Kanani Elaine Titchen

All Publications

• Screening for Unhealthy Relationship Behaviors in Adolescent Patients. Journal of the American Academy of Child and Adolescent Psychiatry Tronick, L., Titchen, K. E. 2026

  View details for DOI 10.1016/j.jaac.2026.03.004

  View details for PubMedID 41850350

• Youth Survivors of Human Trafficking: On Improving Health Care Access and Treatment. Academic pediatrics Titchen, K. E., Chang, E., Kim, J., Tran, S., Nyhan, E., Chisolm-Straker, M. 2025; 25 (4): 102783

  Abstract

  Human trafficking (HT) is a public health issue, with adolescents disproportionately at risk for reasons spanning multiple biopsychosocial domains. We explored youth HT survivors' health care barriers, experiences, and needs.In this qualitative multimethods study, 24 participants (≤26 years old) with HT experience receiving services from nonprofit organizations in San Diego, California completed an electronic survey and were invited to participate in online interviews. Thematic analysis for interview responses was performed using constant comparative methodology. Authors created codes and connections between codes and refined findings by discussion.All participants endorsed labor trafficking, 96% endorsed sex trafficking and 46% reported seeing a health care professional (HCP) while exploited. Nine survey respondents completed follow-up interviews: 100% endorsed labor and sex trafficking and 44% seeing an HCP. Interview participants' barriers to presenting to health care and receiving needed help were categorized into patient-focused-lack of awareness of exploitation and medical needs, emotional bonds to the trafficker, and misperceptions about their ability to obtain care; versus health care system (HCS)-focused-negative experiences and need for consistency with HCPs, and desire for targeted resources and effective care.Barriers to health care for trafficked youth included factors the HCS could change versus those that could be reduced with universal patient education. Participants named lack of legal guardian support and proof of insurance as barriers to health care access while being exploited. Participants noted conventional mental health interventions for recovery are not appropriate and lack survivor-led guidance; participants offered alternatives about how they would receive effective care.

  View details for DOI 10.1016/j.acap.2025.102783

  View details for PubMedID 39827951

• HOOKED: How Human Traffickers Leverage Substance Use for Control. Pediatrics in review Aljadeff, G., Titchen, K. 2024; 45 (6): 366-368

  View details for DOI 10.1542/pir.2023-006197

  View details for PubMedID 38821895

• Increasing Chlamydia and Gonorrhea Testing for Adolescents in the Pediatric Emergency Department. Pediatrics Vayngortin, T., Gracia, M., Clark, K., Vayngortin, B., Bialostozky, M., Heitzman, L., Hollenbach, K., Kumar, M., Titchen, K., Bryl, A. 2024; 153 (1)

  Abstract

  Adolescents who use the emergency department are more likely to engage in high-risk sexual activity and are at an increased risk of sexually transmitted infections. We aimed to increase testing for Chlamydia and gonorrhea from 12% to 50% among adolescents presenting to our pediatric emergency department with at-risk chief complaints over 12 months.Plan-Do-Study-Act cycles were initiated in July 2020. A multidisciplinary team reviewed preexisting data and developed interventions to increase Chlamydia and gonorrhea testing in teens with at-risk complaints, including genitourinary and behavioral health complaints, and females with abdominal pain. Two categories of interventions were implemented: education and electronic medical record optimization. Process measures were the proportion of patients with a documented sexual history and the proportion of patients tested with a documented confidential phone number. Secondary outcome measures included the weekly number of positive test results and the proportion of patients testing positive who were contacted to arrange treatment. Statistical process control charts were used to examine changes in measures over time.Within 14 months of project initiation, the proportion of at-risk patients tested increased from 12% to 59%. Teen phone number documentation remained unchanged from 23%. Sexual history documentation remained unchanged from 46%. The number of positive test results increased from 1.8 to 3.4 per month, and the proportion of patients testing positive who were contacted to arrange treatment remained unchanged at 83%.We surpassed our goal and increased the proportion of at-risk patients tested for Chlamydia and gonorrhea to 59%, sustained for 4 months from the last intervention.

