it. And so helping a person to establish supports and having a therapeutic helping approach establishing a rapport is one of those huge things that helps. But certainly people who never get any kind of help are subject to a long array of serious long-term consequences, including all the risks that come with risky sexual behavior, risk for sexually transmitted infections, and definitely the mental health concerns are the hugest problem for them.

Dr. Srinath: Wow.

Dr. Clayton: Yeah.

Dr. Williams: I think all of our eyes have been widened with this conversation. Spirit's a little bit sunken, won't lie, about learning about all of this.

Dr. Clayton: Right.

Dr. Williams: But with that, you mentioned the population that's been trafficked, that's been exposed to this, that gets the help that they need, can also have success later in life too.

Dr. Clayton: Absolutely. Absolutely.

Dr. Williams: What do we do as providers besides recommending they go to the Child Advocacy Center and getting you all involved?

Dr. Srinath: Right, right.

Dr. Williams: Are there other resources locally that we could tell our listeners about that if they're worried about this, they could talk to their patients or the folks that they're worried about with?

Dr. Clayton: Absolutely. The Division of Adolescent and Young Adult Medicine has really led the charge on raising awareness and finding really effective ways to connect with people who've been trafficked and providing a vital source of support to them in order to help them shift their perspective and change the way that they're living. The Pittsburgh Action Against Rape hotline, or the PAAR hotline is another way that people can access the services that can enable them to make this shift from being trafficked to life after trafficking. And there's also sources through Allegheny County Children, Youth and Families, connecting with the Division of Adolescent and Young Adult Medicine, and also connecting with PAAR can enable people to access the resources through Allegheny County Children, Youth and Families. And so there's definitely a community response. Interestingly, one of the things that I discovered is that there's been a shift in focus from identification and forensic evaluation to a therapeutic orientation and a supportive orientation, which surprisingly aids in criminal prosecution, so that's exciting.

Dr. Williams: There's some sort of light.

Dr. Srinath: Right.

Dr. Clayton: Yes. And I think that as difficult as it is to hear these kinds of things about trafficking, and as we begin to recognize that a lot of it's happening right under our noses, right in front of our faces, that's a critical element in being able to help. And so a lot of people say to me, "Oh my goodness, you do what for a living? You're a child abuse specialist? That must be horrible." But actually, I find that there's a whole lot of hope in what we do every day because we get to see kids at a really terrible point in their lives, and we can help to turn things around by aiding them when they need it the most. I think that we have triumphs every day.

Dr. Srinath: I really like how that's framed because it's exactly what I think we both are thinking. We can't thank you enough for your leadership and your division for truly, truly aiding the children and families in our area, as well as throughout the nation too. More specifically, highlighting a really, really incredibly, I can't even put words to it, problem and giving at least some of the listeners some tools.

Dr. Clayton: Oh, wonderful.

Dr. Srinath: To act upon and to utilize to help these people who have been subjected to trafficking. Thank you, Dr. Clayton.

Dr. Clayton: Thank you.

Dr. Srinath: We so appreciate you.

Dr. Clayton: Thank you so much. Thanks for having me come today.

Dr. Williams: Yeah, thank you again so much for sharing all of your wisdom with us. We really appreciate it. And thank you to all of you who are listening to That's Pediatrics.

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This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider.