Keywords

Child maltreatment, commercial sexual exploitation of children, human trafficking

 

Authors

  1. Hornor, Gail DNP, CPNP, AFN-BC

Abstract

ABSTRACT: Commercial sexual exploitation of children (CSEC) is the sexual abuse of children through buying, selling, or trading their sexual services. This may involve engaging a child under the age of 18 years in prostitution, pornography, stripping, exotic dancing, escort services, or other sexual services. CSEC is a problem of epidemic proportions throughout the world including the United States; however, the actual number of CSEC victims in the United States is unknown. Studies indicate that most child victims are seen by a healthcare provider while being trafficked and that many victims receive care at a pediatric hospital within 1 year of their identification as a victim. CSEC is a significant pediatric healthcare problem. It is vital that forensic nurses possess a thorough understanding of the problem and be poised to better identify, intervene, and prevent CSEC. In this article, we focus on risk factors commonly experienced by victims, recruitment strategies used by traffickers, indicators to identify child victims, and intervention and educational strategies of relevance to forensic nurses.

 

Article Content

Commercial sexual exploitation of children (CSEC) is defined as a range of crimes and activities involving the sexual abuse or exploitation of a child for the financial benefit of any person, or in exchange for anything of value given or received by any person (Office of Juvenile Justice & Delinquency Prevention, 2014). This may involve engaging a child under the age of 18 years in prostitution, pornography, stripping, escort services, or other sexual services. CSEC is a problem of epidemic proportions throughout the world including the United States. The United States is a major source, transit, and destination country for children engaged in CSEC, and children who are U.S. citizens as well as foreign nationals are at risk to be trafficked in the United States (U.S. Department of State, 2018). In fact, U.S. citizens are more likely to experience CSEC in the United States than are foreign nationals (Greenbaum, 2014). Precise numbers of CSEC victims in the United States are unknown; however, the Office of Juvenile Justice and Delinquency Prevention (2014) estimates that over 200,000 children in the United States are victims of CSEC each year and another 200,000-300,000 are at risk of being trafficked and sexually exploited because of their vulnerable status, including 1.6 million runaways. The average age of entry into CSEC is 12-14 years old for girls and 11-13 years old for boys (Kramer & Berg, 2003). Lederer and Wetzel (2014) reported that up to 88% of CSEC victims are seen by a healthcare provider while being trafficked, whereas 83% of victims received care at a pediatric hospital within 1 year of identification as a victim (Hornor & Sherfield, 2018). CSEC is a significant pediatric healthcare problem. It is vital that forensic nurses, especially those working with children, possess a thorough understanding of the problem and be poised to better identify, intervene, and prevent CSEC. In this article, we focus on risk factors commonly experienced by victims, recruitment strategies used by traffickers, indicators to identify child victims, and intervention and educational strategies of relevance to forensic nurses.

 

Risk Factors

Understanding risk factors for CSEC is critical to the development of prevention strategies. CSEC transcends all demographics; victims can be male, female, or transgender. All races are affected by CSEC. Choi (2015), in a literature review of domestic minor sex trafficking in the United States, concluded that race or ethnic minority did not appear to increase risk. The top five risk factors for trafficking identified by the Polaris Project (2017) include recent migration, substance misuse, homelessness/runaways, preexisting mental health concerns, and involvement with the child welfare system. Individual factors that place a child at increased vulnerability for entry into CSEC include those who have experienced multiple forms of child maltreatment, runaways, children with intellectual disabilities, those in foster care, and lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth (Institute of Medicine [IOM] & National Research Council, 2014). Recent studies have shown a strong correlation between child sexual abuse and commercial sexual exploitation (Cole, Sprang, Lee, & Cohen, 2016; Hornor & Sherfield, 2018). Greenbaum (2014) found that children who have experienced child sexual abuse are more than twice as likely as nonabused children to become involved in commercial sex later in life. Poly-maltreatment also appears to be a significant risk factor: experiencing sexual abuse as well as physical abuse, emotional abuse, or neglect. Children with trauma symptoms and/or substance misuse problems have been identified at an increased risk. Trauma symptoms and substance misuse are both risk factors for entry into CSEC, and substance misuse is also a response to being trafficked. Previous involvement with the criminal justice system also places youth at an increased risk for entry into CSEC (IOM & National Research Council, 2014). These youth may be reluctant to cooperate with law enforcement because of previous negative experiences and can be retraumatized by their interactions (Greenbaum, 2014).