  View details for DOI 10.1542/peds.2022-059707

  View details for PubMedID 38053440

  View details for PubMedCentralID PMC11022968

• Characteristics and Perspectives of Human Trafficking Education: A Survey of U.S. Medical School Administrators and Students. Journal of women's health (2002) Talbott, J. M., Lee, Y. S., Titchen, K. E., Chen, J. Y., Kling, J. M. 2023; 32 (2): 192-198

  Abstract

  Objective: To assess the timing, duration, methodology, and content of human trafficking (HT) curricula in U.S. medical schools. Methods: An anonymous, cross-sectional survey was sent through email and phone to administrators of 199 U.S. allopathic and osteopathic medical schools. A supplementary survey was sent to students and faculty through email listservs and social media links. Data collection occurred from April to October 2020 and findings were analyzed through SAS software. All study measures were approved by the institutional review board. Results: Administrators were from 22 states and 34 schools (n = 51/199 schools; response rate: 25.6%) and n = 41 responded to all questions. Of these, 32% (13/41) self-identified as deans, 34.1% (14/41) as faculty, and 29.3% (12/41) as other administrators. Less than half (41.5%, n = 17/41) reported an HT curriculum. There was a wide range in length (average = 3 hours) and when present was almost always mandatory (n = 51, 88.2%). Few curricula mentioned labor (23.5%) or organ (5.9%) trafficking, or at-risk populations such as lesbian, gay, bisexual, trans, queer, and intersex (LGBTQI) members (13.7%), foreign nationals (7.8%), victims of political conflict (3.9%), and indigenous peoples (2.0%). Students and staff (n = 242) were from 34 states and 83 schools, and n = 36 (27.5%) reported a curriculum. Less than half (44.4%) felt the length (average 4.1 hours) was sufficient. Conclusions: Less than half of respondents reported an HT curriculum. It is unclear how well this curriculum prepares students to treat victim-survivors of HT. Future work is necessary to incorporate effective education on HT for trainees and evaluate patient outcomes after curricular implementation.

  View details for DOI 10.1089/jwh.2022.0144

  View details for PubMedID 36301184

• Medical-Theater Arts Partnerships. Pediatrics Titchen, K. E. 2022; 150 (5)

  View details for DOI 10.1542/peds.2022-057822

  View details for PubMedID 36305210

• Labor trafficking of children and youth in the United States: A scoping review. Child abuse & neglect Greenbaum, J., Sprang, G., Recknor, F., Harper, N. S., Titchen, K. 2022; 131: 105694

  Abstract

  Child labor trafficking is a largely unexplored and unpublished phenomenon in the United States.To 1) characterize the state of the science on child labor trafficking, and 2) identify empirical information regarding risk and protective factors, and physical/behavioral health needs of labor-trafficked children/adolescents.This scoping review involved an electronic review of five databases; the search was restricted to studies in English or Spanish and published between Jan 1, 2010-Oct 16, 2020. The search yielded 1190 articles; 48 studies qualified for full review and 8 met inclusion criteria (US-based study addressing risk factors/vulnerabilities for child labor trafficking; protective factors; health impact; or health/behavioral healthcare).Only one study had sufficient sample size to compare sex to labor trafficking among minors; some did not separate data by age group or by type of trafficking. A few shared data from a common source; one was a single case review. Findings suggested that sex and labor trafficking may share common risk factors (e.g., prior child maltreatment and out-of-home placement) as well as within group differences (e.g., labor trafficked children had less prior child welfare involvement than those involved in sex trafficking and were more likely to be younger, male, Black or non-white, and Hispanic). Multiple physical/behavioral health symptoms were reported and may be useful items for a healthcare screen.Child labor trafficking research in the U.S. is in its infancy, although the results of this review point to opportunities for screening and case conceptualization that may be useful to practitioners.

