Commercial sexual exploitation of children (CSEC) is a crime and a public health concern with a long-standing history, globally and in the United States. Among a multitude of risk factors, childhood maltreatment trauma has been identified as most relevant. CSEC victims suffer a range of acute and chronic physical and mental health consequences. Though fearful and distrusting, victims do seek medical care, even while under their trafficker’s control. Nevertheless, many go unrecognized and unaided due to inadequate provider education about victim identification. As members of the largest healthcare profession nationwide, nurses have an important role in confronting CSEC. To fulfill this role, nurses need education to recognize “red flags” of victimization, as well as knowledge about trauma-informed assessment and response. This article offers background information and discusses recruitment tactics, health consequences, clinical care, and implications for nursing practice and research.
Key Words: Sex trafficking, commercial sexual exploitation, prostitution, sexual abuse, child, minor, youth, adolescent, domestic, risk factors, health consequences, clinical care, screening, identification, indicator, assessment, intervention, response, referral, human rights
...sex trafficking is recognized as a human rights violation, a crime and a public health issue occurring in nearly every country Across the globe, and in the United States (U.S.), sex trafficking is recognized as a human rights violation, a crime and a public health issue occurring in nearly every country (Greenbaum, 2013). In the United States, sex trafficking of minors, also referred to as domestic minor sex trafficking (DMST) or commercial sexual exploitation of children (CSEC), has been identified in cities, suburbs, and rural areas in all 50 states (Finklea et al., 2015). Although sex trafficking has been long associated incorrectly with foreign nationals, it is now understood that U.S. citizens make up the majority of child sex trafficking victims in the United States (Clayton et al., 2013; Finklea et al., 2015). Prominent cases have raised public awareness about the prevalence of this crime and human rights violation within the states (Gajanan, 2019; U.S. Attorney’s Office, 2012). The first legal measures addressing the issue appeared in the United States in 2000. A small, yet growing, body of research offers some insight.
...sex trafficking of minors in the United States is a serious problem with immediate and long-term adverse health consequencesIn 2013, the Institute of Medicine (IOM) and National Research Council (NRC) underscored that sex trafficking of minors in the United States is a serious problem with immediate and long-term adverse health consequences (Clayton et al., 2013). Nurses can play a pivotal role in providing child and adolescent CSEC victims with access to safety, support resources, and improved health (Greenbaum, 2013). Unfortunately, most healthcare providers, including nurses, lack necessary knowledge about CSEC to quickly and accurately identify CSEC victims or at-risk children and connect them with community resources (Beck et al., 2015; Greenbaum & Crawford-Jakubiak, 2015). This article offers background information, general guidance, and tips for clinical care to support nurses to effectively fulfill this role.
Legal Perspective and Definitions
...legislative efforts in the United States to address sex trafficking started in 2000 with the enactment of the federal Trafficking Victims Protection Act Based on the United Nation’s Palermo Protocol, legislative efforts in the United States to address sex trafficking started in 2000 with the enactment of the federal Trafficking Victims Protection Act (TVPA). Sex trafficking is therein defined as the “recruitment, harboring, transportation or obtaining of a person, induced by force, fraud, or coercion . . . for the purpose of a commercial sex act,” with a commercial sex act defined as “any sex act on account of which anything of value is given or received by any person” (Victims of Trafficking and Violence Protection Act [TVPA], 2000, 22 U.S.C. §7102). Most significantly, in regard to minors, the law clarifies that force, fraud, or coercion is not required to establish sex trafficking victimization of minors. In other words: youth who are engaged in sex trafficking are always victims, because minors cannot “consent” to sex work. Consequently, the IOM and NRC include the exchange of sex for food, housing, money, or drugs [survival sex] within this definition (Clayton et al., 2013).
...youth who are engaged in sex trafficking are always victims...The U.S. Department of Justice defines commercial sexual exploitation of children (CSEC) more specifically as “sexual abuse of a minor for economic gain”; examples include “physical abuse, prostitution, pornography, stripping, mail-order brides, and the smuggling of children for unlawful purposes” (Albanese, 2007, p. 1). Legislation further underscores that the child is not committing a crime (i.e., prostitution), but is rather repeatedly victimized for profit (Preventing Sex Trafficking and Strengthening Families Act of 2014). By 2015, 34 states had enacted anti-trafficking legislation (Safe Harbor Laws) directed at providing a non-punitive response, e.g. services, to minors involved in CSEC, instead of arresting them for prostitution and related crimes (Green et al., 2018; Havlicek et al., 2016).
These laws are often either incomplete or ineffective due to a lack in resources or variances in definitionThese laws are often either incomplete or ineffective due to a lack in resources or variances in definition. For example, some states only provide immunity for sex trafficked children under a certain age (typically 14 or 15) or for first-time offenders (Green et al., 2018; Havlicek, et al., 2016). Furthermore, it is noteworthy that to date, 16 states have not passed Safe Harbor Laws for the protection of CSEC victims. At the federal level, numerous recent laws address the need for training of personnel in specific professions on sex trafficking and the related challenges. Among these, the Trafficking Awareness Training for Health Care Act emphasizes the importance of healthcare provider education and skills in identifying trafficking victims (Trafficking Awareness Training for Health Care Act, 2015).
