Youth who are at risk for or who have experienced commercial sexual exploitation (CSEC) have specialized health care needs. Their experiences are often unrecognized, even with regular contact with pediatric medical providers. CSEC is a form of child abuse; this has been recognized by federal law and some state laws. Providers must recognize CSEC as a medical diagnosis and maintain a trauma-informed, patient-led approach. This article will assist providers in identifying and appropriately caring for youth who are at risk for or have experienced victimization and/or commercial sexual exploitation and point providers to resources to best support their patients.
Key points
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While the prevalence of commercial sexual exploitation (CSEC) is difficult to quantify, it has been reported across the country and transcends socioeconomic, racial/ethnic, sexual orientation, and gender identities.
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CSEC carries specific physical and mental health risks that need to be identified and addressed.
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A trauma-informed, patient-centered approach to care is required.
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CSEC is child abuse, and pediatric providers must comply with state and federal mandatory reporting laws.
| AAP | American Academy of Pediatrics |
| CPS | Child Protective Services |
| CSEC | commercial sexual exploitation |
| HIV | human immunodeficiency virus |
| MI | motivational interviewing |
| NHTTAC | National Human Trafficking Training and Technical Assistance Center |
| SCM | Stages of Change Model |
| SSCST | Short Screen for Child Sex Trafficking |
| STI | sexually transmitted infections |
| TF-CBT | trauma-focused cognitive behavioral therapy |
| TIC | trauma-informed care |
Introduction
Youth who are at risk for or who have experienced commercial sexual exploitation of children (CSEC) have specialized health care needs. Their experiences are often unrecognized, though many of these youth have regular contact with pediatric medical providers. CSEC is a form of child abuse; this has been recognized by federal law and some state laws. It is important for providers to recognize CSEC as a medical diagnosis and to maintain open-mindedness, flexibility, and a trauma-informed, patient-led approach. This article will assist providers in identifying and appropriately caring for youth who are at risk for or have experienced victimization and/or commercial sexual exploitation and point providers to resources to best support their patients.
Background: definitions and scope of the problem
Definitions
CSEC is an umbrella term that encompasses the “sexual abuse or exploitation of a child for the financial benefit of any person or in exchange for anything of value.” Examples of crimes that are included under this definition include the following:
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Child sex trafficking;
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Commercial production of child pornography (now referred to as “child sexual abuse materials”);
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Exploiting a minor through sex tourism, mail order bride trade, and early marriage;
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Children performing in sexual venues (eg, “peep shows” or strip clubs).
Under federal law (Trafficking Victims Protection Act of 2000), sex trafficking is defined as the “recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act.” A “commercial sex act” is further defined by the TVPA as “any sex act on account of which anything of value is given to or received by any person.” A patient under age 18 years does not need to have experienced force, fraud, or coercion for the commercial sex act to qualify as sex trafficking, although these youth commonly do experience these things. The exchange of a sex act for nonmonetary things of value, such as a place to sleep, food, or transportation, is also considered trafficking. A 2015 amendment to the Child Abuse Protection and Treatment Act established the legal requirements for reporting child maltreatment and added that children who were victims of sex trafficking are also considered victims of child abuse and neglect, regardless of the perpetrator. However, states vary in their interpretation of reporting requirements for nonfamilial trafficking; therefore, it is imperative that pediatric providers are aware of these requirements in their state. , Unfortunately, some exploited youth can still be prosecuted on “prostitution” charges and other associated crimes (eg, drug-related charges, shoplifting, trespassing, or other misdemeanors). Safe Harbor laws in more than 30 states attempt to divert youth who have experienced CSEC away from the juvenile justice system and toward services.
Historically, damaging and inaccurate terms such as “child prostitute” or “prostitution” have been used across fields and in common parlance to refer to individuals who have experienced sex trafficking; these terms cast survivors into the role of a criminal and imply a level of agency that trafficked youth do not have. Adolescents’ brain development is such that they do not have the capacity to fully understand, make decisions about, or consent to the exchange of sex for money or a good of value; this is reflected in the legal definitions of child sex trafficking. Pediatric medical providers must emphasize patients’ dignity and voice to counter how this language can affect how these youth are treated.
No matter which definition or language is used, the following guiding principles set forth by the National Academy of Medicine (formerly the Institute of Medicine) and National Research Council provide an appropriate foundation for any work conducted in this area. These are as follows:
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“Commercial sexual exploitation and sex trafficking of minors should be understood as acts of abuse and violence against children and adolescents.
