The National LGBTQIA+ Health Education Center from The Fenway Institute aims to advance health equity, access, and quality of care for LGBTQIA+ people through evidence-informed and cutting-edge training and education for healthcare providers across the globe.
This publication provides a framework for understanding the forces that drive human trafficking among LGBTQIA+ youth, and offers recommendations for providing meaningful, affirming, and non-judgmental care through the application of a healing-centered approach.
Human trafficking has a considerable impact on the health and human rights of millions of
children and adults around the world.1 The true
prevalence of human trafficking in the United States is difficult to estimate. We do
know that over 10 000 survivors called the National Trafficking Hotline in 2019, and
that hundreds of thousands more are forced or coerced into performing labor, or
experience other forms of exploitation every year.2,3 Among those most vulnerable to human trafficking are teens and young adults who
are lesbian, gay, bisexual transgender, queer, intersex, asexual, and all sexual and
gender minorities (LGTBQIA+).4 Because of
physical, emotional, and sexual abuse in the home, and family rejection related to
their sexual orientation and gender identity, a disproportionate number of
LGBTQIA+ youth experience homelessness, unstable housing, food insecurity,
criminalization, and involvement in the foster care system. Unstable living
conditions put these youth at increased risk for human trafficking, particularly
engagement in the sex trade.5- 7
Most health centers likely care for LGBTQIA+ youth who have experiences with human trafficking, even if providers are not fully aware of these patients' situations. According to a 2014 study, 88% of human trafficking victims accessed health care services while they were being trafficked.8 Another study found that 93% of young people in the sex trade visited a physician in the past year.4 The health care setting represents a crucial opportunity to support youth with experiences of trafficking, as it may be the only opportunity for youth to be alone, separate from trafficker. The purpose of this publication, therefore, is to increase health centers' awareness of and responsiveness to LGBTQIA+ youth experiencing human trafficking. We primarily focus on LGBTQIA+ youth engaged in the sex trade, including forced, coerced, and voluntary sex work and survival sex; however, LGBTQIA+ youth may also experience other forms of labor exploitation. In Part 1 of this publication, we provide a framework for understanding the forces that drive human trafficking among LGBTQIA+ youth. In Part 2, we offer recommendations for providing meaningful, affirming, and non-judgmental care, and for applying a healing-centered approach.
Human trafficking: Human trafficking can be thought of as a pattern of behaviors and tactics used by individuals and institutions to gain and maintain power and control over another person or group of people's labor, without consent, for the purpose of commercial benefit and maintaining existing socio-economic hierarchy. This includes forced or coerced labor of all kinds, including forced or coerced commercial sex work. Federal US law considers all sex trade activity by people younger than 18 years to be human trafficking, regardless of whether the young person experiences force, fraud, or coercion from a third party. Young people whose experiences fall under the federal definition of human trafficking may not personally identify as a victim/survivor or may not identify their experience as one of trafficking.
Sex trade: A broad term that refers to economies of exchanging sexual services for money or material goods, including but not limited to providing escort services, sex work, pornography, exotic dancing, massage, internet work, phone sex operators and more. Young people's experiences in the sex trades are diverse and can be voluntary, as a mechanism for survival, or be forced or coerced to participate by a third party.
Survival sex: Engaging in sexual acts in exchange for goods or services to meet one's basic needs to survive. People who engage in survival sex typically do not have the resources or family support to access other forms of employment and income.
Regardless of whether a young person is selling sex to earn money, to survive, or was forced/coerced by a third party, all young people deserve care, self-determination, and safety.
LGBTQIA+: Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities.
Sexual orientation: How a person characterizes their emotional and physical attraction to others.
Gender identity: A person's inner sense of being a girl/woman/female, boy/man/male, another gender (eg, bigender, nonbinary), or having no gender (eg, agender).
Sex assigned at birth: The sex (female or male) assigned to an infant, most often based on the infant's anatomical and other biological characteristics.
Lesbian: A sexual orientation that describes a woman who is primarily emotionally and physically attracted to other women.
Gay: A sexual orientation that describes people who are primarily emotionally and physically attracted to people of the same sex and/or gender as themselves. Commonly describes men who are primarily attracted to men, but can also describe women attracted to women.