Prevalence of CSEC
Despite garnering considerable attention in the lay press and academic literature, accurate prevalence estimates of CSEC remain elusive. The wide range of reported numbers, ranging from a few thousand to multiple hundred thousand, are based mostly on assumptions or on imprecise methodologies (Stransky & Finkelhor, 2012). The unavailability of reliable estimates results from multiple factors, including the clandestine and transient nature of the crime and victims’ distrust and fear of disclosure, stigma, and shame. Furthermore, data collection challenges are exacerbated by lack of identification by service providers and legal authorities; inconsistent definitions and data collection methods; and no centralized database (Alpert et al., 2014; Clayton etal., 2013; Finklea et al., 2015; Stransky & Finkelhor, 2012). However, The Polaris Project, a website that collects and reports annual data from a national toll-free hotline, offers some insight. In 2017, the project received 7,277 potential sex trafficking cases in the United States. 2,764 of these cases (38%) involved minor victims, and the victims were predominantly female (88.72%) (Polaris Project, 2018).
The wide range of reported numbers, ... are based mostly on assumptions or on imprecise methodologiesAccording to Polaris Project, girls ages 12-18 constitute the largest group of minor victims in the United States, a finding supported by much of the literature (Greenbaum et al., 2018; Havlicek et al., 2016; Naramore et al., 2017; Varma et al., 2015). However, boys are also at risk of CSEC (Choi, 2015; Reid & Piquero, 2014). Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youths are a particularly vulnerable group. For boys and sexual minority youth, CSEC may start even earlier, at age 11 to 13 on average (Hardy et al., 2013). Research also reports victims as young as age 5, particularly for children trafficked by their parents or by close family members (Sprang & Cole, 2018; Landers et al., 2017).
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youths are a particularly vulnerable groupA small number of research studies have identified multiple factors that increase a youth’s risk for victimization of CSEC. These risk factors include but are not limited to: childhood maltreatment trauma (e.g., sexual abuse, physical abuse, emotional abuse, and neglect); followed by running away from home or being “thrown-away;” homelessness; poverty; and the resulting engagement in survival sex. Other risk factors are dysfunctional home environments, including parental substance use and exposure to family members or peers trading sex; as well as child welfare and juvenile justice involvement; placement in foster care; educational achievement challenges; mental health disorders; and substance use (Choi, 2015; Franchino-Olsen, 2019; Jaeckl & Laughon, 2020).
Other risk factors are dysfunctional home environments, including parental substance use...Childhood maltreatment trauma (e.g., childhood sexual abuse [CSA], physical abuse, emotional abuse, and neglect) has been identified as the most prominent cluster of risk factors for CSEC victimization (Chohaney, 2016; Choi, 2015; De Vries & Goggin, 2018; Franchino-Olsen, 2019; Havlicek et al., 2016; Jaeckl & Laughon, 2020; O’Brien et al., 2017; Reid, 2014), with CSA as a key risk factor (Choi, 2015; Franchino-Olsen, 2019, Jaeckl & Laughon, 2020.) Several studies suggest a dose-response relationship with more severe CSA (such as rape) or victimization at a younger age associated with greater risk for CSEC (DeVries & Goggin, 2017; Fedina et al., 2019; Landers et al., 2017). For example, in one study of 87 CSEC victims (Landers et al., 2017), almost half of the victims were between the ages of 6 and 12, and almost 10% were ages 5 or younger. Fedina and colleagues (2019) found half of 115 CSEC victims experienced childhood rape. Particularly in regard to girls, Reid and colleagues (2017), underscored that emotional neglect increased vulnerability, as girls may seek support and affection outside of their home.
Running away or being thrown away have also been identified as important risk factors for CSEC. Between 40% (Chohaney, 2016) and 80% (Shaw et al., 2017) of CSEC victims had run away from home before victimization to CSEC. Youth may have traded sex to obtain food, shelter, money, or drugs (i.e., survival sex) as a result of their homelessness and poverty. Placement in foster care was also associated with increased risk of sex trafficking. In a study of 419 CSEC victims, almost one-fourth had been placed in foster care (Havlicek et al., 2016).
Youth may have traded sex to obtain food, shelter, money, or drugs (i.e., survival sex) as a result of their homelessness and povertyWhile CSEC victims may come from all socioeconomic backgrounds (Choi, 2015; Simons & Whitbeck, 1991), poverty greatly heightens vulnerability to CSEC for youth (Jaeckl & Laughon, 2020). One large study noted that 44% of CSEC victims (n = 913) came from families with an annual income of less than $15,000 (Reid et al., 2017). Again, poverty may be related to CSEC through the use of survival sex, which may both be a gateway into CSEC and complicate efforts to escape exploitation (Cole & Sprang, 2015).
Dysfunctional home and family environments associated with increased risk for CSEC victimization range from a general lack of parental or guardian supervision, such as unsupervised access to social media (Fraley & Aronowitz, 2019) to child maltreatment; also included are domestic violence, parental substance use, and family members or peers trading sex (Choi, 2015; Jaeckl & Laughon, 2020). Summarizing these risk factors in terms of adverse childhood experiences (ACEs), Naramore et al. (2017) reported the highest ACE score of 10 for 83% of their cohort of 102 juvenile CSEC victims. More specifically, parental drug use, for example, was confirmed in 82% of CSEC cases of familial trafficking (where the trafficker is a family member), with the mother accounting for two thirds of these cases (Sprang & Cole, 2018). Also, one-third of CSEC victims were found to have either peers or family members engaged in sex work (Chohaney, 2016; Fedina et al., 2019).