  View details for DOI 10.1016/j.chiabu.2022.105694

  View details for PubMedID 35749904

• The Impact of Human Trafficking Training on Healthcare Professionals' Knowledge and Attitudes. Journal of medical education and curricular development Lee, H., Geynisman-Tan, J., Hofer, S., Anderson, E., Caravan, S., Titchen, K. 2021; 8: 23821205211016523

  Abstract

  The objective of this study was to evaluate a CME-accredited human trafficking didactic and discussion-based training for healthcare professionals by comparing participant knowledge and attitudes on human trafficking before and after attending the training.A novel 18-item survey was developed to test the knowledge of and attitudes towards human trafficking. Participants of 17 standardized trainings delivered by 4 physician-trainers over a two-year period were invited to take a pre-test and 2 post-tests at 1-week and 6-months post training. Surveys were anonymously collected and linked to each participant with a de-identified number. Data were analyzed using SPSS software with scores given to the overall and knowledge and attitude subscales. Data are presented as mean ± standard deviation. Comparisons were made using paired t-tests or ANOVA, as appropriate.Total of 424 participants submitted the pre-test and were predominantly female (81%) and students in healthcare fields (55%). Of these participants, 237 (56%) submitted the 1-week post-test. Scores increased from pre-test to 1-week post-test in both knowledge (54.7 ± 18.7%-84.5 ± 12.8%, P = .001) and attitude (49.4 ± 14.7%-71.0 ± 12.8%, P < .001) subscales. Forty-seven participants (11%) submitted the 6-month post-test, which demonstrated a decrease in knowledge score from the 1-week post-test (84.5 ± 12.8%-50.0 ± 13.6%, P < .001). However, improvements in attitude scores were sustained across time (71.0 ± 12.8%-68.8 ± 12.4%, P < .001).Among health professionals, the CME-accredited LIFT training leads to a short-term improvement in knowledge of human trafficking and a sustained improvement in awareness and attitudes about human trafficking.

  View details for DOI 10.1177/23821205211016523

  View details for PubMedID 34036175

  View details for PubMedCentralID PMC8132095

• Educating paediatric health-care providers about human trafficking. Journal of paediatrics and child health Coughlin, C. G., Greenbaum, J., Titchen, K. 2020; 56 (9): 1335-1339

  Abstract

  Human trafficking is a public health issue and humanitarian crisis. Most alarming is that children are especially at risk. Although many studies demonstrate that the majority of trafficked persons surveyed engage with the health-care system during the time in which they are trafficked, health-care practitioners lack the knowledge, tools and resources to assist these patients. The present efforts in training health-care professionals have been fragmented and largely ineffective. While prior training has produced short-term changes in knowledge or attitudes of health professionals, it has not produced sustained changes in knowledge and attitudes nor meaningful changes in screening or intervention. No training has demonstrated changes in patient outcomes. Trafficked persons, particularly children and survivors of labour trafficking, are inadequately served by our present training options for health-care practitioners, and evidence-based protocols are needed to care for this underserved, disenfranchised and traumatised population. To provide optimal care for trafficked youth, health-care practitioners may benefit from: (i) evaluating training for health care providers (HCP) rigorously and meaningfully; (ii) advocating for high-quality training for all HCPs; (iii) fostering partnerships with key stakeholders to inform training and practice; and (iv) designing HCP training that is comprehensive, spanning all forms of human trafficking and including all populations involved.

  View details for DOI 10.1111/jpc.15116

  View details for PubMedID 32815607

• Sexting and Young Adolescents: Associations with Sexual Abuse and Intimate Partner Violence. Journal of pediatric and adolescent gynecology Titchen, K. E., Maslyanskaya, S., Silver, E. J., Coupey, S. M. 2019; 32 (5): 481-486