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Minors who are commercially sexually exploited or trafficked for sexual purposes should not be considered criminals.
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Identification of victims and survivors and any intervention, above all, should do no further harm to any child or adolescent.”
Reminding ourselves that these children are also patients may assist providers in staying grounded in providing quality, holistic, trauma-informed pediatric care to include both medical and psychosocial components of this complex issue.
Epidemiology
Determining the prevalence of the CSEC is inherently complex. The clandestine nature of CSEC, coupled with the challenges of reaching trafficked minors and their hesitancy to disclose their victimization, creates significant barriers to data collection. Complex risk factors and the need for culturally sensitive approaches can also prove challenging to efforts of accurate data gathering. Additional obstacles include the absence of a unified national system for tracking CSEC cases; inadequate training for professionals who interact with at-risk youth, resulting in likely under recognition of cases; and ethical complexities associated with research with this vulnerable population.
There are currently no credible or supported estimates of the prevalence of CSEC in the United States. While the lack of an accurate prevalence estimate is frustrating, researchers warn against continuing to cite unsupported or heavily qualified estimates due to the risk of frequent citations of such limited estimates being subsequently repeated as fact. At a minimum, it can be stated that trafficking occurs in many jurisdictions throughout the United States and that pediatric providers may encounter these youth in their examination rooms or other health care settings due to the physical and mental health consequences of their exploitation. ,
Patient identification: risk factors, screening, and patient characteristics
Patient Risk Factors and the Social-Ecological Model
The Social-Ecological Model, based on public health and community psychology research and employed by the Centers for Disease Control and Prevention, can be used to understand CSEC risk factors and provide a framework for comprehensive prevention efforts. Although there is not a singular specific antecedent that leads to sex trafficking, certain experiences and factors have been shown to increase the risk for exploitation and trafficking. Individuals with a history of trauma, which may include child maltreatment or violence in the home or community, are at higher risk for trafficking victimization. People who experience instability regarding their basic needs—including homelessness and running away—are also at higher risk for trafficking. , As this model highlights, individual, family or relationship, community, and social determinants of health are interrelated and increase the risk for CSEC.
Additional identified risk factors may include lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual identity and migrant or refugee status in the “individual” category; and sexualization of children and identity-based bias, discrimination, and violence in “societal” factors. Fig. 1 delineates multiple overlapping and interconnected characteristics that have been associated with CSEC.
Understanding human trafficking in the context of societal inequity is important. Systemic biases exacerbate the risk of victimization and act as barriers for individuals to access support services; this affects youth who are minoritized based on their race/ethnicity, ableness, sex, sexual orientation, gender presentation, and other characteristics. For instance, criminal justice system and Child Protective Services (CPS) involvement and poverty disproportionately affect minoritized populations. An example of this can be seen with the adultification of Black girls; namely, “the misconception that Black girls are less innocent and more adult-like than their White peers.” , This may influence the identification of victimization and whether Black trafficking survivors are viewed and supported appropriately. Another example is with male-identified youth, as providers are less likely to screen these youth for trafficking; therefore, it is likely that identification in this population is lower. ,
More recently, the role of technology and digital media use in exploitation cases has been explored. In a large national survey, 1.7% of the youth reported experiencing online commercial exploitation, defined as providing sexual services (commercial talk, images, or other sexual activity) for reward. Of note, 92% of these cases involved self-negotiated exchanges. While it may appear that youth have agency in these interactions, it must be remembered that they are unable to consent to any exchange of sexual acts or images for anything of value.
It is important to note that these individual factors do not inherently cause a person to experience trafficking. The risk for exploitation increases because individual factors are often indicators of the vulnerable positions that youth occupy in the context of societal biases and inequalities. Conversely, a lack of risk factors does not confer immunity to CSEC.
Identification of Trafficked Youth and Mandated Reporting
Understanding the complex factors/forces that place youth at risk is important. In the medical setting, certain potential red flags should also be considered by providers and may raise concerns about possible exploitation when evaluating patients. Concerning features include a patient’s chief complaint; medical and mental health diagnoses; the person(s) who have accompanied the youth to the evaluation; and information from the patient’s medical, reproductive, and social history. A report from the American Academy of Pediatrics (AAP) on child exploitation and trafficking provides a comprehensive view of potential red flags in these populations.