Mental health disorders and substance use play a crucial role in the context of CSECMental health disorders and substance use play a crucial role in the context of CSEC (Choi, 2015; Franchino-Olsen, 2019; Jaeckl & Laughon, 2020). Though more widely explored as health consequences of CSEC, research suggests that substance use and mental health disorders may also constitute risk factors for CSEC (Choi, 2015; Franchino-Olsen, 2019; Jaeckl & Laughon, 2020). For example, Varma and colleagues (2015) reported a history of mental health disorders already prior to CSEC victimization for over one third of CSEC victims (n=27). These findings are in alignment with the well-documented detrimental effects of childhood maltreatment on child and adolescent mental health (Cecil et al., 2017; McCrory, De Brito & Viding, 2012). Furthermore, some research identified substance use antecedent to CSEC victimization, with the mean age for first drug or alcohol use ranging from 12.8 (Edingburgh et al., 2015) to 13.6 (Reid, 2014) years. Children may revert to substance use as they grapple with the consequences of childhood maltreatment trauma, and/or they may be seduced to drugs and alcohol by peers, family members or future traffickers, thus placing them at an increased risk for CSEC victimization.
In addition to individual and family-level risk factors, societal-level risk factors also play a role. These include gender inequality, especially the devaluation and sexualization of women and children; demand for commercial sex; and a more general lack of awareness of CSEC (Alpert et al., 2014).
...some youth may exhibit no known risk factorIn sum, CSEC is a complex phenomenon. While the confluence of multiple risk factors often raises concern for potential victimization, some youth may exhibit no known risk factor. All adolescents are, however, neurodevelopmentally prone to take risks. Even while developmentally appropriate, risk-taking such as this may increase some youths' vulnerability to CSEC (Greenbaum & Crawford-Jakubiak, 2015). It is therefore paramount for nurses to recognize that all children have some risk for CSEC.
The aforementioned risk factors increase the vulnerability of children and adolescents to the recruitment and control tactics of sex traffickers. Nurses must understand these recruitment techniques, which are likely to affect the patient-nurse relationship as well as the assessment, identification, and overall clinical care of the CSEC victim. In the United States, youth are recruited into the commercial sex industry through peer networks, family members, by sex traffickers directly, and, in rare instances, abduction (Ijadi-Maghsoodi et al., 2016; Reid, 2016). Male and female traffickers operate as individuals or as members of organized crime networks.
Traffickers may be strangers, while others are known and trusted by the victim and his/her familyTraffickers may be strangers, while others are known and trusted by the victim and his/her family. Therefore, traffickers may arise from friends; intimate partners (e.g., boyfriends); family members, such as uncles, aunts, or cousins; or even parents or siblings. They may be neighbors or complete strangers. Sometimes survivors themselves become traffickers to avoid further exploitation (Alpert et al., 2014; Clayton et al., 2013; Ijadi-Maghsoodi et al., 2016). Victims may be approached in their homes, schools, shopping malls, playgrounds, public housing areas, foster care group homes, at bus stops, and increasingly online via social media (Clayton et al., 2013, Reid, 2016).
To gain and maintain control, traffickers seek to fulfill economic, developmental, and/or social needs of vulnerable youth. Strategies may include seducing victims with attention and affection or family structure (e.g. the trafficker as boyfriend or “daddy”/father figure), or with money, desired objects, or drugs (Alpert et al., 2014; Reid, 2016; Smith et al., 2009). To maintain control of their victims, traffickers use threats as well as sexual assault, physical, emotional, and psychological abuse (Finklea et al., 2015; Smith et al., 2009). Commonly, perpetrators alternate tactics of abuse with acts of kindness and simulated “love” to build closer relationships with their victims, described as “trauma bonds” (i.e., Stockholm Syndrome). Trauma bonds cause victims to believe that their exploiter is acting in their best interest, thus making it emotionally difficult for them to leave (Landers et al., 2017; Smith et al., 2009).
Substantial and compelling evidence indicates that sex trafficking of minors in the United States poses a serious problem with immediate and long-term severe adverse health consequences (Clayton et al., 2013). Victims suffer a range of acute and chronic physical and mental health sequelae, such as violence-related injuries; sexually transmitted infections (STIs) including HIV/AIDS; unintended pregnancies and abortions (oftentimes self-inflicted); complications of substance use; self-harm behaviors; anxiety; major depression; post-traumatic stress disorder (PTSD); and suicidal ideation (Edingburgh et al., 2015; Clayton et al., 2013; Greenbaum & Crawford-Jakubiak, 2015; Landers et al, 2017; Varma et al., 2015).
...sex trafficking of minors in the United States poses a serious problem with immediate and long-term severe adverse health consequences A study by Varma and colleagues reported a history of fractures or wounds for 40% of CSEC victims. Almost 60% of CSEC survivors became pregnant during CSEC victimization (Muftic & Finn, 2013) and between 53% (Varma et al., 2015) and almost 60% (Muftic & Finn, 2013) had a history of STIs. More specifically, of 198 adolescent female CSEC survivors, almost 60% tested positive for HIV (Shannon et al., 2007). Highlighting the unique vulnerability of children and adolescents in the context of CSEC, Silverman (2011) pointed out that female juvenile CSEC victims are more vulnerable to HIV than adult female sex workers. This increased risk for infection may be attributed to the greater likelihood of lacerations caused by repeated trauma to the immature genital tract, as well as larger areas of cervical ectopy in girls (Silverman, 2011).
Mental health disorders are also disproportionately represented among CSEC victims (Choi, 2015; Franchino-Olsen, 2019; Jaeckl & Laughon, 2020). These include conduct disorder and anger control problems, which were reported in more than half of youthful CSEC survivors (Landers et al., 2017), as well as depression, anxiety, PTSD, self-injury and suicidality (Fraley & Aronowitz, 2019; Hershberger et al., 2018; Landers et al., 2017). More specifically, findings revealed anxiety in almost 50% and depression in over 60% of 87 CSEC survivors (Landers et. al., 2017). PTSD was diagnosed in 76% of CSEC survivors (Edingburgh et al., 2015). Of that number, over 70% also exhibited cutting behaviors, almost 60% suicidal ideation, and 50% had attempted suicide (Edingburgh et al., 2015). For comparison, according to national data, just over 9% of youth cope with severe depression (Mental Health of America, 2020), and just over 8% of female adolescents suffer from PTSD (National Institute of Mental Health, 2017).