Bisexual: A sexual orientation that describes a person who is emotionally and/or physically attracted to people of all genders.
Straight/heterosexual: A sexual orientation that describes women who are primarily emotionally and physically attracted to men, and men who are primarily emotionally and physically attracted to women.
Queer: An umbrella term that describes people who think of their sexual orientation or gender identity as outside of societal norms.
Transgender: An umbrella term used to describe people whose gender identity or gender expression does not align with society's expectations based on the sex they were assigned at birth.
Gender diverse: An umbrella term that describes the community of people who fall outside of the gender binary structure (eg, nonbinary, genderqueer, gender fluid people).
Cisgender: A term used to describe people whose gender identity aligns with society's expectations based on the sex they were assigned at birth.
LGBTQIA+ Youth and the Sex Trade
According to a study conducted in six geographically dispersed US cities with youth in the sex trade, LGTBQIA+ youth (ages 13-24) represented nearly half of all youth in the study (Table 1). These youth primarily identified their race/ethnicity as Black/African American (70%).4
LGBTQIA+ youth in the sex trade have very diverse experiences which can vary depending on many factors. Research suggests that among youth in the sex trade:4
Only 15% are forced, coerced, or exploited by a third party, who were often people in their community or networks.
About 19% relied on a supportive, “mutually beneficial” market facilitator.
62% reported trying to leave the sex trade, although 63% reported that they would know how to leave if they ever wanted to do so.4
Sexual orientation and gender identity of youth in the sex trade, based on a national study of youth in six US cities (n= 949)
Intersectional and Systemic Oppression
Why are LGBTQIA+ youth disproportionately engaged in the sex trade? Multiple intersecting social, structural, and economic forces drive this disparity. The pervasive systemic and individual-level hatred, stigma, and fear of LGBTQIA+ people (ie, homophobia and transphobia) continue to create unsafe home and school environments for many LGBTQIA+ young people. Surveys of LGBTQIA+ youth show high levels of harassment, bullying, and violence from family, peers, and community members.11,12 LGBTQIA+ youth may be forced out of their homes or may choose to leave an abusive home. Youth who become homeless typically have limited access to other means of providing for their basic needs. Finding employment is challenging for youth who do not have access to clean clothes or an address, may be younger than the legal age of employment, and may not have a high school degree. LGBTQIA+ youth, and especially transgender and gender diverse youth, also face significant discrimination from potential employers. These youth may also experience stigmatizing and discriminatory experiences while accessing public accommodations, public benefits programs, and health care.13
In order to survive, many youth experiencing homelessness find they can exchange sex for shelter, food, and other necessities, such as medically necessary gender-affirming hormone therapies, surgeries, and clothing. Some LGBTQIA+ youth experiencing homelessness may also find that being a part of a group of peers engaged in the sex trade and other survival economies is a source of community and social support.5,14
For Black LGTBQIA+ youth and other youth of color, anti-LGBTQIA+ stigma intersects with the negative effects of systemic and individual racism, creating even more vulnerability to homelessness, the sex trade, and other forms of human trafficking.
Among homeless youth in Atlanta, GA, 88% identified as Black/African American or multi-racial, 6.5% as transgender, and 27.5% as lesbian or gay.16
Nationally, about 23% of people experiencing homelessness are Hispanic/Latin/x.17
The disproportionate burdens of homelessness and sex trafficking among LGTBQIA+ youth of color is also associated with a history of involvement in the child welfare system. Studies have found that:
LGBTQIA+ youth are about three times more likely than straight youth to be placed in foster care.12,16
More than 50% of LGBTIQ+ youth have reported feeling safer on the street than in their foster homes.12 Young people may turn to survival economies like the sex trade to be able to support themselves outside of foster placements.
Among young people whose experiences meet the federal definition of sex trafficking, 63% have previously been involved in the child welfare system, and are disproportionately LGBTQIA+.19
The juvenile justice and adult criminal legal systems also disproportionately impact LGBTQIA+ youth, especially Black, Indigenous, and other youth of color.20 In a study of mostly LGBTQIA+ youth of color with involvement in the sex trade in New York City:5
70% had been arrested, mostly for crimes of survival (vagrancy, petty theft, drug possession, prostitution, etc.).
Almost 20% reported police contact at least weekly.
