Case of a Girl with Chronic Abdominal Pain, Frequent Emergency Room Visits, and Opioid Abuse

  • Kanani E. Titchen
  • Hina J. Talib


A 17-year-old G1P0010 girl was referred to an adolescent medicine specialist by the emergency department (ED) for evaluation of chronic abdominal pain recurring over the past year after she was seen in the ED 2 days ago for cervicitis. She has a history of physical and sexual abuse, extensive psychiatric history, prescription narcotic abuse, gynecologic history of pelvic inflammatory disease, and repeated sexually transmitted infections. Physical exam is significant for multiple tattoos, linear thigh hematoma, diffuse abdominal tenderness to palpation, scant vaginal discharge, and tearfulness on pelvic exam. She seems agitated and uses her cell phone to text throughout the clinic visit. Presentation is concerning for chronic pelvic pain and possible domestic minor sex trafficking (DMST). Because victims of DMST rarely self-identify, it is critical for physicians to recognize the warning signs of sex trafficking and effectively intervene on behalf of these patients to directly affect recovery and outcomes.


Chronic pelvic pain (CPP) Human sex trafficking Commercial sexual exploitation of children (CSEC) Domestic minor sex trafficking (DMST) 


  1. 1.
    International Labor Organization. New ILO Global estimate of forced labour: 20.9 million victims. Available at: Accessed 1 May 2016.
  2. 2.
    Victims of Trafficking and Violence Protection Act of 2000, Pub L No. 106-386, 114 Stat 1464.Google Scholar
  3. 3.
    Richard J, Estes N, Weiner A. The commercial sexual exploitation of children in the U.S., Canada and Mexico. Philadelphia: University of Pennsylvania; 2001. p. 260.Google Scholar
  4. 4.
    Macy RJ, Graham LM. Identifying domestic and international sex-trafficking victims during human service provision. Trauma Violence Abuse. 2012;13(2):59–76.CrossRefGoogle Scholar
  5. 5.
    Clarke RJ, Clarke EA, Roe-Sepowitz D, Fey R. Age at entry into prostitution: relationship to drug use, race, suicide, education level, childhood abuse, and family experiences. J Hum Behav Soc Environ. 2012;22(3):270–89. Scholar
  6. 6.
    Spangenberg M. Prostituted youth in New York city: an overview. ECPAT-USA. 2001. Available at: Accessed 27 June 2016.
  7. 7.
    Alpert EJ, Ahn R, Albright E, Purcell G, Burke TF, Macias-Konstantopoulos WL. Human trafficking: guidebook on identification, assessment, and response in the health care setting. Boston : MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital and Waltham: Committee on Violence Intervention and Prevention, Massachusetts Medical Society. Available at: Accessed 27 June 2016.
  8. 8.
    Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36–49.PubMedGoogle Scholar
  9. 9.
    Lederer L, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61–91.Google Scholar
  10. 10.
    Lloyd R, Orman A. Training manual on the Commercial Sexual Exploitation of Children (CSEC). New York: Girls Educational Mentoring Services (GEMS); 2009.Google Scholar
  11. 11.
    Greene JM, Ennett ST, Ringwalt CL. Prevalence and correlates of survival sex among runaway and homeless youth. Am J Public Health. 1999;89(9):1406–9.CrossRefGoogle Scholar
  12. 12.
    Oram S, Khondoker M, Abas M, Broadbent M, Howard LM. Characteristics of trafficked adults and children with severe mental illness: a historical cohort study. Lancet Psychiatry. 2015;2:1084–91.CrossRefGoogle Scholar
  13. 13.
    Zimmerman C, Hossain M, Yun K, et al. The health of trafficked women: a survey of women entering post-trafficking services in Europe. Am J Public Health. 2008;98:55–9. Scholar
  14. 14.
    Raphael J, Reichert J, Powers M. Pimp control and violence: domestic sex trafficking of Chicago women and girls. Women Crim Justice. 2010;20:89–104.CrossRefGoogle Scholar
  15. 15.
    Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS Med. 2012;9(5):e1001224.CrossRefGoogle Scholar
  16. 16.
    Barrows J, Finger R. Human trafficking and the healthcare professional. South Med J. 2008;101(5):521–4.CrossRefGoogle Scholar
  17. 17.
    Muftic LR, Finn MA. Health outcomes among women trafficked for sex in the United States: a closer look. J Interpers Violence. 2013;28(9):1859–85.CrossRefGoogle Scholar
  18. 18.