...the literature widely suggests substance use is a consequence of CSEC Furthermore, the literature widely suggests substance use is a consequence of CSEC (see, e.g., Edinburgh et al., 2015; O’Brien et al., 2017; Shaw et al., 2017), as victims seek to cope with the multiple trauma of CSEC victimization. Studies have consistently found high rates of substance use in trafficked youth, with rates ranging from 50% (Landers et al., 2017) to nearly 75% (Shaw et al., 2017). Notably, in one study, 70% of adolescent CSEC victims were found to use drugs or alcohol while 50% were multiple drug users (Varma et al., 2015). By contrast, only a little over 4% of American youth total report substance use problems (Mental Health of America, 2020).
Evidence suggests that CSEC victims do seek medical care, even while under their trafficker’s control Evidence suggests that CSEC victims do seek medical care, even while under their trafficker’s control (Alpert et al., 2014; Greenbaum & Crawford-Jakubiak, 2015). Research reveals that about 43% (Varma et al., 2015) to 82% (Curtis et al., 2008) of juvenile CSEC victims report a health visit within two to six months prior to their study participation. Nevertheless, many victims go unrecognized and unaided (Alpert et al., 2014; Clayton et al., 2013; Greenbaum & Crawford-Jakubiak, 2015). Identification challenges include inadequate education about victim identification and trauma-informed approaches for healthcare providers; a lack of effective screening protocols and response strategies; and reluctance by victims to disclose their circumstances (Barnert et al., 2017; Chaffee & English, 2015; Finlea et al., 2015).
...even when victims self-identify/disclose, they may not want help and choose to return to their traffickers Hesitation for victims to disclose is associated with their distrust of service providers and fear of arrest, along with their feelings of shame or guilt about their situation; fear of, loyalty to, or dependence on their perpetrators; and/or failure to recognize their own victimization (Greenbaum & Crawford-Jakubiak, 2015). For example, 50% of 87 CSEC victims showed no awareness of their exploitation. Seventy percent indicated signs of trauma-bonding with their perpetrators, which coincided with victims actively defending and justifying their exploiter’s actions, convinced that their trafficker operated in their best interest (Lander et al., 2017). Thus, even when victims self-identify/disclose, they may not want help and choose to return to their traffickers (Smith et al., 2009).
Screening and Indicators
Recognizing victims is challenging... the busy healthcare setting lacks validated screening tools for minorsRecognizing victims is challenging. While spontaneous self-identification of victims is rare, healthcare providers may note possible CSEC indicators that necessitate screening (Alpert et al., 2014). Unfortunately, the busy healthcare setting lacks validated screening tools for minors. While several screening protocols have been developed, they either have not been validated yet for multiple research populations (Chang et al., 2015; Greenbaum et al., 2015) or not for children (Vera Institute of Justice, 2014). Nevertheless, healthcare providers can integrate screening questions from these protocols (see Table 1), into patient interviews, such as, “have you ever been asked to have sex with another person” or “have you ever been asked to exchange sex for housing, food, money, or drugs” (Clayton et al., 2013).
Table 1. Examples of Key Screening Questions
Numerous indicators of CSEC, known as red flags, may raise healthcare providers’ attention (Alpert et al., 2014; Greenbaum & Crawford-Jakubiak, 2015); for a detailed list, see Polaris Project (2014). Red flags include, but are not limited to, signs of the health consequences listed above, alongside poor dentition or nutrition; inappropriate or expensive clothing; having large amounts of cash; appearing much older than their age; the presence of tattoos reflecting branding (e.g., a bar code or a person’s street name); or gang insignia (Alpert et al., 2014; Greenbaum & Crawford-Jakubiak, 2015; IOM, 2013). Victims may appear withdrawn, aggressive, and sometimes even hostile as a consequence of experiencing trauma (Greenbaum, 2014). Another clue arises when victims provide inconsistent or questionable histories that do not explain their injuries and/or not knowing the date, their address, or even where they are. A domineering, aggressive figure who speaks for a victim may also give rise to suspicion (Alpert et al., 2014; Greenbaum & Crawford-Jakubiak, 2015; Polaris Project, 2014).
Another clue arises when victims provide inconsistent or questionable histories...Medical conditions related to CSEC may include signs and symptoms of the health consequences outlined above, such as violence-related physical injuries; conditions commonly associated with sexual exploitation (e.g., recurrent STIs, pregnancy, or abortion complications); substance use; and mental health sequelae (e.g., anxiety, PTSD, or suicidal behavior). This also applies to the presence of the aforementioned risk factors (Alpert et al., 2014; Clayton et al., 2013; Greenbaum & Crawford-Jakubiak, 2015). Overall, it may be noted that, although these clinical indicators are widely referenced, none are specific to CSEC. Thus, caution to adhering exclusively to these clues is mandatory (Greenbaum, 2013).
While detailed guidance has been published elsewhere (Becker & Bechtel, 2015; Greenbaum & Crawford-Jakubiak, 2015), familiarity with the key aspects of clinical intervention will assist nurses and all levels of healthcare providers in confronting CSEC (Ahn et al., 2013). Overall, providers must conduct a sensitive and developmentally appropriate assessment based on principles of trauma-informed care to avoid re-traumatizing these victims; maximize the patient’s sense of safety; and help establish trust (Greenbaum, 2013; SAMHSA, 2014).