  Abstract

  To explore whether sexting by young adolescent girls and boys is associated with adverse life experiences including exploitative or violent sexual relationships.Cross-sectional, anonymous survey of a convenience sample of minor adolescents younger than age 18 years recruited while waiting for care in clinics affiliated with a children's hospital in a low-resource, high-poverty, urban community.Five hundred fifty-five adolescents aged 14-17 years, 63% girls and 37% boys.We measured sexting by asking, "Have you ever sent a sexually suggestive or naked picture of yourself to another person through text or e-mail?" The survey also measured risk behaviors, sexual abuse, intimate partner violence (IPV), and arrest and included a validated depression scale.Mean age was 15.6 ± 1.1 years; 59% were Hispanic, 28% were black; 44% of girls and 46% of boys ever had sex; 24% of girls and 20% of boys ever sent a sext. More girls than boys reported sexual abuse (16% vs 3%; P < .01), IPV victimization (15% vs 7%; P < .01), and depression (33% vs 17%; P < .01). More boys than girls reported arrest (15% vs 7%; P < .01). Independent associations with sexting for girls were: ever had sex (odds ratio [OR], 4.59; 95% confidence interval [CI], 2.29-9.19; P < .001); sexual abuse (OR, 3.81; 95% CI, 1.80-8.05; P < .001); IPV victim (OR, 2.72; 95% CI, 1.11-6.62; P < .05), and for boys: ever had sex (OR, 4.26; 95% CI, 1.47-12.32; P < .01); sexual abuse (OR, 38.48; 95% CI, 1.48-999.46; P < .05); IPV perpetration (OR, 16.73; 95% CI, 1.64-170.75; 95% CI, P < .05), as well as cannabis use, older age, other race, and arrest.For young adolescents, sexting is independently associated with exploitative and abusive sexual relationships including sexual abuse and IPV with similarities and differences in predictors of sexting for girls and boys.

  View details for DOI 10.1016/j.jpag.2019.07.004

  View details for PubMedID 31330248

• Multi-level prevention of human trafficking: The role of health care professionals. Preventive medicine Greenbaum, V. J., Titchen, K., Walker-Descartes, I., Feifer, A., Rood, C. J., Fong, H. F. 2018; 114: 164-167

  Abstract

  As a major public health issue, human trafficking (HT) affects individuals, families, communities, and societies around the world. A public health approach to combating HT has been advocated. Such an approach seeks to prevent HT by engaging diverse stakeholder groups in addressing risk factors at multiple levels. As a key stakeholder group, health care professionals (HCPs) play a critical role in HT prevention. Herein, we use the Centers for Disease Control (CDC) Social-Ecological Model as a framework to present potential HT prevention strategies for health care professionals. As clinicians, HCPs may deliver tailored interventions to patients and families to address individual- and relationship-level risk factors for HT in the health care setting. As educators, advocates, and researchers, HCPs may collaborate across sectors to implement community- and society-level prevention strategies. Such strategies may include enhancing awareness of HT through education; advocating for local and national policies that promote community health and wellness; combating social or cultural norms that contribute to HT; and building a strong evidence-base to guide future HT prevention programs. Guided by the CDC Social-Ecological Model, we recommend that HCPs use their diverse skills to target risk factors for HT at multiple levels and thereby expand their impact in preventing this form of exploitation.

  View details for DOI 10.1016/j.ypmed.2018.07.006

  View details for PubMedID 29981790

• Fasoracetam in adolescents with ADHD and glutamatergic gene network variants disrupting mGluR neurotransmitter signaling. Nature communications Elia, J., Ungal, G., Kao, C., Ambrosini, A., De Jesus-Rosario, N., Larsen, L., Chiavacci, R., Wang, T., Kurian, C., Titchen, K., Sykes, B., Hwang, S., Kumar, B., Potts, J., Davis, J., Malatack, J., Slattery, E., Moorthy, G., Zuppa, A., Weller, A., Byrne, E., Li, Y. R., Kraft, W. K., Hakonarson, H. 2018; 9 (1): 4

  Abstract

  The glutamatergic neurotransmitter system may play an important role in attention-deficit hyperactivity disorder (ADHD). This 5-week, open-label, single-blind, placebo-controlled study reports the safety, pharmacokinetics and responsiveness of the metabotropic glutamate receptor (mGluR) activator fasoracetam (NFC-1), in 30 adolescents, age 12-17 years with ADHD, harboring mutations in mGluR network genes. Mutation status was double-blinded. A single-dose pharmacokinetic profiling from 50-800 mg was followed by a single-blind placebo at week 1 and subsequent symptom-driven dose advancement up to 400 mg BID for 4 weeks. NFC-1 treatment resulted in significant improvement. Mean Clinical Global Impressions-Improvement (CGI-I) and Severity (CGI-S) scores were, respectively, 3.79 at baseline vs. 2.33 at week 5 (P < 0.001) and 4.83 at baseline vs. 3.86 at week 5 (P < 0.001). Parental Vanderbilt scores showed significant improvement for subjects with mGluR Tier 1 variants (P < 0.035). There were no differences in the incidence of adverse events between placebo week and weeks on active drug. The trial is registered at https://clinicaltrials.gov/ct2/show/study/NCT02286817 .