 

The familial psychosocial risk factors that predispose an individual to experience child maltreatment also increase the risk for entry into trafficking. These familial factors include teenage parent, parental substance abuse, parental mental illness, interpersonal violence, previous involvement with child protective services or law enforcement, financial stressors, and lack of support systems (Hornor, 2015). Children from dysfunctional families or who are LGBTQ are at an increased risk to be rejected, to be ejected from, or to run away from home (Davies & Allen, 2017).

 

There are also societal factors that increase risk for children being sexually exploited. These include poverty and lack of resources within the community. Children with less supervision are more vulnerable to being sexually exploited through trafficking. Expectations for employment opportunities may impact both traffickers' and victims' willingness to become involved in CSEC. The sexualization of children in the media may also be a factor that places all children at risk, particularly girls (IOM & National Research Council, 2014).

 

Recruitment

Traffickers (pimps) typically seek out potential victims who are economically or socially vulnerable (Anthony, 2018; Greenbaum, Bodrick, Committee on Child Abuse and Neglect, & Section on International Child Health, 2017). The recruitment process may be quite prolonged or very abrupt. Recruitment may begin over the Internet or via face-to-face encounters and includes common social networking apps, dating Web sites, chat rooms, or online job listings. Specific groups such as LGBTQ youth or those speaking Spanish, Chinese, Korean, or other languages can be targeted (Anthony, 2018). Trafficking victims may be recruited by strangers or acquaintances, oftentimes older men or women, who lure youth with promises of housing, money, drugs, attention, acceptance, jobs, modeling/acting opportunities, or other desirables (Anthony, 2018; Greenbaum, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2015). In a review of 6,000 survivors of sex trafficking, the Polaris Project (2015) found that about a third of those trafficked were romantically involved with their trafficker. This style of recruiting is often referred to as finesse pimping (Hornor, 2015). The finesse trafficker uses a grooming process to manipulate the teen via kindness, gifts, and attention, thereby gaining the teen's trust, affection, and loyalty. Eventually, the teen is isolated from other supports, with obvious coercion and violence beginning relatively late in the relationship (Greenbaum, 2014).

 

Many American teens are recruited by their peers, often victims of CSEC themselves (Anthony, 2018; Greenbaum, 2014). They may be working for a trafficker and are rewarded for identifying and luring vulnerable teens into CSEC. The recruiting peer may be working by themselves or under the control of a trafficker. Both types of recruiting peers introduce vulnerable teens to using their bodies to obtain material possessions, while at the same time instigating psychological and material dependence (Anthony, 2018). The vulnerable teen is now a member of a peer group where exploitation is normalized (Greenbaum, 2014), and their social media use and contact with family and friends are tightly controlled (Anthony, 2018).

 

Recruitment involving violence, intimidation, threats, or aggression (Hornor, 2015) is also common. This type of recruitment is often called guerrilla pimping (Deshpande & Nour, 2013). The victim is conditioned to the life of sex trafficking by the use of starvation, confinement, beatings, rape, threats of violence to self or family members, and forced drug use (Hom & Woods, 2013). A relationship of coercive control is created. The conditioning is sporadic with the abusive acts interchanged with generous or kind acts, which result in a trauma bond where the victims are afraid of the trafficker yet grateful to the trafficker for allowing them to live. This psychological bond formed between victim and exploiter ensures compliance and complicates efforts to separate identified trafficking victims (Sahl & Knoepke, 2018).

 

Although homeless teens and those involved in the child welfare system are at an extreme risk for recruitment into CSEC (Greenbaum, 2014; Greenbaum et al., 2015), victims also report being recruited while living at home and attending school (Kotrla, 2010). Recruitment often occurs at public places such as malls, corner stores, sporting events, truck stops, and even outside juvenile justice centers (while waiting to meet a probation officer). Unfortunately, even family members such as mothers, fathers, or grandparents are known to sell their teens for sexual and other labor exploitation (Greenbaum et al., 2017; Hom & Woods, 2013).

