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Aspects of Abuse: Commercial Sexual Exploitation of Children Melissa Jimenez, MD,a Allison M. Jackson, MD, MPH,b,c and Katherine Deye, MDb,c
Commercial sexual exploitation of children (CSEC) and adolescents is a serious worldwide problem. It is, in essence, the sexual abuse of a minor for economic gain. In the United States, there is no uniform nationwide database to capture the incidence and prevalence of CSEC. Therefore, there is a great variation in the estimates, but the actual numbers are unknown. Given the clandestine nature of the practice, it is often underreported and underidentified. Healthcare providers will often encounter victims of commercial sexual exploitation due to mental health,
physical health, and sexual health consequences, and therefore should be knowledgeable in the signs of possible sexual exploitation. The aim of this article is to educate healthcare providers on how vulnerable children may become sexually exploited, the health consequences involved with sexual exploitation, how to better identify possible victims, and the medical evaluation of a victim of sexual exploitation.
Introduction
Epidemiology
Curr Probl Pediatr Adolesc Health Care 2015;45:80-85
There is no uniform nationwide database to capture the ommercial sexual exploitation of children incidence and prevalence of CSEC. Therefore, there is a (CSEC) and adolescents is a serious worldgreat variation in the estimates, but wide problem. Given the actual numbers are unknown. the clandestine nature of the Many estimates have been given as practice, it is often underreported Victims of sex trafficking to the children at risk for sexual and underidentified. Furthermore, exploitation. However, these estiwere overwhelmingly more in the United States, there currently mates are based on the number of exists no uniform nationwide data likely to be female and children in high-risk situations (i.e., collection for CSEC victims, so under the age of 25 years, homeless children, runaways, and exact incidence and prevalence while suspected perpetrators throwaways), but these are not true numbers are unknown. Healthcare were more likely to be male values.1 They are mostly educated providers will often encounter vicguesses or are values drawn from tims of commercial sexual exploiand over the age of 25 incomplete data.2 Median age in tation due to mental health, physical years. multiple studies shows that the health, and sexual health conseaverage age of entry into CSEC is quences and therefore should be under 16 years and could possibly be as young as 13 or 14 knowledgeable in the signs of possible sexual exploitation, 3,4 years. It is thought that victims are becoming younger as well as the medical evaluation of a child or adolescent because traffickers fear victims may have HIV or AIDS.4 suspected to have been sexually exploited. The U.S. Department of Justice released a special report in 2011 called “Characteristics of Suspected Human Trafficking Incidents, 2008–2010,” in which From the aMayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Cincinnati, OH; bFreddie Mac Foundation Child and data collected from federally funded human trafficking Adolescent Protection Center, Children's National Medical Center, Washtask forces were analyzed.5 They found that about 80% ington, DC; and cThe George Washington University School of Medicine of suspected cases of human trafficking were classified and Health Sciences, Washington, DC. as sex trafficking and that 83% of victims were identified Curr Probl Pediatr Adolesc Health Care 2015;45:80-85 1538-5442/$ - see front matter as U.S. citizens. Analysis was then performed on those & 2015 Mosby, Inc. All rights reserved. suspected cases that were later confirmed to be human http://dx.doi.org/10.1016/j.cppeds.2015.02.003
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trafficking. This analysis included both victim and suspect characteristics. Victims of sex trafficking were overwhelmingly more likely to be female and under the age of 25 years, while suspected perpetrators were more likely to be male and over the age of 25 years.
Risk Factors
sexual exploitation to determine who was recruiting individuals into prostitution, where recruitment occurs, and what methods are used to recruit victims.7 The NHTRC analysis found that the majority of times (82.62%), pimps recruited individuals. A pimp is a trafficker who primarily profits from the sexual exploitation of others. Others who were involved in recruitment include bottoms (a person who is directed by the pimp to recruit and/or manage other individuals under his/her control), facilitators (a third party who may acquaint a pimp with a potential victim), and caregivers (including biological parents and other family members). Recruitment most often occurred socially, such as at parties or through friends. Other places in which recruitment occurs were online (especially via online video games and social media accounts), in public places, residences or shelters, schools, and bars or clubs. Other studies have found that pimps may target victims in places where there is little adult supervision, such as arcades and malls.8 The last question asked by the NHTRC was what methods were used to recruit. Most commonly, pimps showed romantic interest in potential victims—acting as an intimate partner. Other methods included posing as benefactors offering help, false job offers, and abduction.7
If taken into the context of an ecological model, there are numerous societal, community, relationship, and individual risk factors that cause individuals to be susceptible to sexual exploitation. Individual risk factors are those personal factors that increase the risk of a child being exploited, including a prior history of maltreatment (including sexual, psychological, and physical abuse), involvement in foster care, any criminal history, a history of homelessness or running away, or a history of substance abuse. Lesbian, Gay, Bisexual, and Transgender (LGBT) youths are also at risk for exploitation, partially due to the increased risk of homelessness and/or running away. Relationship factors are those close relationships that increase the risk of a child being exploited. These include family dysfunction; mental illness in the family; and the promotion of prostitution by parents, siblings, and/or significant others. Community factors are the settings in which relationships