  View details for DOI 10.1038/s41467-017-02244-2

  View details for PubMedID 29339723

  View details for PubMedCentralID PMC5770454

• Domestic Sex Trafficking of Minors: Medical Student and Physician Awareness. Journal of pediatric and adolescent gynecology Titchen, K. E., Loo, D., Berdan, E., Rysavy, M. B., Ng, J. J., Sharif, I. 2017; 30 (1): 102-108

  Abstract

  Our aim was to assess: (1) medical trainee and practicing physician awareness about domestic sex trafficking of minors; and (2) whether respondents believe that awareness of trafficking is important to their practice.We designed an anonymous electronic survey, and a convenience sample was collected from June through October 2013.Voluntary participants were 1648 medical students, residents, and practicing physicians throughout the United States.Data were analyzed for correlations between study cohort characteristics and: (1) agreement with the statement: "knowing about sex trafficking in my state is important to my profession"; (2) knowledge of national statistics regarding the sex trafficking of minors; and (3) knowledge of appropriate responses to encountering a trafficked victim.More practicing physicians than residents or medical students: (1) agreed or strongly agreed that knowledge about human trafficking was important to their practice (80.6%, 71.1%, and 69.2%, respectively; P = .0008); (2) correctly estimated the number of US trafficked youth according to the US Department of State data (16.1%, 11.7%, and 7.9%, respectively; P = .0011); and (3) were more likely to report an appropriate response to a trafficked victim (40.4%, 20.4%, and 8.9%, respectively; P = .0001).Although most medical trainees and physicians place importance on knowing about human trafficking, they lack knowledge about the scope of the problem, and most would not know where to turn if they encountered a trafficking victim. There exists a need for standardized trafficking education for physicians, residents, and medical students.

  View details for DOI 10.1016/j.jpag.2015.05.006

  View details for PubMedID 26341745

• Ovarian Cystadenoma in a Trafficked Patient. Pediatrics Titchen, K. E., Katz, D., Martinez, K., White, K. 2016; 137 (5)

  Abstract

  The topic of child sex trafficking is receiving increased attention both in the lay press and in research articles. Recently, a number of physician organizations have issued policy statements calling for the education and involvement of physicians in combating this form of "modern-day slavery." Primary care and emergency medicine physicians have led these efforts, but a number of these victims may present to surgeons. Surgeons are in a unique position to identify trafficked patients; during the process of undraping, intubation, and surgical preparation, signs of trafficking such as tattoos, scars, dental injuries, and bruising may be evident. In addition, these patients may have specific needs in terms of anesthesia and postoperative care due to substance abuse. Here, we report the case of an 18-year-old girl with a history of sexual exploitation who presents for cystadenoma excision. To our knowledge, this is the first report of a sex-trafficked pediatric patient presenting for surgery.

  View details for DOI 10.1542/peds.2015-2201

  View details for PubMedID 27244785

• Caveolin-1 and accelerated host aging in the breast tumor microenvironment: chemoprevention with rapamycin, an mTOR inhibitor and anti-aging drug. The American journal of pathology Mercier, I., Camacho, J., Titchen, K., Gonzales, D. M., Quann, K., Bryant, K. G., Molchansky, A., Milliman, J. N., Whitaker-Menezes, D., Sotgia, F., Jasmin, J. F., Schwarting, R., Pestell, R. G., Blagosklonny, M. V., Lisanti, M. P. 2012; 181 (1): 278-93