Rather than feeling supported by these institutions, many LGBTQIA+ youth report mistreatment and refusals of help.5,17,21 Involvement in the child welfare and criminal legal systems can have lifelong negative social and health impacts on young LGBTQIA+ people, and can increase vulnerability to economic insecurity, trauma, and human trafficking.5
Downstream Health Effects
Youth with experiences in the sex trade and human trafficking often experience health issues associated with homelessness, unprotected sex, inadequate nutrition, physical and emotional abuse, and dangerous working conditions. These youth may also have their access to health care restricted by people who are controlling and exploiting them.20
Common health issues among youth who have been trafficked and/or have experience in the sex trade include:6,21,22
Bruises, scars and other signs of physical abuse
Substance use disorders (as a form of coping and/or control by trafficker)
Anxiety disorders, post-traumatic stress disorder, and depression
HIV and sexually transmitted infections
Rectal and pelvic pain and trauma
Fatigue, dizziness, and back pain
Malnutrition and exhaustion
Compared to non-LGBTQIA+ youth, LGBTQIA+ youth have an even greater risk for mental health and substance use disorders because of acute and chronic stress associated with societal stigma against sexual and gender minorities (referred to as minority stress).23 People who have multiple marginalized identities, such as a Black, Indigenous, and other LGBTQIA+ youth of color, often contend with additional layers of minority stress.24Figure 1 illustrates how systemic oppression results in social and economic inequities, which in turn can lead to vulnerability to human trafficking and negative physical and behavioral health outcomes among LGBTQIA+ youth.
Health centers and health care providers are well-positioned to promote the health and wellbeing of LGTBQIA+ youth with experiences in the sex trade and/or who have been trafficked. While young people may come and go from the sex trade and other underground or survival economies, health centers have the opportunity to offer a stable setting that is a source of long-term support for young people. The health care provider's overall goals when caring for LGBTQIA+ youth and any youth who may be experiencing human trafficking are to:25,26
Build a trusting relationship, increase connection, and reduce isolation1
Affirm and foster the youth's strengths and assets
Address social determinants of health through community partnerships and systems changes
Re-Thinking the Focus on Identification, Screening, and Disclosure
To meet the goals of healing-centered engagement and care, health centers may need to reconsider their process for screening and disclosure of human trafficking, particularly among minors. Though important for identifying individual patient needs, such as mental health, screening for highly sensitive topics such as the sex trade and intimate partner violence has limitations, particularly if there is an expectation of disclosure by the patient. There are several reasons why LGBTQIA+ youth may not disclose their experience in the sex trade and human trafficking to health care providers, including:
Fear of judgement, stigma, or disappointment from their provider
Concerns that disclosure will increase violence or control from an abusive partner or trafficker
Fear that the provider will report to the child welfare or criminal justice systems
Not knowing how the information will be used or protected
Additionally, youth may not view themselves as victims or understand their experience as trafficking, even for youth whose experiences may fall under the federal definition of trafficking. They may not identify a person in their life as their trafficker, or want to focus on traumatic events in their lives. A healing-centered approach, therefore, moves beyond a deficits-based, identification-focused approach to a strengths-based and support-focused approach.
Health care providers do not need to know everything that has happened to a young person to provide effective care. If young people share their story, they should be doing this because they see the provider as a trusted source of support—disclosure should never be necessary for providing trauma-sensitive care or access to resources for survivors of trafficking, abuse, and other forms of trauma.
A healing-centered approach, therefore, uses a future-focused question framing:
Instead of: “What happened to you?”
Use this framing: “Where do you want to go and how may I help you get there?”
Using a healing-centered approach enables young people to maintain autonomy over their personal narrative and their health care decisions, while helping them meet their goals and needs. The main points to keep in mind are to:
Listen to what the patient tells you
Discuss the limits of confidentiality
Explain the processes that will occur based on what the patient has disclosed
Ask for consent before putting information in the medical record or sharing the information with others
The next section describes an evidence-informed promising practice that providers can use to provide resources and support to their young patients without depending on disclosure.