take Recruitment most often place that affect whether a child occurred socially, such as at Health Consequences will be exploited. These factors are numerous but can include parties or through friends. The possible health consequenincome poverty, the presence of ces of CSEC are numerous and pre-existing adult prostitution include psychological and physical markets in areas with a large transient youth population, health consequences.9 Physical health consequences the presence in local communities of a large number of can be further broken down into general health sexually unattached and transient males, and the existence consequences, reproductive health consequences, subof organized criminal networks that engage in prostitution. stance abuse consequences, and consequences of Finally, broad societal factors that help create a climate in violence and abuse. Psychological abuses are numerwhich it is acceptable for children to be sexually exploited ous and can include intimidation, threats against loved include the sexualization of children, a lack of response to ones, lies, deception, blackmail, isolation, and forced crimes committed against children, and groups advocating dependency. This can lead to mental health consefor child–adult sexual relationships. The lack of knowledge quences such as depression, post-traumatic stress of CSEC and the lack of resources to help those who have symptoms, dissociation, irritability, suicidal ideation, been identified as victims of CSEC only further the self-harm, and suicide.10 6 exploitation of these children. Frequently, victims of CSEC will have their medical needs neglected, which can lead to poor control of chronic diseases such as asthma and diabetes. They can Recruitment also be deprived of basic necessities such as food, light, and sleep, which can lead to exhaustion, fatigue, The National Human Trafficking Resource Center malnutrition, and starvation.10 Sexual abuses such as (NHTRC) recently analyzed 422 cases of commercial
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TABLE 2 forced and coerced sex, forced prostitution, and limited Specific health indicators access to reproductive health products lead to reproMalnourishment and poorly controlled medical conditions such as ductive health consequences such as STIs (including asthma or diabetes. HIV/AIDS), PID, unwanted pregnancies, forced or Signs of physical abuse, such as bruising, burns, broken bones, broken coerced abortions, as well as damage to vaginal and/or teeth, and multiple scars. Infections that could be easily treated through routine physicals. anal tract, leading to pain during intercourse.10 Addiction to drugs/alcohol. Victims of CSEC are also at a higher risk for Paying with cash due to lack of insurance. substance use and abuse. This is through use of drugs Multiple or frequent STIs, PID, and pregnancies. Evidence of cutting or branding, as well as tattoos on the neck/lower as a coping mechanism for the abuse being suffered, or back that the individual is reluctant to explain. through force and/or coercion as a control mechanism, Adapted from identifying victims of human trafficking. What to look as well as to make victims appear less credible if for during a medical exam/consultation. Polaris Project, 2010. 9 they encounter law enforcement. Consequences of substance abuse include needle-introduced infection, resources, fear law enforcement and/or deportation, overdose, and participation in high-risk activity. lack transportation, or do not speak the same language Nearly all victims of CSEC report experiencing some as healthcare providers.11 form of violence. This includes forced sex, being Providers may find it diffipunched, beaten, kicked, torcult to identify victims of tured, threatened with a due to several barriers weapon, and strangled.9 VioThey have also developed assess- CSEC as well. A study found that lence such as this can lead to ment tools, interactive training 28% of trafficked women long-term consequences such modules, and pre-recorded saw healthcare providers as chronic pain, physical diswho did not recognize that abilities, and death. webinars in order to increase these women were victims of awareness among law exploitation.12 Reasons for enforcement and healthcare Victim Identification these missed opportunities providers. These tools and trainings can include the nature of the Since victims of sexual can be found on the Polaris Project crime (hidden), lack of exploitation frequently come awareness or understanding website under “Training and in contact with healthcare of the problem, a negative providers in order to treat a Technical Assistance” (http:// perception of victims (i.e., variety of illness and infecwww.polarisproject.org/ assigning blame), misidentifitions, it is imperative that cation (i.e., classification as what-we-do/ healthcare providers are domestic violence), lack of training-and-technical-assistance). familiar with the possible resources, safety concerns, signs of trafficking. There and language barriers.11 are many reasons that victims The Polaris Project has also developed a list of of CSEC are not identified, both victim dependent and potential red flags and indicators that can be useful in provider dependent. At times, victims are unable to trying to identify victims of CSEC (Tables 1 and 2). self-identify, they lack knowledge of available They have also developed assessment tools, interactive training modules, and pre-recorded webinars in order TABLE 1 to increase awareness among law enforcement and General indicators healthcare providers. These tools and trainings can be The individual does not have any legal documentation and is not in found on the Polaris Project website under “Training control of his/her money. and Technical Assistance” (http://www.polarisproject. Individual claims to be visiting in the area, yet cannot give an address or place at which he/she is staying. org/what-we-do/training-and-technical-assistance). There are numerous inconsistencies in his/her story. There are also several screening tools that have been The individual is not allowed to speak for him/herself. created to help identify CSEC victims, such as the Rapid The individual avoids eye contact. Screening Tool for Child Trafficking and the CompreAdapted from identifying victims of human trafficking. What to look hensive Screening and Safety Tool for Child for during a medical exam/consultation. Polaris Project, 2010.