 

Identification of Commercially Exploited Children

Knowledge of the indicators of CSEC may be the only way for a victim to be recognized and protected within the healthcare and welfare systems. Those who are victimized may not view themselves as victims, nor will they self-disclose for a variety of reasons. Their traffickers may have convinced them that they are responsible for their situation because of their own mistakes and choices and that they will be incarcerated if identified and/or rejected by their family or friends (Greeenbaum, 2016). Traffickers may also threaten physical harm to the victim or their loved ones upon disclosure (Anthony, 2018).

 

The relationship of CSEC victims with their traffickers is complex with combinations of random abuse coupled with displays of affection, described as trauma bonds (Chaffee & English, 2015). Trauma bonds are more likely if the victim perceives that the captor is capable of inflicting harm yet may be the only source of food and shelter. Screening for CSEC that is dependent on victim disclosure can be challenging and vague or unfocused (Hardy, Compton, & McPhatter, 2013; Kalergis, 2009). Trauma bonds may inhibit disclosure by victims or willingness to leave the trafficker. Thus, to self-disclose could be seen as a threat to physical safety and the provision of basic needs. In addition, youth who have had contact with child protection and juvenile justice systems may be reluctant to disclose exploitation to forensic nurses as mandated reporters (English, 2017).

 

Given the abusive and neglectful nature of CSEC, there are multiple healthcare occasions in which the forensic nurse might encounter victims including primary care pediatric practice, community-based adolescent clinics and urgent care, school-based health centers, sexual assault treatment centers, behavioral and substance abuse health services for youth, and emergency departments. It is incumbent that pediatric healthcare providers, especially the forensic nurse, assess and observe for indicators of CSEC. Unfortunately, the indicators are varied and imprecise and can be misidentified and attributed to mental health and behavioral disorders, chaotic family circumstances, and adolescent high-risk sexual behaviors. On the basis of a compilation of the literature (Clawson & Grace, 2007; Hassain, Zimmerman, Abas, Light, & Watts, 2010; Jimenez, Jackson, & Deye, 2015; Office of Refugee Resettlement, 2012; Varma, Gillespie, McCracken, & Greenbaum, 2015), we have enumerated some of the more focused indicators of CSEC and have summarized them in Table 1.

  
Table 1 - Click to enlarge in new windowTABLE 1 Indicators of Commercial Sexual Exploitation of Youth

Given forensic nurse knowledge of CSEC indicators, we must also consider the type and depth of screening questions used and the amount of time the provider can allot for the encounter as well as whether or not the provider has an ongoing relationship with the victim. Before interviewing a youth suspected of being engaged in commercial sexual exploitation, the forensic nurse should be familiar with specific laws governing adolescent confidential services, mandated reporting of maltreatment, and specifically trafficking in their particular state (Schapiro & Mejia, 2018). It is crucial to meet with the patient alone and to use an independent interpreter when language barriers exist. A general psychosocial screen, if time and context permit, such as the HEEADSSS Assessment, which addresses home, education/employment, eating, activities, drugs, sexuality, suicidal ideation, and safety (Klein, Goldering, & Adelman, 2014), can build rapport and help the forensic nurse understand the overall context of the adolescent's life.

 

Research on validated screening tools has been limited (Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States et al., 2013), although a number of organizations have published screening tools or lists of recommended questions in recent years (Basson et al., 2016; Chang, Lee, Park, Sy, & Quach, 2015; Greenbaum et al., 2015; Office of Refugee Resettlement, 2012) The West Coast Children's Clinic (2016) has an identification tool, The Commercial Sexual Exploitation Tool, designed for use in behavioral health that includes seven separate risk scales: housing and caregiving, prior abuse or trauma, physical health and appearance, environment and exposure, signs of current trauma, coercion, and exploitation.