...providers must conduct a sensitive and developmentally appropriate assessment based on principles of trauma-informed care...Upon obtaining informed consent, providers must first address a patient’s acute medical reasons for seeking care, including a detailed survey of traumatic injuries and a sensitive genitourinary examination. Due to the intimacy and potentially triggering effects of such assessment methods, it is absolutely crucial that clinicians avoid re-traumatizing victims and respect refusal of sensitive examinations (Greenbaum, 2013). Following treating and documenting physical injuries, providers evaluate the patient’s overall health, including mental health and substance use-related issues. They must additionally address reproductive health needs, including offering testing and prophylaxis for STIs and pregnancy and providing emergency contraception (Becker & Bechtel, 2015, Greenbaum & Crawford-Jakubiak, 2015). Referral to forensically trained child abuse pediatric teams and child advocacy centers should be provided (Ahn et al., 2013; Greenbaum et al., 2013). Furthermore, providers should connect victims with local agencies that can address immediate needs, such as food and shelter, as well as long-term needs, including housing, food, safety, mental health support, legal assistance, income assistance, and schooling (Clayton et al., 2013).
...it is absolutely crucial that clinicians avoid re-traumatizing victims and respect refusal of sensitive examinations If healthcare providers suspect or confirm CSEC, they must follow their state mandatory child abuse-reporting laws (Greenbaum & Crawford-Jakubiak, 2015). It is, however, essential to mitigate further harm to victims; asking the patient may offer the most reliable way to ascertain the dynamics of the situation (Chung & English, 2015). The National Trafficking Hotline (1-888-373-7888) provides an initial resource to inform both healthcare providers and victims on reporting recommendations and about local resources that assist human trafficking victims. For additional resources, see Table 2.
Table 2. Selected Resources
National Trafficking Hotline (operated by Polaris)
National Human Trafficking Resource Center (U.S.)
Office on Trafficking in Persons
National Runaway Safeline
Children of the Night
Implications and Future Directions for Nursing Practice and Research
Nurses are called to confront CSEC in practice and in research. Research evidence supports the importance of healthcare provider education about identifying trafficking victims. In a survey-based study (n = 168), 37 % of healthcare providers, who had received training on CSEC, reported greater confidence in their ability to identify victims and were more likely to report having encountered a victim in their practice, versus those who reported no prior training (Beck et al., 2015).
Nurses are called to confront CSEC in practice and in researchAmong healthcare providers, nurses play a pivotal role in CSEC victim identification. Nursing is the largest healthcare profession in the United States, with more than 3.8 million registered nurses nationwide (AACN, 2019). They serve patients in a vast array of healthcare settings, including primary care, health departments, schools, urgent care clinics, emergency departments and hospitals. To quickly and accurately identify, interact with and refer trafficking victims and at-risk youth, nurses need continuing education and support. Education for nurses should be victim-centered and trauma-informed, and needs to include risk factors and indicators of CSEC; and education about implicit bias (Alpert et al., 2014; Greenbaum & Crawford-Jakubiak, 2015). Nurses need to know whom to contact as well as referral options for victims (Table 2), such as the National Trafficking Hotline. Furthermore, nurses should help to implement CSEC prevention strategies, such as child abuse detection, parenting education and support, and reduction of risky behaviors.
Education for nurses should be victim-centered and trauma-informed, and needs to include risk factors and indicators of CSEC; and education about implicit bias Despite the growing body of research on CSEC/DMST, our knowledge is still limited by small studies using weak designs. The gaps in the literature and a paucity of nursing research on CSEC/DMST present an opportunity for nurses to contribute and confront CSEC. Future nursing research should employ rigorous methodology, and stronger research designs. Many current studies use cross-sectional designs, making it difficult to identify risk trajectories (Choi, 2015, Jaeckl & Laughon, 2020). Sample sizes are mostly small. Some studies include victims of different types of human trafficking, risking imprecise findings. Others combine minors and adults in the sample, thus risking the conflation of CSEC with (adult) sex work. (Choi, 2015; Jaeckl & Laughon, 2020)
Further research should address the numerous gaps in the literature on CSEC risk factors (Choi, 2015, Franchino-Olsen, 2019, Jaeckl & Laughon, 2020). Researchers should examine gender as a risk factor, particularly for often-overlooked groups: boys, LGBTQ, and intersex youth (Choi, 2015; Franchino-Olsen, 2019). Research should provide a more nuanced understanding about how pathways to CSEC victimization may differ by various ethnic and socioeconomic backgrounds, as well as between rural and urban environments. The relationship between CSEC and foster care needs to be examined. Higher level studies should discern what risk behaviors potentially indicate future CSEC victimization and the behaviors that are outcomes of CSEC, such as the relationship between CSEC and drugs or mental health disorders. Furthermore, research should aim to develop effective, validated screening tools, applicable for children and adolescents, and effective prevention and intervention programs. Overall, it is paramount that research includes the voices of CSEC survivors.
...it is paramount that research includes the voices of CSEC survivors Ultimately, nursing research should strive to inform state, local, and institution-based policies for CSEC. Findings and data should provide resources to develop screening and response strategies for child protection and juvenile justice agencies; and healthcare and school systems. This research can inform education for service providers, particularly nurses, to efficiently identify and assist CSEC victims and at-risk youths.