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TABLE 3
Examples of a strengths-based approach to help identify possible CSEC victims It seems as though you have been on the streets for some time. It takes a lot of strength to live on the streets, and you must be really strong to have survived. It can also get lonely. Who has got your back when you are away from home? Do you have a boyfriend or girlfriend? Do you have to protect yourself or does someone help protect you? How do they do that? Does anyone give you a place to stay at night? Where do you usually go to sleep? How are you making money to buy food and clothes? Have you ever had to do anything you did not like so you could get money? I can tell you are tough, but sometimes even the toughest people get stuck in scary situations. Has anything ever happened where you have gotten hurt pretty bad and needed help? What did you do? During that time, what strengths helped you get through it? Personal correspondence with Elizabeth Scaife, Shared Hope International.
Trafficking.13 Shared Hope International also created the Intervene Intake Tool, which provides a tiered set of questions that are modeled after a trauma-informed and strengths-based approach. Questions typically invasive in nature are reorganized into a framework that empowers and guides the youth through the disclosure process while reducing re-traumatization. It screens for indicators of pimp- and gang-controlled trafficking. Unfortunately, few of these screening tools have been validated. Validated tools include the Human Trafficking Interview and Assessment Measure-14 (HTIAM-14), the Child and Adolescent Needs and Strengths (CANS)–Commercial Sexual Exploitation, and the New York City Trafficking Assessment Project (NYCTAP) screening tool validated through Vera Institute of Justice. Healthcare providers may find it difficult to use screening tools in the Emergency Department or a fast-paced clinic environment to identify possible CSEC victims. If a provider chooses to not use a screening tool to help identify suspected CSEC victims, it is important to build a rapport while asking questions to help identify whether they may be victims of CSEC. This can be done by framing questions in a
strength-based manner and addressing the child on his/ her level (Table 3).
Role of the Healthcare Provider Healthcare providers should evaluate victims of sexual exploitation in order to assess for injury, as well as to evaluate for sexually transmitted infections and pregnancy. Healthcare providers often also participate in forensic evidence collection, which is then passed on to law enforcement for analysis. Prior to beginning an interview, medical providers may consider separating the patient from his/her belongings and escort. At times, victims may be wearing some sort of communication device, so having victims change into a hospital gown and separating them from their clothes may help them feel more comfortable in speaking openly and honestly.
Medical Interview The medical interview should be performed prior to examining the child in order to guide the evaluation. It
TABLE 4
Medical interview of the sexually exploited child Current medical symptoms (physical/emotional) Do you have any areas on your body that are currently painful or tender to touch? What types of sexual activity have you recently experienced? Was it with men, women, or both? Was it oral sex, anal sex, and/or vaginal sex? Do you currently have any abnormal bleeding, fever, abdominal pain, or vaginal discharge? Have you recently used any alcohol or drugs? If so, did you take them willingly, or were you forced to do so? Have you ever had a lapse in your memory while taking alcohol or drugs? Gynecologic history Have you ever had a sexually transmitted infection? If so, did you seek medical attention? How many times have you been treated for a sexually transmitted infection? Have you ever been pregnant? If so, have you ever had an abortion? If not, did you have problems with your pregnancy? Did you get medical treatment during your pregnancy? Were there any problems with the delivery? Where is the baby now? Prior injuries Have you ever been punched, kicked, slapped, choked, or cut by someone else? If so, have you ever lost consciousness afterward? Have you ever felt pain during intercourse? Was there any bleeding afterwards? Did you still have to work, even with an injury? Adapted from Greenbaum et al.1
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83
is important to review the limits of confidentiality with the child prior to beginning the interview, as much of the information obtained will likely be shared with law enforcement. The interview should begin with past medical history and include information on previous hospitalizations, psychiatric treatment, injuries, gynecologic and menstrual history, history of drug and alcohol use, medications, and allergies.6 There are numerous potential questions that can be asked during a medical interview with a child who is suspected of having been sexually exploited. These include questions about reproductive health, prior sexual victimization, prior violence, prior inflicted injuries, prior confinement, emotional health, as well as drugs and alcohol (Table 4).1
Diagnostic Testing and Treatment Universal screening for sexually transmitted infections should be done on suspected victims of CSEC. Testing for HIV, Neisseria gonorrhoeae, Chlamydia trachomatis, Syphilis, Trichomonas vaginalis, Hepatitis B, and Hepatitis C should be considered. Given the decreased likelihood for follow-up of victims of CSEC, prophylaxis should generally be offered prophylaxis against common STIs such as Gonorrhea, Chlamydia, and Trichomoniasis. Additionally, HIV post-exposure prophylaxis should also be offered if the patient presents within the appropriate timeframe.6