Confidentiality, Universal Education & Empowerment, and Support (CUES)
CUES is a healing-centered approach to providing patients with information and support. Originally developed specifically for youth experiencing intimate partner violence, CUES can be easily adapted for youth experiencing human trafficking. CUES does not rely on disclosure in order to provide a patient with information and resources they might need. Through CUES, providers ensure that young patients are aware of available survivor support services and are invited to pass the information on to friends and family members. CUES includes sample scripts that providers can adapt or use verbatim with their patients.
Providers explain the limits around disclosure and confidentiality, which will differ by jurisdiction. For example:
“Your story is your own and I don't want you to feel like you have to share anything to get support. If a young person tells me [insert local legal requirements], then I have to get others involved. If there was ever a time that this situation comes up, I will always make sure you know, and will involve you in this process as much as you would want to be involved.”
An important note: When talking with youth, try to avoid using the word “report.” Youth may interpret “report” as meaning they did something wrong and that they will get “in trouble.”
UNIVERSAL EDUCATION AND EMPOWERMENT
The universal education and empowerment step aims to raise awareness among young patients about (1) what constitutes sexual coercion and exploitation and why this is relevant for their health and wellness, and (2) what resources are available to support them.
The following script invites—but does not require—patients to share their experiences in advance of sharing resources. This topic should be brought up only after establishing a trusting relationship with the patient.
“So many of the young people I take care of have been placed in situations where adults have taken advantage of them or people they are close to have hurt them or made them feel unsafe. If this is part of your experience, I want to make sure you have support should you ever need it.”
As part of the educational step, providers hand out safety cards to patients to start the conversation about relationships and how they affect health. Futures Without Violence has cards with LGBTQIA+ and youth-friendly information on healthy versus nonconsensual and abusive relationships, along with local and national resources for survivors of abusive relationships and trafficking.
CUES also suggests sharing an extra safety card with each patient, and encouraging the patient to share the card with a friend or family member. For telehealth visits, providers can ask to send patients a link to resources should the patient or a friend need them. Studies show that young people in the sex trade share health information with other young people in their community and networks.4,6,18 Sharing cards and links with a focus on how young people can share with others can promote social support, connection, and healing–and increases the chance that young people who may have less access to health care get important support information.
The following scripts are examples of how to introduce this idea to patients:
“I've started giving two of these cards to all of my patients—in
case you are ever struggling in a relationship or if you feel like someone
is taking advantage of you—and also so you have the info to help a
friend or family member.”“I am sharing this information with all young people because I think it's so important for young people to know how to help each other. This might be relevant for you at some point, and I bet there's someone you could share this with.”“I need your help with getting the information about these super helpful crisis lines to other young people. I want everyone to know that you don't have to even use your name to reach out for help. Would you please do me a favor and put these numbers into your phone to have in case a friend needs this info?”
“I've started giving two of these cards to all of my patients—in
case you are ever struggling in a relationship or if you feel like someone
is taking advantage of you—and also so you have the info to help a
friend or family member.”
“I am sharing this information with all young people because I think it's so important for young people to know how to help each other. This might be relevant for you at some point, and I bet there's someone you could share this with.”
“I need your help with getting the information about these super helpful crisis lines to other young people. I want everyone to know that you don't have to even use your name to reach out for help. Would you please do me a favor and put these numbers into your phone to have in case a friend needs this info?”
The Universal Education and Empowerment approach was evaluated in school-based health centers in California through a cluster-randomized controlled trial. The study found that compared to the control group, the students who received the Universal Education and Empowerment approach had:
Increased recognition of what constitutes sexual coercion
Increased awareness of relationship abuse resources
Reduced reports of relationship abuse victimization at three months (among those with recent victimization)
Increased disclosure of history of unhealthy relationship to the provider
If a youth shares their experiences, it is an incredible gift. Providers can build stronger relationships with their patients when they thank the patient for sharing a challenging experience:
“I am so grateful that you shared that with me. Thank you for trusting me with your story.”It is also important for providers to offer choices to their patients, rather than to steer patients towards a particular outcome:“I hear you saying that things are complicated. Would you like me to offer some thoughts on what other young people have found helpful? I'm also ok with just listening as well.”“Thank you for sharing this with me, I'm so sorry this is happening. A lot of my patients experience things like this. There are resources that can help. I would be happy to connect you today if that interests you.”
“I am so grateful that you shared that with me. Thank you for trusting me with your story.”