Significant progress has been made since CSEC was first addressed in the United States in 2000. Federal and emerging state legislation aims not only to protect foreign-born children and youths, but also U.S. victims of CSEC. Federal legislation defines CSEC explicitly as “sexual abuse of a minor for economic gain,” (TVPA of 2000, 22 U.S.C. §7102), clarifying that the minor is not committing a crime (i.e., prostitution) but is repeatedly victimized for profit (Preventing Sex Trafficking and Strengthening Families Act of 2014, Title I, Section 101). However, only 34 states have enacted Safe Harbor Laws, which provide non-punitive responses to CSEC victims. All too often, these laws are either incomplete or ineffective and it remains unclear why state legislation flounders at addressing CSEC effectively.
Even though CSEC victims may fear arrest and distrust authority figures, including healthcare providers, victims do seek healthcare while being trafficked. Many, however, go unrecognized and unaided. In this context, nurses hold an important role in confronting CSEC. To fulfill this role, nurses need education about victim identification, assessment, and response strategies. As victims do not typically self-identify out of fear, guilt, or shame, and validated, effective screening tools for children are not available, nurses need to recognize “red flags” of CSEC victimization. They need understanding of trauma-informed assessment and response.
...nurses need to recognize “red flags” of CSEC victimizationThere are many opportunities for nurses to contribute to research on CSEC. By expanding the understanding of risk and protective factors, nurses can inform the development of best practices and protocols to identify exploited youth; provide them with trauma-informed care; and tap resources to effectively address immediate and long-term needs. Finally, nurses should collaborate in multi-sector efforts to develop policies that confront CSEC effectively and ultimately provide children and youth with safety and improved health.
Simone E. Jaeckl, MSN, RN
Ms. Jaeckl is a PhD student in the School of Nursing at University of Virginia. Her research is situated at the intersection of health, law and gender-based violence with a special interest in human trafficking prevention and intervention, both domestically and abroad. She holds a law degree from the University of Hamburg, Germany, and was engaged in the prosecution of sex trafficking and related crimes.
Kathryn Laughon, PhD, RN, FAAN
Dr. Laughon is an Associate Professor of Nursing and Director of the PhD Program at University of Virginia School of Nursing in Charlottesville, VA.
Ahn R., Alpert E. J., Purcell G., Konstantopoulos W. M., McGahan A., Cafferty, E., Eckardt, M., Conn, K. L., Cappetta, K., & Burke, T.F. (2013). Human trafficking: Review of educational resources for health professionals. American Journal of Preventative Medicine, 44(3), 283–289. DOI: 10.1016/j.amepre.2012.10.025
Albanese, J. National Institute of Justice, Office of Justice Programs. (2007). Commercial sexual exploitation of children: What do we know and what do we do about it? National Institute of Justice, US Department of Justice. Retrieved from: https://nij.ojp.gov/library/publications/commercial-sexual-exploitation-children-what-do-we-know-and-what-do-we-do
Alpert E. J., Ahn R., Albright E., Purcell G., Burke T. F., & Macias-Konstantopoulos W. L. (2014). Human trafficking: Guidebook on identification, assessment, and response in the health care setting. MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA and Committee on Violence Intervention and Prevention, Massachusetts Medical Society. Retrieved from: http://www.massmed.org/Patient-Care/Health-Topics/Violence-Prevention-and-Intervention/Human-Trafficking-(pdf)/
American Association of Colleges of Nursing [AACN]. (2019). Nursing fact sheet. AACN. Retrieved from: https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Fact-Sheet
Barnert, E., Iqbal, Z., Bruce, J., Anoshiravani, A., Kolhatkar, G., & Greenbaum, J. (2017). Commercial sexual exploitation and sex trafficking of children and adolescents: A narrative review. Academic Pediatrics, 17(8), 825–829. DOI: 10.1016/j.acap.2017.07.009
Beck, M. E., Lineer, M. M., Melzer-Lange, M., Simpson, P., Nugent. M., & Rabbitt, A. (2015). Medical providers' understanding of sex trafficking and their experiences with at-risk patients. Pediatrics, 135(4), e895-e902. DOI: 10.1542/peds.2014-2814
Becker, H. J. & Bechtel, K. (2015). Recognizing victims of human trafficking in the pediatric emergency department. Pediatric Emergency Care, 31(2), 144-150. Retrieved from: https://www.wisconsinacep.org/resources/LLSA%20Articles/2017%20Articles/Human%20Trafficking.pdf
Cecil, C. A. M., Viding, E., Fearon, P., Glaser, D., & McCrory, E. J. (2017). Disentangling the mental health impact of childhood abuse and neglect. Child Abuse & Neglect, 63, 106-119. DOI: 10.1016/j.chiabu.2016.11.024
Chaffee, T., & English, A. (2015). Sex trafficking of adolescents and young adults in the United States: Healthcare provider’s role. Current Opinion in Obstetrics and Gynecology, 27(5), 339–344. DOI: 10.1097/GCO.0000000000000198
Chang, K. S. G., Lee, K., Park, T., Sy, E., & Quach, T. (2015). Using a clinic-based screening for primary care providers to identify commercially sexually exploited children. Journal of Applied Research on Children: Informing Policy for Children at Risk, 6(1), Article 6. Retrieved from: https://digitalcommons.library.tmc.edu/cgi/viewcontent.cgi?article=1235&context=childrenatrisk
Chohaney, M. L. (2016). Minor and adult domestic sex trafficking risk factors in Ohio. Journal of the Society for Social Work and Research, 7(1), 117–141. DOI: 10.1086/685108
Choi, K. R. (2015). Risk factors for domestic minor sex trafficking in the United States: A literature review. Journal of Forensic Nursing, 11(2), 66-76. DOI: 10.1097/JFN.0000000000000072
Chung, R. J., & English, A. (2015). Commercial sexual exploitation and sex trafficking of adolescents. Current Opinion in Pediatrics, 27(4), 427-433. DOI: 10.1097/MOP.0000000000000242
Clayton, E. W., Krugman, R. D., & Simon, P. (Eds.). (2013). Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States, Institute of Medicine and National Research Council. The National Academies Press.