Resources and Referrals
As discussed previously, victims of CSEC report a variety of psychological health problems, including depression, PTSD, and As with any encounter with a attempted suicide.9 Therefore, patient, the chief complaint The National Human Trafficking it is imperative that physicians should dictate the evaluation. who evaluate CSEC victims Resource Center (HTRC) has a The patient should first be starefer them for mental health bilized before initiating a thorhotline (1-888-3737-888) that services. Local child advocacy ough physical exam, as victims may also be helpful in obtaining centers may be helpful for of sexual exploitation typically obtaining referrals for mental mental health services for vicdo not present for care until it is tims. The hotline is also available health services. The National necessary. When the patient is Human Trafficking Resource stable, he/she should be examto healthcare providers for gen- Center (HTRC) has a hotline ined for signs of sexual and eral information and guidance, (1-888-3737-888) that may physical injury; drug use; malalso be helpful in obtaining such as providing assessment nutrition; as well as physical, questions that providers can use mental health services for vicmedical, and dental neglect.6 tims. The hotline is also availCare should be taken to to elicit more information from able to healthcare providers for approach the physical exam in suspected victims. general information and guida caring and sensitive manner. ance, such as providing assessPatients should be prepared for ment questions that providers what the physical and genital exam will entail. They can use to elicit more information from suspected should be draped with a sheet, and only the part of the victims. Along with calling the National Human body currently being examined should be uncovered. Trafficking Resource Center Hotline, law enforcement Non-genital injury should be assessed and docuand child protective services should also be contacted mented first. Following this, the genital and anal exam should a physician suspect a child is a victim of sexual should be performed. The female genital exam should exploitation. be performed either in the supine frog-leg position or in the lithotomy position. The anal exam can be performed in the lateral decubitus position if the patient is Conclusion male or if the previous positions do not offer an adequate view of the anus. All injuries should be The commercial sexual exploitation of children is a documented using a body map and photography global health issue that directly affects healthcare whenever possible.14 During the exam, forensic eviproviders. Healthcare providers are uniquely poised to identify victims of CSEC due to their close interactions dence collection can be performed if appropriate.
Physical Exam
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with victims who suffer the health consequences associated with long-term abuse. However, these victims often go undetected. The needs of victims of sexual exploitation are extremely complex, and healthcare providers should be educated in the signs of CSEC and should be familiar with the medical evaluation of any sexually exploited child or adolescent.
References 1. Greenbaum J, Kellogg N, Reena I, et al. APSAC Practice Guidelines: The Commercial Sexual Exploitation of Children: The Medical Provider’s Role in Identification, Assessment and Treatment. http://www.kyaap.org/your-childs-health-3/childsex-trafficking; 2013 Accessed 01.07.14. 2. Finkelhor D, Stransky M. How Many Juveniles are Involved in Prostitution in the U.S.? Crimes Against Children Research Center. University of New Hampshire; 2008. 3. Barnitz L. Effectively responding to the commercial sexual exploitation of children: A comprehensive approach to prevention, protection, and reintegration services. Child Welfare 2001;80(5):597–610. 4. Friedman SA. Who is There to Help Us? How the System Fails Sexually Exploited Girls in the United States: Examples From Four American Cities. Brooklyn, NY: ECPAT-USA; 2005. 5. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008–2010. Bureau of Justice Statistics; 2011. 6. Cooper SW, Estes RJ, Giardino AP, Kellogg ND, Vieth VI. Medical, Legal, & Social Science Aspects of Child Sexual Exploitation. St. Louis (MO): G.W. Medical Publishing, Inc, 2005.
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7. Polaris Project. Human Trafficking Trends in the United States 2007–2013. National Human Trafficking Resource Center; 2013. 8. Albanese J. Commercial Sexual Exploitation of Children: What Do We Know and What Do We Do About It? Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2007. https://www. ncjrs.gov/pdffiles1/nij/215733.pdf. 9. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61–91. 10. Zimmerman C, Yun K, Shvab I, et al. The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings From a European Study. London, United Kingdom: London School of Hygiene and Tropical Medicine (LSHTM), 2003. 11. Clawson HJ, Dutch N, Solomon A, Goldblatt Grace L. Human trafficking into and within the United States: A Review of the Literature. Washington: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2009. http://aspe.hhs.gov/hsp/07/humantrafficking/ litrev/index.pdf. 12. Family Violence Prevention Fund. San Francisco, CA: Family Violence Prevention Fund. Turning pain into power: Trafficking survivors’ perspectives on early intervention strategies. www.childhood-usa.org/upl/files/4109.pdf; 2005 Accessed 29.12.14. 13. Walts KK, French S, Moore H, Ashai S. Building Child Welfare Response to Child Trafficking. Chicago (IL): Loyola University Chicago, Center for the Human Rights of Children, 2011. 14. Kellogg N. Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116(2): 506–12.