In addition to clinical concerns about a patient, screening tools can identify patients for whom further, more in-depth assessments are needed. The Short Screen for Child Sex Trafficking (SSCST), which has been validated for use in emergency departments, teen clinics, and child advocacy centers, has been used to try to identify within these settings possible patients who experience CSEC. It is a 6-item tool that includes questions about risk factors (eg, substance abuse, prior sexually transmitted infections [STIs], previous involvement with law enforcement) rather than asking direct questions about trafficking. It has demonstrated sensitivity between 84% and 92% and specificity between 53% and 74%, characteristics that ensure that most patients who experience CSEC are not missed. Box 1 is the SSCST. Two or more positive questions yield a positive screen.
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Is there a previous history of drug and/or alcohol use?
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Has the youth ever run away from home?
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Has the youth ever been involved with law enforcement?
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Has the youth ever broken a bone, had traumatic loss of consciousness, or sustained a significant wound?
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Has the youth ever had a sexually transmitted infection?
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Does the youth have a history of sexual activity with more than 5 partners?
It is essential to use the SSCST in conjunction with a careful and comprehensive assessment that includes consideration of risk factors, red flags, and a patient’s medical, behavioral, and psychosocial history to ensure appropriate intervention and support for at-risk youth. If not already done, once a youth screens positive for possible CSEC concerns, providers should have a detailed conversation with the patient reviewing the limits of confidentiality and the provider’s role as a mandated reporter. The patient should understand that they do not have to answer questions and should be empowered to choose what information they share—the goal is not to elicit a disclosure. It is important to monitor the patient’s level of distress during these conversations while also assessing the patient’s risk of harm and safety.
Before implementing a screening tool, it is imperative that health care settings have a plan in place to respond to high-risk youth or those who make a disclosure. The HEAL Protocol Toolkit is an excellent resource to assist with developing a response to potential trafficking cases. The degree of response to the issue of trafficking depends on the provider’s level of concern. At a minimum, universal education about healthy relationships should be provided. More resources should be offered to those for whom the provider has greater concern; examples include a social work or child protection team consult, linkage to community resources, and mentoring programs. When a provider has a reasonable suspicion that a minor patient is being trafficked, a report to the appropriate child abuse hotline must be made in the jurisdiction in which the suspected abuse occurred, in accordance with applicable state laws, specifically mentioning the concern for trafficking. Youth who are currently involved in the child welfare system require a new report when trafficking is suspected.
The focus of the health care encounter should be to provide comprehensive, trauma-informed, individualized, human rights–based health care to these youth. As mentioned earlier, identification can be challenging, as these patients rarely spontaneously disclose their circumstances to health care providers. Many victims may not perceive their situation as victimization, while others may lack the desire to leave their current situation. Additionally, feelings of shame, guilt, or fear of reprisal from traffickers can contribute to their silence. Youth may have experienced maltreatment and possible foster care placement, which may lead to distrust of adults and professionals; others may fear the involvement of police, CPS, or even immigration authorities. The enduring legacy of systemic racism, historical trauma, and various forms of discrimination, including homophobia and transphobia, exacerbates this distrust. Moreover, victims’ perceptions or lived experiences of implicit or explicit bias within the health care system can create additional barriers to seeking help and disclosing their situation. , Health care providers must navigate these complexities using a culturally sensitive and trauma-informed approach to create a safe and supportive environment to foster trust and facilitate appropriate interventions.
As previously discussed, regarding sex trafficking or sexual assault, it is important to follow state-specific requirements for mandatory reporting, which may include notifying CPS or law enforcement. Forensic evidence collection and a specialized medical examination may be warranted, typically performed by child abuse pediatricians, forensic nurse examiners, and/or emergency medical providers. Consultation with regional specialists, such as child abuse pediatricians, can help with decision-making regarding these concerns. Forensic evidence collection should occur only if a patient provides consent and/or assent, in accordance with state laws. Clinical studies demonstrate that evidence collection within 24 to 72 hours has the highest yield; however, states have varied guidelines for when forensic evidence can be collected, and it is recommended that providers familiarize themselves with their state’s sexual assault resources and guidelines.
Clinical considerations
Patient Presentation and Trauma-Informed Care
As described earlier, CSEC is child abuse. Many patients with a history of CSEC will have experienced multiple adverse childhood experiences, which are likely to affect their health and shape their responses to the people and situations they will encounter in a health care setting. , , For this reason, the National Human Trafficking Training and Technical Assistance Center (NHTTAC) identifies trauma-informed care (TIC) as a core competency for the provision of care to all persons with a history of trafficking. The Substance Abuse and Mental Health Administration identifies 6 principles of TIC, shown in Fig. 2 .