Cole, J., & Sprang, G. (2015). Sex trafficking of minors in metropolitan, micropolitan, and rural communities. Child Abuse and Neglect, 40, 113–123. DOI: 10.1016/j.chiabu.2014.07.015
Curtis, R., Terry, K., Dank, M., Dombrowski, K., & Khan, B. (2008). The commercial sexual exploitation of children in New York City: Volume 1: The CSEC population in New York City: Size, characteristics, needs. Center for Court Innovation. Retrieved from: https://www.ncjrs.gov/pdffiles1/nij/grants/225083.pdf
De Vries, I., & Goggin, K. E. (2018). The impact of childhood abuse on the commercial sexual exploitation of youth: A systematic review and meta-analysis. Trauma, Violence, and Abuse, 21(5) 1-18. DOI: 10.1177/1524838018801332
Edinburgh, L., Pape-Blabolil, J., Harpin, S. B., & Saewyc, E. (2015). Assessing exploitation experiences of girls and boys seen at a child advocacy center. Child Abuse and Neglect, 46, 47–59. DOI: 10.1016/j.chiabu.2015.04.016
Fedina, L., Williamson, C., & Perdue, T. (2019). Risk factors for domestic child sex trafficking in the United States. Journal of Interpersonal Violence, 34(13), 2653–2673. DOI: 10.1177/0886260516662306
Finklea, K., Fernandes-Alcantara, A. L., & Siskin, A. (2015). Sex trafficking of children in the United States: Overview and issues for Congress (No. 7-5700). Congressional Research Service. Retrieved from: https://fas.org/sgp/crs/misc/R41878.pdf
Franchino-Olsen, H. (2019). Vulnerabilities relevant for commercial sexual exploitation of children/domestic minor sex trafficking: A systematic review of risk factors. Trauma, Violence, and Abuse, 1-13. DOI: 10.1177/1524838018821956
Fraley, H. E., & Aronowitz, T. (2019). Obtaining exposure and depth of field: School nurses “seeing” youth vulnerability to trafficking. Journal of Interpersonal Violence. DOI: 10.1177/0886260519836779
Gajanan, M. (2019, July 8). Here is what to know about the sex trafficking case against Jeffrey Epstein. Time. Retrieved from: https://time.com/5621911/jeffrey-epstein-sex-trafficking-what-to-know/
Green, B., Gies, S. V., Healy, E. B., & Bobnis, A. (2018). Safe harbor laws: Changing the legal response to minors involved in commercial sex, phase 3: The qualitative analysis. Development Services Group, Inc. Retrieved from: https://www.ncjrs.gov/pdffiles1/ojjdp/grants/253244.pdf
Greenbaum, J. (Ed.). (2013). The commercial sexual exploitation of children: The medical provider's role in identification, assessment and treatment: APSAC Practice Guidelines. American Professional Society on the Abuse of Children. Retrieved from: https://healtrafficking.org/wp-content/uploads/2017/06/APSAC-Commercial-Sexual-Exploitation-of-Children.pdf
Greenbaum, J., Crawford-Jakubiak, J. E., & Committee on Child Abuse and Neglect. (2015). Child sex trafficking and commercial sexual exploitation: Healthcare needs of victims. Pediatrics, 135(3), 566-574. DOI: 10.1542/peds.2014-4138
Greenbaum, V. J., Dodd, M., & McCracken, C. (2018). A short screening tool to identify victims of child sex trafficking in the healthcare setting. Pediatric Emergency Care, 34(1), 33-37. DOI: 10.1097/PEC.0000000000000602
Hardy, V. L., Compton, K. D., & McPhatter, V. S. (2013). Domestic minor sex trafficking: Practice implications for mental health professionals. Affilia, 28(1), 8-18. DOI: 10.1177/0886109912475172
Havlicek, J., Huston, S., Boughton, S., & Zhang, S. (2016). Human trafficking of children in Illinois: Prevalence and characteristics. Children and Youth Services Review, 69, 127–135. DOI: 10.1016/j.childyouth.2016.08.010
Hershberger, A. R., Sanders, J., Chick, C., Jessup, M., Hanlin, H., & Cyders, M. A. (2018). Predicting running away in girls who are victims of commercial sexual exploitation. Child Abuse & Neglect, 79, 269–278. DOI: 10.1016/j.chiabu.2018.02.023
Ijadi-Maghsoodi, R.,Cook, M., Barnert, E. S., Gaboian, S., & Bath, E. (2016). Understanding and responding to the needs of commercially sexually exploited youth: Recommendations for the mental health provider. Child Adolescent Psychiatric Clinicals of North America, 25(1), 107-122. DOI: 10.1016/j.chc.2015.08007
Landers, M., McGrath, K., Johnson, M. H., Armstrong, M. I., & Dollard, N. (2017). Baseline characteristics of dependent youth who have been commercially sexually exploited: Findings from a specialized treatment program. Journal of Child Sexual Abuse, 26(6), 692–709. DOI: 10.1080/10538712.2017.1323814
McCrory, E., De Brito, S. A., & Viding, E. (2012). The link between child abuse and psychopathology: A review of neurobiological and genetic research. Journal of the Royal Society of Medicine, 105(4), 151-156. DOI: 10.1258/jrsm.2011.110222
Mental Health of America. (2020). Youth ranking 2020. Mental Health in America--Youth Data. Retrieved from: http://www.mentalhealthamerica.net/issues/mental-health-america-youth-data
Muftic L., R., & Finn, M., A. (2013). Health outcomes among women trafficked for sex in the United States: A closer look. Journal of Interpersonal Violence, 28(9), 1859-1885. DOI: 10.1177/0886260512469102