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Aspects of Abuse: Commercial Sexual Exploitation of Children Melissa Jimenez, MD,a Allison M. Jackson, MD, MPH,b,c and Katherine Deye, MDb,c
Commercial sexual exploitation of children (CSEC) and adolescents is a serious worldwide problem. It is, in essence, the sexual abuse of a minor for economic gain. In the United States, there is no uniform nationwide database to capture the incidence and prevalence of CSEC. Therefore, there is a great variation in the estimates, but the actual numbers are unknown. Given the clandestine nature of the practice, it is often underreported and underidentified. Healthcare providers will often encounter victims of commercial sexual exploitation due to mental health,
physical health, and sexual health consequences, and therefore should be knowledgeable in the signs of possible sexual exploitation. The aim of this article is to educate healthcare providers on how vulnerable children may become sexually exploited, the health consequences involved with sexual exploitation, how to better identify possible victims, and the medical evaluation of a victim of sexual exploitation.
Introduction
Epidemiology
Curr Probl Pediatr Adolesc Health Care 2015;45:80-85
There is no uniform nationwide database to capture the ommercial sexual exploitation of children incidence and prevalence of CSEC. Therefore, there is a (CSEC) and adolescents is a serious worldgreat variation in the estimates, but wide problem. Given the actual numbers are unknown. the clandestine nature of the Many estimates have been given as practice, it is often underreported Victims of sex trafficking to the children at risk for sexual and underidentified. Furthermore, exploitation. However, these estiwere overwhelmingly more in the United States, there currently mates are based on the number of exists no uniform nationwide data likely to be female and children in high-risk situations (i.e., collection for CSEC victims, so under the age of 25 years, homeless children, runaways, and exact incidence and prevalence while suspected perpetrators throwaways), but these are not true numbers are unknown. Healthcare were more likely to be male values.1 They are mostly educated providers will often encounter vicguesses or are values drawn from tims of commercial sexual exploiand over the age of 25 incomplete data.2 Median age in tation due to mental health, physical years. multiple studies shows that the health, and sexual health conseaverage age of entry into CSEC is quences and therefore should be under 16 years and could possibly be as young as 13 or 14 knowledgeable in the signs of possible sexual exploitation, 3,4 years. It is thought that victims are becoming younger as well as the medical evaluation of a child or adolescent because traffickers fear victims may have HIV or AIDS.4 suspected to have been sexually exploited. The U.S. Department of Justice released a special report in 2011 called “Characteristics of Suspected Human Trafficking Incidents, 2008–2010,” in which From the aMayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Cincinnati, OH; bFreddie Mac Foundation Child and data collected from federally funded human trafficking Adolescent Protection Center, Children's National Medical Center, Washtask forces were analyzed.5 They found that about 80% ington, DC; and cThe George Washington University School of Medicine of suspected cases of human trafficking were classified and Health Sciences, Washington, DC. as sex trafficking and that 83% of victims were identified Curr Probl Pediatr Adolesc Health Care 2015;45:80-85 1538-5442/$ - see front matter as U.S. citizens. Analysis was then performed on those & 2015 Mosby, Inc. All rights reserved. suspected cases that were later confirmed to be human http://dx.doi.org/10.1016/j.cppeds.2015.02.003
C
80
Curr Probl PediatrAdolesc Health Care, March 2015
trafficking. This analysis included both victim and suspect characteristics. Victims of sex trafficking were overwhelmingly more likely to be female and under the age of 25 years, while suspected perpetrators were more likely to be male and over the age of 25 years.
Risk Factors
sexual exploitation to determine who was recruiting individuals into prostitution, where recruitment occurs, and what methods are used to recruit victims.7 The NHTRC analysis found that the majority of times (82.62%), pimps recruited individuals. A pimp is a trafficker who primarily profits from the sexual exploitation of others. Others who were involved in recruitment include bottoms (a person who is directed by the pimp to recruit and/or manage other individuals under his/her control), facilitators (a third party who may acquaint a pimp with a potential victim), and caregivers (including biological parents and other family members). Recruitment most often occurred socially, such as at parties or through friends. Other places in which recruitment occurs were online (especially via online video games and social media accounts), in public places, residences or shelters, schools, and bars or clubs. Other studies have found that pimps may target victims in places where there is little adult supervision, such as arcades and malls.8 The last question asked by the NHTRC was what methods were used to recruit. Most commonly, pimps showed romantic interest in potential victims—acting as an intimate partner. Other methods included posing as benefactors offering help, false job offers, and abduction.7
If taken into the context of an ecological model, there are numerous societal, community, relationship, and individual risk factors that cause individuals to be susceptible to sexual exploitation. Individual risk factors are those personal factors that increase the risk of a child being exploited, including a prior history of maltreatment (including sexual, psychological, and physical abuse), involvement in foster care, any criminal history, a history of homelessness or running away, or a history of substance abuse. Lesbian, Gay, Bisexual, and Transgender (LGBT) youths are also at risk for exploitation, partially due to the increased risk of homelessness and/or running away. Relationship factors are those close relationships that increase the risk of a child being exploited. These include family dysfunction; mental illness in the family; and the promotion of prostitution by parents, siblings, and/or significant others. Community factors are the settings in which relationships