It is also important for providers to offer choices to their patients, rather than to steer patients towards a particular outcome:
“I hear you saying that things are complicated. Would you like me to offer some thoughts on what other young people have found helpful? I'm also ok with just listening as well.”
“Thank you for sharing this with me, I'm so sorry this is happening. A lot of my patients experience things like this. There are resources that can help. I would be happy to connect you today if that interests you.”
These safety cards from Futures Without Violence may be adapted to be more community specific or reflect local resources. For more information on adapting safety cards for your health center, email firstname.lastname@example.org.
Tools including the safety cards
Hanging out or hooking up safety card (general adolescent)
Creating Safety During the Visit
In addition to the steps of CUES, there are other strategies for fostering safety for young patients while they are at the health center:
Offer supports that address immediate needs: snacks and water, a place to charge or use their cellphone, public transportation vouchers, emergency gift cards.
After seeing patients alone for part of the visit, invite support people that the patient may have brought with them to be present during an exam and affirm this care and safety strategy.
Get consent before touching a patient during a physical exam.
Explain what is going to happen during a physical exam before it happens and verbally walk patients through each step as it happens.
Allow young people to have their phone with them and look at their phone during the visit; this may be especially important for young people who are being controlled by someone.
Make a plan or appointment for when they can return to the health center or connect back with the provider, underscoring that someone cares about and is watching out for them.
Ensure that all staff—including the front desk, pharmacy, and behavioral health—are
trained on healing-centered and trauma-informed care for young people and
are aware of supportive resources in the community.
Harm Reduction Guidelines for Mandatory Reporting
Mandatory reporting laws vary by state but generally require health care providers to report to a governmental agency instances of abuse or harm against minors. Types of abuse can include: child abuse, severe neglect, exploitation, child sexual assault, and crime-related injuries from a weapon.
While child welfare systems can provide support to families and youth, involvement with these systems can also increase vulnerability and harm. Consequently, some youth may choose to withhold information from providers. Mandatory reporters can follow these general harm reduction guidelines to ensure that youth with human trafficking experience receive the supports they need.
Know your state's specific mandatory reporting laws so you can know when a report is mandated or not, and can avoid over-reporting.
Begin your discussion by explaining to youth in plain language about their rights and what instances would require getting child welfare or other agencies involved.
Reassure youth that you will provide access to supportive services even if they do not disclose their experiences.
Consult others on the care team before making a report. Mandatory laws can be complicated, vague, and narrower than expected. Rely on your team when deciding to make a report.
Involve the youth to the extent that they want to be involved if mandatory reporting is required:
“Remember how we talked about situations when a young person is being harmed, and in my role I have to involve child welfare? This is one of those situations. Would you be interested in making the call with me?”
Recognize that mandatory reporting is NOT the primary intervention and may further expose a youth to harm without additional supports. Focus instead on “mandatory supporting.” For example:
What else can you do to ensure that the patient has access to care and support for the harm that they have experienced?
What can you do to help the patient navigate the child welfare or criminal justice system?
Does the patient have a caring and consistent adult in their lives who can help them?
Do you keep a current list of resources and referrals who provide affirming services to LGTBQIA+ youth? Examples of helpful referrals include support and advocacy groups for survivors of human trafficking and intimate partner violence; mental health counselors; substance use disorder treatment providers; safe housing; and LGBTQIA+ specific youth services.
Advocate for opportunities within the health center and the community that enable young people to talk about their experiences and receive support without nonconsensual systems involvement.
Key Resources: Teen Dating Violence Awareness Month Webinar: Not Neutral: The Impact of Mandatory Reporting on Domestic Violence Survivors
HRSA Health Center Reporting of Human Trafficking
If a patient does disclose human trafficking experience, HRSA health center program grantees should enter the applicable International Classification of Diseases (ICD)-10 codes for human trafficking in the medical record. HRSA also requires health centers to report annually to the Uniform Data System (UDS) the number of visits at which selected ICD-10 codes for human trafficking has been coded, and the number of patients who have had one or more visit where human trafficking has been coded.31
What non-disclosure data can your organization collect that reflects the positive impact you are having? For example:
Number of referrals to agencies that support housing and survivors
Number of times universal education was offered
Health Promotion Strategies
In addition to sharing resources, providers can offer health promotion and harm reduction strategies related to sexual health and behavioral health.