  Abstract

  Increasing chronological age is the most significant risk factor for human cancer development. To examine the effects of host aging on mammary tumor growth, we used caveolin (Cav)-1 knockout mice as a bona fide model of accelerated host aging. Mammary tumor cells were orthotopically implanted into these distinct microenvironments (Cav-1(+/+) versus Cav-1(-/-) age-matched young female mice). Mammary tumors grown in a Cav-1-deficient tumor microenvironment have an increased stromal content, with vimentin-positive myofibroblasts (a marker associated with oxidative stress) that are also positive for S6-kinase activation (a marker associated with aging). Mammary tumors grown in a Cav-1-deficient tumor microenvironment were more than fivefold larger than tumors grown in a wild-type microenvironment. Thus, a Cav-1-deficient tumor microenvironment provides a fertile soil for breast cancer tumor growth. Interestingly, the mammary tumor-promoting effects of a Cav-1-deficient microenvironment were estrogen and progesterone independent. In this context, chemoprevention was achieved by using the mammalian target of rapamycin (mTOR) inhibitor and anti-aging drug, rapamycin. Systemic rapamycin treatment of mammary tumors grown in a Cav-1-deficient microenvironment significantly inhibited their tumor growth, decreased their stromal content, and reduced the levels of both vimentin and phospho-S6 in Cav-1-deficient cancer-associated fibroblasts. Since stromal loss of Cav-1 is a marker of a lethal tumor microenvironment in breast tumors, these high-risk patients might benefit from treatment with mTOR inhibitors, such as rapamycin or other rapamycin-related compounds (rapalogues).

  View details for DOI 10.1016/j.ajpath.2012.03.017

  View details for PubMedID 22698676

  View details for PubMedCentralID PMC3388151

• Carrageenan/MIV-150 (PC-815), a combination microbicide. Sexually transmitted diseases Fernández-Romero, J. A., Thorn, M., Turville, S. G., Titchen, K., Sudol, K., Li, J., Miller, T., Robbiani, M., Maguire, R. A., Buckheit, R. W., Hartman, T. L., Phillips, D. M. 2007; 34 (1): 9-14

  Abstract

  The objective of this article is to study the effect of PC-815, a novel combination microbicide containing carrageenan and the nonnucleoside reverse transcriptase inhibitor (NNRTI) MIV-150, in blocking HIV-1 and HIV-2 infections in vitro as compared with Carraguard alone.The goal of this study was to develop a combination microbicide that is more efficacious than Carraguard against HIV-1 and HIV-2.The microtiter syncytial assay was used to evaluate: 1) the antiviral and virucidal activity of MIV-150 against HIV-1MN; 2) the additive effect of MIV-150 when combined with carrageenan; and 3) a possible interference of seminal fluid in the antiviral activity of these compounds.MIV-150 effectively inactivated free virus. Combination of MIV-150 and Carraguard demonstrated an additive antiviral effect. Seminal fluid had no effect on the antiviral activity of MIV-150 or Carraguard. The average concentration that blocks 50% of infection (EC50) for PC-815 was approximately 10 times stronger than Carraguard for the different clinical isolates used in the study.Theoretically, PC-815 is likely to be a more efficacious microbicide than Carraguard.

  View details for DOI 10.1097/01.olq.0000223287.46097.4b

  View details for PubMedID 16924181

• Ethanol drinking in socially housed squirrel monkeys. Behavioural pharmacology Mandillo, S., Titchen, K., Miczek, K. A. 1998; 9 (4): 363-7

  Abstract

  This study proposes a method to assess voluntary alcohol drinking in socially living squirrel monkeys. Group-housed squirrel monkeys were induced to drink a sucrose solution and subsequently an ethanol/sucrose solution in an experimental chamber attached to the home colony room, allowing the daily intake to be monitored for each individual without disrupting the social context. Sucrose concentration (0.03-0.6 M, corresponding to 1-20%) and ethanol concentration (0-4%) were gradually increased in tap water and in a 0.6 M (ca. 20%) sucrose solution during daily 30-min and 10-min sessions, respectively. Blood ethanol levels ranged from 10-50 mg/dl and remained below intoxication level. These experiments demonstrate that it is feasible to arrange conditions under which individual socially housed squirrel monkeys voluntarily drink a sweetened ethanol solution.

  View details for PubMedID 10065925