take Recruitment most often place that affect whether a child occurred socially, such as at Health Consequences will be exploited. These factors are numerous but can include parties or through friends. The possible health consequenincome poverty, the presence of ces of CSEC are numerous and pre-existing adult prostitution include psychological and physical markets in areas with a large transient youth population, health consequences.9 Physical health consequences the presence in local communities of a large number of can be further broken down into general health sexually unattached and transient males, and the existence consequences, reproductive health consequences, subof organized criminal networks that engage in prostitution. stance abuse consequences, and consequences of Finally, broad societal factors that help create a climate in violence and abuse. Psychological abuses are numerwhich it is acceptable for children to be sexually exploited ous and can include intimidation, threats against loved include the sexualization of children, a lack of response to ones, lies, deception, blackmail, isolation, and forced crimes committed against children, and groups advocating dependency. This can lead to mental health consefor child–adult sexual relationships. The lack of knowledge quences such as depression, post-traumatic stress of CSEC and the lack of resources to help those who have symptoms, dissociation, irritability, suicidal ideation, been identified as victims of CSEC only further the self-harm, and suicide.10 6 exploitation of these children. Frequently, victims of CSEC will have their medical needs neglected, which can lead to poor control of chronic diseases such as asthma and diabetes. They can Recruitment also be deprived of basic necessities such as food, light, and sleep, which can lead to exhaustion, fatigue, The National Human Trafficking Resource Center malnutrition, and starvation.10 Sexual abuses such as (NHTRC) recently analyzed 422 cases of commercial
Curr Probl PediatrAdolesc Health Care, March 2015
81
TABLE 2 forced and coerced sex, forced prostitution, and limited Specific health indicators access to reproductive health products lead to reproMalnourishment and poorly controlled medical conditions such as ductive health consequences such as STIs (including asthma or diabetes. HIV/AIDS), PID, unwanted pregnancies, forced or Signs of physical abuse, such as bruising, burns, broken bones, broken coerced abortions, as well as damage to vaginal and/or teeth, and multiple scars. Infections that could be easily treated through routine physicals. anal tract, leading to pain during intercourse.10 Addiction to drugs/alcohol. Victims of CSEC are also at a higher risk for Paying with cash due to lack of insurance. substance use and abuse. This is through use of drugs Multiple or frequent STIs, PID, and pregnancies. Evidence of cutting or branding, as well as tattoos on the neck/lower as a coping mechanism for the abuse being suffered, or back that the individual is reluctant to explain. through force and/or coercion as a control mechanism, Adapted from identifying victims of human trafficking. What to look as well as to make victims appear less credible if for during a medical exam/consultation. Polaris Project, 2010. 9 they encounter law enforcement. Consequences of substance abuse include needle-introduced infection, resources, fear law enforcement and/or deportation, overdose, and participation in high-risk activity. lack transportation, or do not speak the same language Nearly all victims of CSEC report experiencing some as healthcare providers.11 form of violence. This includes forced sex, being Providers may find it diffipunched, beaten, kicked, torcult to identify victims of tured, threatened with a due to several barriers weapon, and strangled.9 VioThey have also developed assess- CSEC as well. A study found that lence such as this can lead to ment tools, interactive training 28% of trafficked women long-term consequences such modules, and pre-recorded saw healthcare providers as chronic pain, physical diswho did not recognize that abilities, and death. webinars in order to increase these women were victims of awareness among law exploitation.12 Reasons for enforcement and healthcare Victim Identification these missed opportunities providers. These tools and trainings can include the nature of the Since victims of sexual can be found on the Polaris Project crime (hidden), lack of exploitation frequently come awareness or understanding website under “Training and in contact with healthcare of the problem, a negative providers in order to treat a Technical Assistance” (http:// perception of victims (i.e., variety of illness and infecwww.polarisproject.org/ assigning blame), misidentifitions, it is imperative that cation (i.e., classification as what-we-do/ healthcare providers are domestic violence), lack of training-and-technical-assistance). familiar with the possible resources, safety concerns, signs of trafficking. There and language barriers.11 are many reasons that victims The Polaris Project has also developed a list of of CSEC are not identified, both victim dependent and potential red flags and indicators that can be useful in provider dependent. At times, victims are unable to trying to identify victims of CSEC (Tables 1 and 2). self-identify, they lack knowledge of available They have also developed assessment tools, interactive training modules, and pre-recorded webinars in order TABLE 1 to increase awareness among law enforcement and General indicators healthcare providers. These tools and trainings can be The individual does not have any legal documentation and is not in found on the Polaris Project website under “Training control of his/her money. and Technical Assistance” (http://www.polarisproject. Individual claims to be visiting in the area, yet cannot give an address or place at which he/she is staying. org/what-we-do/training-and-technical-assistance). There are numerous inconsistencies in his/her story. There are also several screening tools that have been The individual is not allowed to speak for him/herself. created to help identify CSEC victims, such as the Rapid The individual avoids eye contact. Screening Tool for Child Trafficking and the CompreAdapted from identifying victims of human trafficking. What to look hensive Screening and Safety Tool for Child for during a medical exam/consultation. Polaris Project, 2010.
