Nurses United to End Sexual Exploitation and Trafficking of Children By Kelly Martin-Vegue, RN, MSW The commercial sexual exploitation of children (CSEC) is the recruitment, solicitation, or induction of youth 17 years or younger into sexual acts in exchange for money, basic needs, or anything of value 1. Commercial sex acts include, but are not limited to, prostitution, pornography, exotic dancing, escort services and any transactional sex act with a minor. Under the federal Victims of Trafficking and Violence Protection Act of 2000, commercially sexually exploited youth are victims of human trafficking and do not need to be trafficked across state or international borders to qualify, nor to prove force, fraud or coercion 2. Local researcher and Executive Director of Opportunities for Prostitution Survivors Debra Boyer explains, There is no curriculum that can provide an abused and frightened 14-year-old girl with the cognitive ability and refusal skills to out-think a 26-year-old offering love, money, and to take care of her. 3 Commercial sexual exploitation and trafficking affects youth of all gender identities, with some research noting up to 45-67% of CSEC to be boys 4. Instead of being criminalized or ignored, as previously, CSEC are finally recognized to be survivors of human trafficking, entitled to victim-centered services, and for the systems they encounter, such as juvenile justice, child welfare, law enforcement and healthcare, to be trauma-informed. Moreover, youth who are commercially sexually exploited are more likely to have experienced childhood sexual abuse, poverty, child welfare involvement and homelessness, as well as being disproportionately youth of color, LGBTQ+ identifying, and face intersectional disadvantage 5. Any effort to respond to and end the sex trafficking of youth must employ an anti-oppressive framework capable of identifying historic and systemic disenfranchisement causing immediate but preventable vulnerabilities. Research data regarding the exact number of youth exploited by sex trafficking in the U.S. is notoriously difficult to obtain due to the covert and underground nature of the commercial sex trades, insufficient or non-existent screening protocols, and hesitancy of youth to disclose sex trafficking experiences. A national study involving six cities/regions performed by the Center for Court Innovation estimates 4,457-20,994 youth are commercially sexually exploited in the U.S. with the average age of first exposure of 15.8 years old 6. The National Center for Missing and Exploited Children reports 1 in 5 youth who run away are at risk for exploitation and up to 60% of runaways exposed to sex trafficking have prior involvement in the child welfare system 7. The Center for Children & Youth
Justice (CCYJ) in Seattle launched a statewide data project to determine local prevalence, identify the means of exploitation, and report on the demographic characteristics of CSEC. In 2016, CCYJ, in partnership with 14 agencies and courts statewide, found 167 children (approximately 10% of all youth screened) were highly suspected or confirmed to be commercially sexually exploited, with an average age of 15 years 8. Notably, Washington State continues to be an innovative leader in addressing this issue through multisystem reform, legislative policy, wraparound service delivery, demand reduction efforts, and data collection. For example, Washington s Safe Harbor law (2010) enforces diversion services for CSEC, as well as heightened penalties for perpetrators, and the victim-centered Model Protocol for Responding to Commercially Sexually Exploited Youth developed by CCYJ 9. CCYJ, in partnership with Seattle-based homeless youth service provider YouthCare, began statewide implementation of the Model Protocol in 2013. A local leader on this issue, Justice Bobbe J. Bridge, ret., founding President/CEO of the Center for Children & Youth Justice, was appointed to the National Advisory Committee on the Sex Trafficking of Children and Youth in the U. S., demonstrating national recognition of tireless effort to reform system delivery and serve CSEC with a victim-centered protocol. Additionally, the Office of the Attorney General of Washington State and the Center for Children & Youth Justice convened the Commercially Sexually Exploited Children Statewide Coordinating Committee, assembling multidisciplinary experts and stakeholders from across the state to examine current response efforts, ultimately reporting back to the state legislature with recommendations on evolving laws and practices. There are currently 11 county-based CSEC Task