A helpful opening statement can be:
“I can imagine how taking care of yourself while all of this is going on could be really difficult. Can I let you know about some ways that can help protect your health?”
Reproductive and Sexual Health
Take an inclusive and sensitive sexual health history and explain why this information is relevant for their health care.
Ask questions to capture diverse sexual behaviors
Ask open ended questions that do not assume gender of partners or certain kinds of sexual behaviors (eg, “Who are you having sex with?” “What kinds of sex are you engaging in?”)
Ask questions about body parts used during sexual activities
Remain open and nonjudgmental
Offer information about non-detectable forms of birth control (eg, extra doses of Plan B, IUDs with strings removed) as well as PrEP
Key resource: Taking a Sexual History with Sexual and Gender Minority Individuals
Screen for and treat sexually transmitted infections based on the sexual history.
Key resource: CDC STD guidelines for special populations
Screen for HIV infection, but recognize that people in the sex trade may fear knowing their HIV status, may not be able to consistently engage in HIV care and treatment, and may be more vulnerable to abuse if their status is known.
Offer condoms, lubrication, and sex-positive health information that is not only about safety, but also pleasure.
Encourage pre-exposure prophylaxis (PrEP) to prevent HIV.
Key resources: PrEP learning resources; CDC guidelines on PrEP
For those able to become pregnant, offer multiple doses of levonorgestrel morning-after pill (Plan B); prescribe an IUD (cut strings if needed to hide IUD from abusive partners).
Hand out a safety checklist for sex workers.
Affirm LGBTQIA+ youth by acknowledging the role of homophobia, transphobia, racism, and other forms of stigma and discrimination in creating or exacerbating behavioral and physical health disorders.28,29
Key Resources: LGBTQIA+ behavioral health learning resources
Explain how trauma can overwhelm a person's capacity to cope with everyday stressors.
Refer youth to resources that teach coping skills and foster resilience.
Key resources: Seeking Safety Intervention for Adolescents: a present-focused coping skills intervention that promotes safety from trauma and addiction; Healthy Divas empowerment and health care intervention for transgender women with HIV
Encourage patients to use only with a trusted friend.
Explain how to test drugs for contaminants.
Provide information on local syringe exchange programs and substance use disorder treatment options.
Understand substance use among LGBTQIA+ populations.
Key resource: Mental Health and Substance Use Among Gay, Bisexual, and MSM
Provide information on naloxone and buprenorphine.
Key resource: Addressing Opioid Use Disorder among LGBTQ Populations
Gender-Affirming Health Care
Provide access to gender-affirming medical interventions through partnerships with other health care agencies or by learning to provide gender-affirming hormone therapy.
Key resources: Transgender health care learning resources; Transgender Health Project ECHO
Provide access to legal advice specific to transgender and gender diverse populations, such as name and sex marker change on government-issued documents.
Key resource: Transgender legal issues
Develop Partnerships, Networks, and Programs to Meet Basic Needs
According to young people in the sex trade, their most pressing needs are housing, employment, and food.4 Health centers should develop programs and build robust referral systems and partnerships with organizations that provide these types of services for youth, before the need arises. Health centers should also provide patients with navigation and facilitated support to access referrals. Examples of partners include:
Domestic/sexual violence/human trafficking survivor support organizations
Food banks and other food access programs; or develop an onsite food pantry
Organizations that serve youth experiencing housing instability and homelessness
Key resources: Supportive Housing and Health Services for LGBTQIA+ Youth Experiencing Homelessness: Promising Practices; True Colors, Inc.; Point Source Youth
Programming that provides social support and services specifically for LGBTQIA+ youth
Program Highlights: Ruth Ellis Center, APICHA Community Health Center, Callen-Lorde HOTT (health outreach to teens)
Organizations that provide peer support for people in the sex trade
Substance use harm reduction services
Tip! Seek out funds to offer transportation vouchers or provide ride services for youth to attend appointments
Key resources: Partnership Building Resources
Promising Practice: Direct Cash Assistance
In response to the stated needs of young people who are experiencing housing insecurity and who have experiences in the sex trade, programs are exploring ways of providing direct cash assistance. Has your health center experimented with direct cash assistance programming before? Are you partnered with organizations in your area who provide direct cash assistance? Learn more about this promising practice from Point Source Youth.