82
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TABLE 3
Examples of a strengths-based approach to help identify possible CSEC victims It seems as though you have been on the streets for some time. It takes a lot of strength to live on the streets, and you must be really strong to have survived. It can also get lonely. Who has got your back when you are away from home? Do you have a boyfriend or girlfriend? Do you have to protect yourself or does someone help protect you? How do they do that? Does anyone give you a place to stay at night? Where do you usually go to sleep? How are you making money to buy food and clothes? Have you ever had to do anything you did not like so you could get money? I can tell you are tough, but sometimes even the toughest people get stuck in scary situations. Has anything ever happened where you have gotten hurt pretty bad and needed help? What did you do? During that time, what strengths helped you get through it? Personal correspondence with Elizabeth Scaife, Shared Hope International.
Trafficking.13 Shared Hope International also created the Intervene Intake Tool, which provides a tiered set of questions that are modeled after a trauma-informed and strengths-based approach. Questions typically invasive in nature are reorganized into a framework that empowers and guides the youth through the disclosure process while reducing re-traumatization. It screens for indicators of pimp- and gang-controlled trafficking. Unfortunately, few of these screening tools have been validated. Validated tools include the Human Trafficking Interview and Assessment Measure-14 (HTIAM-14), the Child and Adolescent Needs and Strengths (CANS)–Commercial Sexual Exploitation, and the New York City Trafficking Assessment Project (NYCTAP) screening tool validated through Vera Institute of Justice. Healthcare providers may find it difficult to use screening tools in the Emergency Department or a fast-paced clinic environment to identify possible CSEC victims. If a provider chooses to not use a screening tool to help identify suspected CSEC victims, it is important to build a rapport while asking questions to help identify whether they may be victims of CSEC. This can be done by framing questions in a
strength-based manner and addressing the child on his/ her level (Table 3).
Role of the Healthcare Provider Healthcare providers should evaluate victims of sexual exploitation in order to assess for injury, as well as to evaluate for sexually transmitted infections and pregnancy. Healthcare providers often also participate in forensic evidence collection, which is then passed on to law enforcement for analysis. Prior to beginning an interview, medical providers may consider separating the patient from his/her belongings and escort. At times, victims may be wearing some sort of communication device, so having victims change into a hospital gown and separating them from their clothes may help them feel more comfortable in speaking openly and honestly.
Medical Interview The medical interview should be performed prior to examining the child in order to guide the evaluation. It
TABLE 4
Medical interview of the sexually exploited child Current medical symptoms (physical/emotional) Do you have any areas on your body that are currently painful or tender to touch? What types of sexual activity have you recently experienced? Was it with men, women, or both? Was it oral sex, anal sex, and/or vaginal sex? Do you currently have any abnormal bleeding, fever, abdominal pain, or vaginal discharge? Have you recently used any alcohol or drugs? If so, did you take them willingly, or were you forced to do so? Have you ever had a lapse in your memory while taking alcohol or drugs? Gynecologic history Have you ever had a sexually transmitted infection? If so, did you seek medical attention? How many times have you been treated for a sexually transmitted infection? Have you ever been pregnant? If so, have you ever had an abortion? If not, did you have problems with your pregnancy? Did you get medical treatment during your pregnancy? Were there any problems with the delivery? Where is the baby now? Prior injuries Have you ever been punched, kicked, slapped, choked, or cut by someone else? If so, have you ever lost consciousness afterward? Have you ever felt pain during intercourse? Was there any bleeding afterwards? Did you still have to work, even with an injury? Adapted from Greenbaum et al.1
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is important to review the limits of confidentiality with the child prior to beginning the interview, as much of the information obtained will likely be shared with law enforcement. The interview should begin with past medical history and include information on previous hospitalizations, psychiatric treatment, injuries, gynecologic and menstrual history, history of drug and alcohol use, medications, and allergies.6 There are numerous potential questions that can be asked during a medical interview with a child who is suspected of having been sexually exploited. These include questions about reproductive health, prior sexual victimization, prior violence, prior inflicted injuries, prior confinement, emotional health, as well as drugs and alcohol (Table 4).1
Diagnostic Testing and Treatment Universal screening for sexually transmitted infections should be done on suspected victims of CSEC. Testing for HIV, Neisseria gonorrhoeae, Chlamydia trachomatis, Syphilis, Trichomonas vaginalis, Hepatitis B, and Hepatitis C should be considered. Given the decreased likelihood for follow-up of victims of CSEC, prophylaxis should generally be offered prophylaxis against common STIs such as Gonorrhea, Chlamydia, and Trichomoniasis. Additionally, HIV post-exposure prophylaxis should also be offered if the patient presents within the appropriate timeframe.6