Forces adapting the Model Protocol to their unique demographic regions. The King County CSEC Task Force coalition is particularly robust in membership, offering quarterly meetings and regular trainings, such as CSEC 101: Responding to Commercially Sexually Exploited Youth, And Boys Too, and Motivational Interviewing with CSEC. Other local services include the Bridge Continuum, which operates a partnership between YouthCare, Friends of Youth, and Nexus Youth and Families to offer specialized services for youth at risk for or experiencing sex trafficking, including immediate connection to a community advocate, case management, housing, mental and physical healthcare, chemical dependency treatment, education and job training. Nationwide, healthcare agencies are similarly mobilizing, sounding the call to action to also provide trauma-informed healthcare for CSEC. While only 13 states
have laws requiring human trafficking training for healthcare professionals 10, up to 88% of sex trafficking victims report accessing healthcare while being trafficked 11. Healthcare professionals, organizations, and agencies must rise to the obvious need for identifying and responding in accordance with trauma-informed practice standards for commercially exploited youth. In 2015, the American Academy of Pediatrics released a comprehensive report labeling the commercial sexual exploitation of children a public health crisis 12. Additionally, the National Institute of Medicine 13, the American Professional Society on the Abuse of Children 14, and the American Medical Women s Association have released practice guidelines for identifying, assessing, and treating survivors 15. Despite this progress, the fragmented response system and lack of training specific to CSEC continues. Given the known health risks resulting from adverse childhood experience (ACES), ensuring access to trauma-informed healthcare can mitigate the mounting disadvantage of toxic stress exposure endured by CSEC during critical developmental years. One of the largest research studies performed in an outpatient medical clinic, examining risk profiles of both CSEC and non-csec experiencing homelessness, was carried out in Los Angeles. Yates & colleagues examined 620 youth, with 25% reporting to medical professionals that they were being exploited in the commercial sex industry 16. Among the CSEC, 24.8% reported age of first sexual intercourse to be less than 10, compared to only 7.8% of the non-csec homeless youth. The entire sample of CSEC attributed their experiences within the commercial sex industry to be related to personal survival. Specific medical concerns experienced by CSEC at greater incidence than non-csec homeless youth included STI/STD (19%), pelvic inflammatory disease (5.8%), pregnancy (18.3%), asthma (2.6%), infectious disease (13.1%), sexual assault (2.6%), and high-risk behaviors for HIV (100%). More than half of the CSEC reported depression (54.6%) and nearly the same number (47.4%) had previously tried to commit suicide. Similarly, Martin et al. surveyed adult women involved in the commercial sex industry in Minneapolis (N=117), revealing those who were first commercially sexually exploited as children experienced higher incidence of sexually transmitted diseases, earlier onset of initial drug use, reported earlier age of first sexual experience, and were less likely to receive HIV testing than those who entered the commercial sex industry as adults 17. HIV risk is disproportionately high for CSEC due to dangerous sexual environments, IV drug injection, and inconsistent barrier protection; however, transgender male-to-female survivors,
specifically trans youth of color, are in the highest risk category for HIV transmission. In a multisite study of 151 demographically diverse transgender female youth ages 15-24, 67% of the sample had been sexually trafficked and 23% reported being HIV positive 18. Healthcare providers must understand their important role in the fight to end the commercial sexual exploitation and trafficking of children. Providers can assist in victim identification, documentation, reporting, referral, advocacy, and provision of culturally proficient, comprehensive physical and mental healthcare for CSEC. The health impact and negative life consequences of sex trafficking are multifaceted, far-reaching, and potentially life threatening. The commercial sexual exploitation of children is a reportable crime according to the Washington State mandatory reporting law for healthcare providers and it is advised to report both to law enforcement as well as child protective services. Regarding