    Macias-Konstantopoulos WL, Munroe D, Purcell G, Tester K, Burke TF, Ahn R. The commercial sexual exploitation and sex trafficking of minors in the Boston metropolitan area: experiences and challenges faced by front-line providers and other stakeholders. J Appl Res Child. 2015;6(1):4.Google Scholar
  19. 19.
  20. 20.
    Black MC, Basile KC, Breiding MJ, et al. National Intimate Partner and Sexual Violence Survey: 2010 summary report; 2011.Google Scholar
  21. 21.
    Bauman LJ, Berman R. Adolescent relationships and condom use: trust, love and commitment. AIDS Behav. 2005;9(2):211–22.CrossRefGoogle Scholar
  22. 22.
    Catallozzi M, Bell DL, Short MB, Marcell AV, Ebel SC, Rosenthal SL. Does perception of relationship type impact sexual health risk? Sex Transm Dis. 2013;40(6):473–5.CrossRefGoogle Scholar
  23. 23.
    Fortenberry JD, Tu W, Harezlak J, Katz BP, Orr DP. Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health. 2002;92(2):211–3.CrossRefGoogle Scholar
  24. 24.
    Ellen JM, Cahn S, Eyre SL, Boyer CB. Types of adolescent sexual relationships and associated perceptions about condom use. J Adolesc Health. 1996;18(6):417–21.CrossRefGoogle Scholar
  25. 25.
    Norris AE, Ford K. Sexual experiences and condom use of heterosexual, low-income African American and Hispanic youth practicing relative monogamy, serial monogamy, and nonmonogamy. Sex Transm Dis. 1999;26(1):17–25.CrossRefGoogle Scholar
  26. 26.
    Hom KA, Woods SJ. Trauma and its aftermath for commercially sexually exploited women as told by front-line service providers. Issues Ment Health Nurs. 2013;34(2):75–81.CrossRefGoogle Scholar
  27. 27.
    Titchen KE, Katz D, Martinez K, White K. Ovarian cystadenoma in a trafficked patient. Pediatrics. 2016;137(5): pii: e20152201.CrossRefGoogle Scholar
  28. 28.
    Goldberg AP, Moore JL, Houck C, Kaplan DM, Barron CE. Domestic minor sex trafficking patients: a retrospective analysis of medical presentation. J Pediatr Adolesc Gynecol. 2017;30(1):109–15.CrossRefGoogle Scholar
  29. 29.
    Powell J. The approach to chronic pelvic pain in the adolescent. Obstet Gynecol Clin N Am. 2014;41:343–55.CrossRefGoogle Scholar
  30. 30.
    Lee V, Tobin JM, Foley E. Relationship of cervical ectopy to chlamydia infection in young women. J Fam Plann Reprod Health Care. 2006;32:104–6.CrossRefGoogle Scholar
  31. 31.
    Greenbaum J, Crawford-Jakubiak J. Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics. 2015;135(3):566–74.CrossRefGoogle Scholar
  32. 32.
    American Professional Society on the Abuse of Children, Greenbaum J, Kellogg N, Isaac R, et al. The commercial sexual exploitation of children: the medical provider’s role in identification, assessment and treatment. Available at: Accessed 12 Aug 2015.Google Scholar
  33. 33.
    Lampe A, Sölder D, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. 2000;96:929–33.PubMedGoogle Scholar
  34. 34.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. 2015. Available at: Accessed 4 Dec 2016.
  35. 35.
    Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, Stanzer M, Stoklosa H, Wiener DE, Wingkun N. Human trafficking: a guide to identification and approach for the emergency physician. Ann Emerg Med. 2016;68(4):501–8.e1.CrossRefGoogle Scholar
  36. 36.
    Zimmerman C, Watts C. World Health Organization ethical and safety recommendations for interviewing trafficked women. Geneva: World Health Organization; 2003. Available at: Accessed 4 Dec 2016.
  37. 37.
    Titchen KE, Loo D, Berdan L, Rysavy MB, Ng JJ, Sharif I. Domestic sex trafficking of minors: medical student and physician awareness. J Pediatr Adolesc Gynecol. 2017;30(1):102–8.CrossRefGoogle Scholar
  38. 38.
  39. 39.
    Child Welfare Information Gateway. (2016). Mandatory reporters of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available at: Accessed 4 Dec 2016.
  40. 40.
    Baldwin S, Chang K, Chisolm-Straker M, Grace A, Littenberg N, Stoklosa H. Heal trafficking: health professional advocacy, education, & linkage. Available at: Accessed 7 May 2015.
  41. 41.
    American Medical Women’s Association. PATH: physicians against the trafficking of humans. Available at: Accessed 7 May 2016.

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Division of Adolescent MedicineChildren’s Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of MedicineBronxUSA
  2. 2.Post-doctoral Fellowship in Adolescent Medicine, Division of Adolescent MedicineChildren’s Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of MedicineBronxUSA

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