 

The American Academy of Pediatrics (Greenbaum et al., 2015) recommends asking the following three questions when the healthcare provider is concerned of possible victimization:

 

* "Has anyone ever asked you to have sex in exchange for something you wanted or needed (money, food, shelter, or other items)?"

 

* "Has anyone ever asked you to have sex with another person?"

 

* "Has anyone ever taken sexual pictures of you or posted such pictures on the Internet?"

 

 

Jimenez et al. (2015) recommend using a strength-based approach to questioning adolescents who are runaways or living on the streets, that is, acknowledging the skills they have developed to survive, asking how they are earning money, and asking if they are under particular threats or have any protectors. The Urban Institute has incorporated youth in developing a six-question tool, the Human Trafficking Screening Tool-Short Form (Dank et al., 2017, p. 30), to identify both sexual and labor trafficking for use with homeless and runaway youth. Lessons learned from working with victims of intimate partner violence have been applied to CSEC, including universal screening, posters or flyers advertising confidential community-based resources in the clinic setting, and recognition that victims may disclose only after repeated encounters and screenings (Williamson, Dutch, & Clawson, 2009).

 

One primary care clinic with a largely Asian immigrant clientele started screening adolescents seeking reproductive health services who displayed additional CSEC risk factors, asking them whether they had traded sex or dates for money or other favors or were being asked to have sex with others (Chang et al., 2015). After a chart review showed underidentification of trafficked youth compared with community prevalence, the authors recommended universal rather than targeted screening. Other providers in the same community adapted and condensed this screen to one universal question: "Over the years, we've noticed that more and more youth have turned to the streets to make money for themselves or for other people. Have you ever, or do you trade sex or 'go on dates' for money, clothes, a place to stay, drugs or other favors?" (Mays, 2014, p. 273). Behavioral health clinicians recommend neutral explorations of indicators, including asking teens to tell them the story behind particular tattoos and piercings (Newby & McGuinness, 2012), as a way to gain understanding of the teen's context.

 

Trauma-Informed Care

It is crucial that forensic nurses incorporate an understanding of trauma-informed care when screening adolescents in an attempt to identify CSEC victimization. Trauma-informed care requires the healthcare provider to understand the victim's vulnerability to avoid retraumatization and to ensure that the victim is fully aware he or she is in control of the conversation and free to decide any information disclosed (Chung & English, 2015). Victims must also be aware of possible limits to confidentiality-that if they disclose information that reveals that the adolescent is unsafe or at risk, the forensic nurse may need to involve other agencies to ensure their safety. Trauma-informed care dictates that victims must be treated with respect and have all aspects of their care thoroughly explained and consent obtained and that care should be transparent and empowering to the individual. Identification of CSEC victims is further complicated by a lack of training and awareness among pediatric healthcare providers, including forensic nurses (Chisolm-Straker, Richardson, & Cossio, 2012). Additional factors confounding identification include a lack of time, competing clinical priorities, and the absence of protocols and tools to aid in identification (Chung & English, 2015).

 

Resources

The forensic nurse must be aware of available resources when identifying CSEC victims. The National Human Trafficking Hotline (1-888-3737-888) and the National Human Trafficking Resource Center (NHTRC) call specialists are experts in human trafficking who provide guidance with screening questions for patients and can speak with the patient directly. The NHTRC Web site (https://humantraffickinghotline.org/) provides a wealth of information about CSEC and all forms of human trafficking (NHTRC, 2018). All pediatric healthcare providers, including forensic nurses, are mandated reporters of child abuse and neglect. CSEC is a form of child sexual abuse, and healthcare providers must report suspected exploitation to law enforcement and child protective services.

 

Forensic nurses and other pediatric healthcare providers must recognize that there are safety concerns to consider when identifying potential victims of commercial sexual exploitation, for both the victim and healthcare workers. Discussions of concerns must be discreet and private and not subject to being overheard by potential traffickers or their confederates. It is important to ensure that adequate facility security support and/or local law enforcement is available immediately if needed.