trainings, services, and routes of advocacy, health care workers may explore the following opportunities and resources for engaging further on this issue. The Center for Children & Youth Justice Model Protocol for Responding to Commercially Sexually Exploited Children (task force development, training, and data collection) https://ccyj.org/ King County CSEC Task Force (trainings, resources, advocacy) http://www.kingcounty.gov/courts/superior-court/juvenile/csec.aspx The Bridge Continuum (24-7 community advocates, case management, resources for CSEC) 24 hour hotline: 1-855-400-CSEC http://www.youthcare.org/our-programs/services-sexually-exploitedyouth#.wyyfau1k04k Opportunities for Prostitution Survivors (support groups, drop-in, youth/adults) http://seattleops.org REST (Real Escape from the Sex Trade: drop-in, case management, housing for adult survivors) https://iwantrest.com/
Seattle Against Slavery (training, demand reduction, outreach) http://www.seattleagainstslavery.org/ Seneca Family of Agencies (training and outreach) http://senecafoa.org/washington Ending Exploitation Collaborative http://www.endingexploitation.com/about-ending-exploitationcollaborative.html HEAL Trafficking https://healtrafficking.org/ Polaris Project https://polarisproject.org/ National Human Trafficking Training and Assistance Center https://www.acf.hhs.gov/otip/training/nhttac 1 IOM (Institute of Medicine) and NRC (National Research Council). 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, D.C.: The National Academies Press. 2 Law, P. (2000). Victims of trafficking and violence protection act of 2000. Public Law, 106, 386. 3 Boyer, D. (2008). Who Pays the Price?: Assessment of Youth Involvement in Prostitution in Seattle. The Firm. 4 Curtis, R., Terry, K., Dank, M., Dombrowski, K., Khan, B., Muslim, A.,... & Rempel, M. (2008). The commercial sexual exploitation of children in New York City. New York: Center for Court Innovation. 5 Rowe-Sepowitz, D. (2014). YES Project: Youth Experiences Survey: Exploring the sex trafficking experiences of Arizona s runaway and homeless young adults. Office of Sex Trafficking Intervention Research. http://www.trustaz.org/downloads/rr-stir-youth-experiences-surveyreport-nov-2014.pdf 6 Swander, R., et al., (2016). Youth Involvement in the Sex Trade: A National Study. Center for Court Innovation.
http://www.courtinnovation.org/sites/default/files/documents/youth%20involvement%20in% 20the%20Sex%20Trade_3.pdf 7 Child Sex Trafficking (2016). National Center for Missing and Exploited Children. http://www.missingkids.org/cst 8 Project Respect 2016 Statewide Participant Summary Information. The Center for Children & Youth Justice. Seattle, Washington. 9 Bridge, B. (ret.) Justice, Kimball, T., Oakley, N., & Briner, L. (2012). Washington State Model Protocol for Commercially Sexually Exploited Children. The Center for Children & Youth Justice. 10 Atkinson, H. G., Curnin, K. J., & Hanson, N. C. (2016). US state laws addressing human trafficking: education of and mandatory reporting by health care providers and other professionals. Journal of Human Trafficking, 2(2), 111-138. 11 Lederer, L. J., & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals Health L., 23, 61. 12 Greenbaum, J., Crawford-Jakubiak, J. E., & Committee on Child Abuse and Neglect. (2015). Child sex trafficking and commercial sexual exploitation: health care needs of victims.pediatrics, 135(3), 566-574. 13 National Research Council. (2013). Confronting commercial sexual exploitation and sex trafficking of minors in the United States. National Academies Press. 14 Greenbaum, J., Kellogg, N., & Reena, I. (2013). APSAC Practice Guidelines: The Commercial Sexual Exploitation of Children: The Medical Provider s Role in Identification, Assessment and Treatment. 15 Miller, J. D., Brown, C. M., Speights, J. B., Patel, P., & Kanani Titchen, M. D. (2014). Position Paper on the Sex Trafficking of Women and Girls in the United States May 2014. 16 Yates, G. L., MacKenzie, R. G., Pennbridge, J., & Swofford, A. (1991). A risk profile comparison of homeless youth involved in prostitution and homeless youth not involved. Journal of Adolescent Health, 12(7), 545-548. 17 Martin, L., Hearst, M. O., & Widome, R. (2010). Meaningful differences: Comparison of adult women who first traded sex as a juvenile versus as an adult. Violence against women, 16(11), 1252-1269.
18 Wilson, E. C., Garofalo, R., Harris, R. D., Herrick, A., Martinez, M., Martinez, J.,... & Adolescent Medicine Trials Network for HIV/AIDS Interventions. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS and Behavior, 13(5), 902-913.