Provide Information On Resources For Survivors Of Human Trafficking, Abuse, And Exploitation
Ensure all youth leave with contact information for support after the visit.
Provide safety cards and develop a palm-sized handout with a list of hotlines
Provide a phone for youth to privately talk with a support line or let them know they can always return to the health center to contact a support line
Display posters on human trafficking and other forms of violence that show images of people of all genders, races, and ethnicities; include contact information for resources and other assistance for patients and providers
Caring Relationships Healthy You poster
National Survivor Network Human Trafficking posters
National Support Lines
24/7 support for young people experiencing dating violence
Text LOVEIS to 22522
National Trafficking Hotline
24/7 support for people who are being trafficked
Text HELP or INFO to 233733 or call 1 (888) 373 7888
24/7 through video phone (855) 812 1001
Email and chat for Deaf, DeafBlind, DeafDisabled survivors
The Network/La Red
24-hour hotline for LGBTQIA+ people experiencing partner abuse
617-742-4911 (voice) 800-832-1901 (Toll-Free)
Crisis Text Line
Text HOME to 741741 for free
24/7 crisis counseling (only English)
Peer support for trans folks
9am - 3am CT: 877 565 8860
The Trevor Project
24/7 support for LGBTQ Youth
Text START to 678-678
Create A Trusting And Welcoming Environment For LGBTQIA+ Youth
Train all staff on LGBTQIA+ health disparities, affirming communication, and addressing bias.
Recruit and retain LGBTQIA+ clinical care and staff, and provide mentorships, professional development, and other training options in LGBTQIA+ health care and adolescent care.
Include sexual orientation, gender identity, and gender expression in non-discrimination policies and procedures.
Develop policies that allow patients to use the restroom that aligns with their gender identity; offer gender inclusive single occupancy restrooms.
Leave safety cards in waiting areas and restrooms for patients to take on their own terms.
Collect information on patient sexual orientation and gender identity (SOGI) to monitor and address health disparities in LGBTQIA+ patient populations.
Collect and consistently apply information on names and pronouns used by all patients to ensure respectful communication. Recognize that previously provided pronouns may have changed since the last visit.
Add images of same-sex couples and gender diverse people to websites and health educational materials.
Review all forms, promotional materials, and website pages for inclusivity related to relationship status, gender identity, sexual orientation, and anatomy.
Key resources: Organizational change strategies for creating inclusive health care environments for LGBTQIA+ people
Actively Support Transformational Community Change
Learn more about structural ways to reduce marginalization and vulnerability among LGBTQIA+ youth and youth in the sex trade, and use your health provider expertise to support efforts such as:30
Decriminalize survival strategies
Ensure affordable, safe, and inclusive housing
Support worker and labor rights (eg, enforcement of labor laws, work hour limits, safety requirements, and health care benefits)
The intersection of anti-LGTBQIA+ stigma and structural racism increase vulnerability to homelessness, the sex trade, and human trafficking among LGBTQIA+ youth. To promote the health and wellbeing of these youth, health center providers can start by building trusting relationships and fostering the strengths and assets of these youth. We recommend that providers shift away from the goals of disclosure and reporting of human trafficking towards a more healing-centered approach that focuses on confidentiality, education and empowerment, and support. Positive structural changes to the health center can include forming robust community partnerships with agencies that serve these youth, creating health care environments that affirm LGTBQIA+ youth, and helping to bring about community changes, such as increasing availability of affordable, safe and inclusive housing.
Additional General Resources
The National Health Network on Intimate Partner Violence and Human Trafficking
National LGBTQIA+ Health Education Center
Online toolkit for health centers to prevent and address violence
Credit Designation Statement: This activity has been reviewed and is acceptable for up to 1.0 Prescribed credits by the AAFP.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
This publication was developed in collaboration with Elizabeth Miller, MD, PhD, Children's Hospital of Pittsburgh, Futures Without Violence, and the National LGBTQIA+ Health Education Center, and is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of awards as follows: U30CS22742 totaling $700,000 with 0 percent financed with non-governmental sources, and U30CS39198 totaling $725,000 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government. For more information, please visit HRSA.gov.
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