 

Interventions

Providing care for victims of CSEC is complex because of the relative pervasive physical and emotional consequences. The U.S. Department of State (2018) groups health problems related to sex trafficking into six categories: infectious disease, noninfectious disease, reproductive health problems, substance abuse, mental health problems, and violence. As previously discussed, it is of utmost importance that the forensic nurse recognize the indicators of CSEC in their patient population. Commonly, victims of CSEC present to a healthcare setting with an acute injury that is related to the violent nature of their role (American Professional Society on the Abuse of Children [APSAC], 2017).

 

Conducting a thorough history is paramount to obtaining medically relevant information but also provides an opportunity for the forensic nurse to establish rapport with the victims. It is key that the forensic nurse obtain information regarding the child's overall health and safety in addition to assessing for and treating the presenting health concern. Comprehensive information is gathered by the multidisciplinary team of interviewers, investigators, law enforcement officers, and mental health professionals. Yet, the forensic nurse plays a unique role in documenting current health concerns as well as the adverse physical and emotional effects of commercial sexual exploitation of the child victim (APSAC, 2017).

 

The physical examination should be completed slowly, carefully, and respectfully, with the focus of the examination dictated by the acuity of the presenting complaint. If possible, the forensic nurse should attempt to conduct the examination without the presence of the suspected trafficker. If the patient is medically stable, a comprehensive examination should include a thorough inspection for inflicted physical and sexual injury, forensic evidence collection, and testing for sexually transmitted infections (STIs), signs of forcible restraint, self-injury, drug use, malnutrition, and other signs of neglect including untreated chronic conditions (APSAC, 2017). The collection of forensic evidence requires the skills of a trained nurse or physician, preferably a sexual assault nurse examiner, to ensure compliance with legal protocols. Universally, any suspected victim of commercial sexual exploitation should be tested for gonorrhea, chlamydia, trichomonas, syphilis, HIV, and Hepatitis B, C, and D (APSAC, 2017). Varma et al. (2015) found that most victims of sexual exploitation had higher-than-average rates of STIs, physical abuse, history of sexual violence, drug/alcohol use, and a history of prior involvement with child protective services and/or law enforcement. Less commonly, they may present with exacerbations of chronic, poorly controlled diseases, such as asthma, drug intoxication and/or withdrawal, and reproductive issues such as pregnancy, urinary tract infections, and vaginal or rectal trauma.

 

Often, victims have transient living conditions and are less likely to be adherent with follow-up care for their medical concerns. Therefore, it is generally recommended that prophylaxis for pregnancy and common STIs, following the Centers for Disease Control and Prevention (CDC) guidelines, be provided at the point of care (Workowski, Berman, & Centers for Disease Control and Prevention, 2010). Consideration should also be given to encourage HIV postexposure prophylaxis in high-risk populations, including victims of acute sexual assault. It is important to discuss the risks and benefits of the medication regimen of these drugs, with emphasis being on strict adherence to the dosing schedule and periodic follow-up and laboratory monitoring. Recognizing the need to reduce the risk of HIV transmission in this population, the CDC also recommends offering HIV preexposure prophylaxis. Current research indicates that daily use of preexposure prophylaxis reduces the risk of HIV transmission by more than 90% (CDC, 2018). Long-acting reversible contraception such as intrauterine devices and Nexplanon should be offered to high-risk youth for pregnancy prevention.

 

Basic needs must be met before the victim can begin to heal. It is important for forensic nurses to be aware of local resources available to CSEC victims. Caring for these patients requires a multidisciplinary and interprofessional approach. Any assessment of the CSEC victim must also evaluate their basic needs such as food, shelter, clothing, income, and safety/protection from the trafficker. Clawson, Dutch, and Williamson (2008a) recommend a complete psychiatric evaluation to identify preexisting mental health issues and to tailor a comprehensive long-term plan of care for these victims. Evidence-based mental health treatment including trauma-informed care is crucial for victims of sex trafficking (Clawson, Salomon, & Grace, 2008). Trauma-informed treatment is guided by the provider's understanding of the trauma-related issues that victims are exposed to and how trauma impacts behavior and ability to adhere to treatment (Clawson, Dutch, & Williamson, 2008b). Trauma-focused cognitive behavioral therapy has the highest degree of empirical support of any treatment model and is geared specifically for traumatized youth (National Center for Trauma-Informed Care, 2014). Treatment must also include education regarding basic life skills, job training, and employment. The psychological consequences of human trafficking require long-term and comprehensive therapy. In addition, victims may have preexisting mental health diagnoses that can further complicate needed intervention.