Resources and Referrals
As discussed previously, victims of CSEC report a variety of psychological health problems, including depression, PTSD, and As with any encounter with a attempted suicide.9 Therefore, patient, the chief complaint The National Human Trafficking it is imperative that physicians should dictate the evaluation. who evaluate CSEC victims Resource Center (HTRC) has a The patient should first be starefer them for mental health bilized before initiating a thorhotline (1-888-3737-888) that services. Local child advocacy ough physical exam, as victims may also be helpful in obtaining centers may be helpful for of sexual exploitation typically obtaining referrals for mental mental health services for vicdo not present for care until it is tims. The hotline is also available health services. The National necessary. When the patient is Human Trafficking Resource stable, he/she should be examto healthcare providers for gen- Center (HTRC) has a hotline ined for signs of sexual and eral information and guidance, (1-888-3737-888) that may physical injury; drug use; malalso be helpful in obtaining such as providing assessment nutrition; as well as physical, questions that providers can use mental health services for vicmedical, and dental neglect.6 tims. The hotline is also availCare should be taken to to elicit more information from able to healthcare providers for approach the physical exam in suspected victims. general information and guida caring and sensitive manner. ance, such as providing assessPatients should be prepared for ment questions that providers what the physical and genital exam will entail. They can use to elicit more information from suspected should be draped with a sheet, and only the part of the victims. Along with calling the National Human body currently being examined should be uncovered. Trafficking Resource Center Hotline, law enforcement Non-genital injury should be assessed and docuand child protective services should also be contacted mented first. Following this, the genital and anal exam should a physician suspect a child is a victim of sexual should be performed. The female genital exam should exploitation. be performed either in the supine frog-leg position or in the lithotomy position. The anal exam can be performed in the lateral decubitus position if the patient is Conclusion male or if the previous positions do not offer an adequate view of the anus. All injuries should be The commercial sexual exploitation of children is a documented using a body map and photography global health issue that directly affects healthcare whenever possible.14 During the exam, forensic eviproviders. Healthcare providers are uniquely poised to identify victims of CSEC due to their close interactions dence collection can be performed if appropriate.
Physical Exam
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with victims who suffer the health consequences associated with long-term abuse. However, these victims often go undetected. The needs of victims of sexual exploitation are extremely complex, and healthcare providers should be educated in the signs of CSEC and should be familiar with the medical evaluation of any sexually exploited child or adolescent.
References 1. Greenbaum J, Kellogg N, Reena I, et al. APSAC Practice Guidelines: The Commercial Sexual Exploitation of Children: The Medical Provider’s Role in Identification, Assessment and Treatment. http://www.kyaap.org/your-childs-health-3/childsex-trafficking; 2013 Accessed 01.07.14. 2. Finkelhor D, Stransky M. How Many Juveniles are Involved in Prostitution in the U.S.? Crimes Against Children Research Center. University of New Hampshire; 2008. 3. Barnitz L. Effectively responding to the commercial sexual exploitation of children: A comprehensive approach to prevention, protection, and reintegration services. Child Welfare 2001;80(5):597–610. 4. Friedman SA. Who is There to Help Us? How the System Fails Sexually Exploited Girls in the United States: Examples From Four American Cities. Brooklyn, NY: ECPAT-USA; 2005. 5. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008–2010. Bureau of Justice Statistics; 2011. 6. Cooper SW, Estes RJ, Giardino AP, Kellogg ND, Vieth VI. Medical, Legal, & Social Science Aspects of Child Sexual Exploitation. St. Louis (MO): G.W. Medical Publishing, Inc, 2005.
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7. Polaris Project. Human Trafficking Trends in the United States 2007–2013. National Human Trafficking Resource Center; 2013. 8. Albanese J. Commercial Sexual Exploitation of Children: What Do We Know and What Do We Do About It? Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2007. https://www. ncjrs.gov/pdffiles1/nij/215733.pdf. 9. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61–91. 10. Zimmerman C, Yun K, Shvab I, et al. The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings From a European Study. London, United Kingdom: London School of Hygiene and Tropical Medicine (LSHTM), 2003. 11. Clawson HJ, Dutch N, Solomon A, Goldblatt Grace L. Human trafficking into and within the United States: A Review of the Literature. Washington: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2009. http://aspe.hhs.gov/hsp/07/humantrafficking/ litrev/index.pdf. 12. Family Violence Prevention Fund. San Francisco, CA: Family Violence Prevention Fund. Turning pain into power: Trafficking survivors’ perspectives on early intervention strategies. www.childhood-usa.org/upl/files/4109.pdf; 2005 Accessed 29.12.14. 13. Walts KK, French S, Moore H, Ashai S. Building Child Welfare Response to Child Trafficking. Chicago (IL): Loyola University Chicago, Center for the Human Rights of Children, 2011. 14. Kellogg N. Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116(2): 506–12.
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