Naramore, R., Bright, M. A., Epps, N., & Hardt, N. S. (2017). Youth arrested for trading sex have the highest rates of childhood adversity: A statewide study of juvenile offenders. Sexual Abuse: Journal of Research and Treatment, 29(4), 396–410. DOI: 10.1177/1079063215603064
National Institute of Mental Health (2017). Post-traumatic stress disorder (PTSD). Mental Health Information. Retrieved from: https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml
O’Brien, J. E., White, K., & Rizo, C. F. (2017). Domestic minor sex trafficking among child welfare–involved youth: An exploratory study of correlates. Child Maltreatment, 22(3), 265–274. DOI: 10.1177/1077559517709995
Polaris Project. (2014). Identifying victims of human trafficking: What to look for during a medical exam/consultation. Potential trafficking indicators for medical professionals. Polaris Project. Retrieved from: https://www.zontayakima.org/advocacy/PolarisProject-WhattoLookforduringMedicalExams.pdf
Polaris. (2018). 2017 Statistics from the National Human Trafficking hotline and BeFree textline. Resources: U.S. National Hotline Trafficking hotline Statistics. Retrieved from: https://polarisproject.org/wp-content/uploads/2019/09/2017NHTHStats-1.pdf
Preventing Sex Trafficking and Strengthening Families Act of 2014, Pub. L. No. 113-183 (2014). H. E. 4980 – 113th Congress (2013-14). Retrieved from: https://www.congress.gov/bill/113th-congress/house-bill/498
Reid, J. A., Baglivio, M. T., Piquero, A. R., Greenwald, M. A., & Epps, N. (2017). Human trafficking of minors and childhood adversity in Florida. American Journal of Public Health, 107(2), 306–311. DOI: 10.2105/AJPH.2016.303564
Reid, J. A. (2014). Risk and resiliency factors influencing onset and adolescence-limited commercial sexual exploitation of disadvantaged girls. Criminal Behaviour and Mental Health, 24(5), 332–344. DOI: 10.1002/cbm.1903
Reid, J. A. (2016). Entrapment and enmeshment schemes used by sex traffickers. Sexual Abuse, 28(6), 491-511. DOI: 10.1177/1079063214544334
Reid, J. A., & Piquero, A. R. (2014). Age-graded risks for commercial sexual exploitation of male and female youth. Journal of Interpersonal Violence, 29(9), 1747-1777. DOI: 10.1177/0886260513511535
Shannon, K., Bright, V., Gibson, K., & Maka Project Partnership. (2007). Sexual and drug-related vulnerabilities for HIV infection among women engaged in sex work in Vancouver, Canada. Canadian Journal of Public Health, 98(6), 465-469. DOI: 10.1007/BF03405440
Shaw, J. A., Lewis, J. E., Chitiva, H. A., & Pangilinan, A. R. (2017). Adolescent victims of commercial sexual exploitation versus sexually abused adolescents. Journal of the American Academy of Psychiatry and the Law, 45(3), 325–331.
Simons, R. L., & Whitbeck, L. B. (1991). Sexual abuse as a precursor to prostitution and victimization among adolescent and adult homeless women. Journal of Family Issues, 12(3), 361–379. DOI: 10.1177/019251391012003007
Silverman, J. G. (2011). Adolescent female sex workers: Invisibility, violence and HIV. Archives of Disease in Childhood, 96(5), 478-481. DOI: 10.1136/adc.2009.178715
Smith, L., Vardaman, S., & Snow, M. (2009). The national report on domestic minor sex trafficking: America’s prostituted children. Shared Hope International.
Sprang, G., & Cole, J. (2018). Familial sex trafficking of minors: Trafficking conditions, clinical presentation, and system involvement. Journal of Family Violence, 33(3), 185–195. DOI: 10.1007/s10896-018-9950-y
Substance Abuse and Mental Health Administration [SAMHSA]. (2014). Concept of trauma and trauma-informed approach. SAMHSA Trauma and Justice Strategic Initiative. Retrieved from: https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Stransky, M., & Finkelhor, D. (2012). Sex trafficking of minors: How many juveniles are being prostituted in the US? Crimes against Children Research Center, University of New Hampshire.
Trafficking Awareness Training for Health Care Act of 2015 No. 398. (2015). H. R. 398 – 114th Congress (2015-16). Retrieved from: https://www.congress.gov/bill/114th-congress/house-bill/398
U.S. Attorney's Office. (2012, June 26). Leader of Crips gang pleads guilty to prostituting eight juveniles. Federal Bureau of Investigation [FBI] Washington Field Office. Retrieved from: https://archives.fbi.gov/archives/washingtondc/press-releases/2012/leader-of-crips-gang-pleads-guilty-in-virginia-to-prostituting-eight-juveniles
Varma, S., Gillespie, S., McCracken, C., & Greenbaum, V. J. (2015). Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse and Neglect, 44, 98–105. DOI:10.1016/j.chiabu.2015.04.004
Vera Institute of Justice (2014). Screening for human trafficking: Guidelines for administering the Trafficking Victims Identification Tool (TVIT). Author. Retrieved from: https://www.vera.org/downloads/publications/human-trafficking-identification-tool-and-user-guidelines.pdf
Victims of Trafficking and Violence Protection Act [TVPA] of 2000, Pub. L. No. 106-386, 114 Stat. 1470 (2000). Retrieved from: https://www.govinfo.gov/content/pkg/PLAW-106publ386/pdf/PLAW-106publ386.pdf