 

Prevention of CSEC

The prevention of CSEC requires a multitiered approach (see Table 2). Forensic nurses can play a vital role in primary, secondary, and tertiary prevention of CSEC in America.

  
Table 2 - Click to enlarge in new windowTABLE 2 Interventions to Prevent the Commercial Sexual Exploitation of Children

Primary Prevention

Forensic nurses must be advocates for inclusion of appropriate prevention strategies. At the primary prevention level, prevention of CSEC should begin at the first newborn healthcare visit and continue with every subsequent primary care encounter. A crucial component is the education of parents in strategies for positive parenting including the importance of having developmentally appropriate expectations of children, encouraging nonphysical methods of discipline, stressing the importance of praise, and the encouragement of open, respectful communication (Seay, Freysteinson, & McFarlane, 2014). O'Brien (2018) found that positive parental relationships are protective against sexual exploitation. Forensic nurses can access the CDC (2014) to obtain positive parenting handouts for various age groups that incorporate anticipatory guidance for safety, education, development, and the establishment of caring relationships between parents and their children.

 

Secondary Prevention

Forensic nurses can play a vital role in the prevention of CSEC at the secondary level. Universal screening of pediatric patients for psychosocial trauma exposure (child maltreatment, separation from parents, witness to domestic violence, unsafe environments, parental substance abuse, parental mental health concerns, etc.) is crucial. If screening reveals a concern for suspected child maltreatment, a report to child protective services is indicated. When psychosocial traumas are identified, children and families must be linked with appropriate interventions and adherence must be monitored. Trauma-exposed children and teens should be screened for CSEC. Children and teens who have been trauma exposed, but are not yet CSEC victims, require referral for trauma-informed care (Choi, 2015; Greenbaum, 2016; Hornor & Sherfield, 2018; Kassam-Adams et al., 2015). Optimally, for children/teens to heal from trauma exposure, it is vital to eliminate or at least greatly reduce their exposure to trauma (Berliner & Kolko, 2016). However, trauma-informed mental health care can serve as a support to a child for whom total elimination of trauma exposure is not possible. Greenbaum (2014) found that stabilization of a child's or adolescent's mental health status via appropriate focused interventions can aid in the prevention of entry into CSEC.

 

Tertiary Prevention

At the tertiary level of prevention, forensic nurses can call upon their community-based human trafficking task force, a multidisciplinary team including law enforcement, child protection, and mental health workers, to allow for more prompt identification of CSEC victims. The human trafficking task force often includes an agency to provide outpatient case management services including linkages with appropriate mental health therapy and placement in safe environments. Youth with four or more individual risk factors (see Table 3) need a specialized approach and response from pediatric health care, which includes linkage to case management (Covenant House, 2013). Forensic nurses can facilitate this linkage. This very specialized case management can be invaluable in preventing entry into CSEC or rescuing youth from continuing in CSEC. Forensic nurses can create a protocol for distribution of children and teens who have gone missing throughout their institution so that missing youth can be identified upon presentation for health care. Optimally, the forensic nurse may involve a pediatric mental health professional who is prepared to meet with the youth/family to establish rapport, gather additional psychosocial information, provide trauma-informed interventions, and engage a monitoring system that enhances treatment adherence. The high risk for CSEC status must be recorded in the child's healthcare record in a clearly visible manner for all providers.

  
Table 3 - Click to enlarge in new windowTABLE 3 Commercial Sexual Exploitation of Children High-Risk Indicators

Educational Strategies

Educating Children and Parents

There are many barriers to protecting children from becoming victimized by adults seeking to exploit them. CSEC prevention has relied largely on child-focused education, specifically teaching children how to identify, avoid, and disclose sexual victimization (Mendelson & Letourneau, 2015). There have been specific CSEC prevention programs that are designed to identify at-risk adolescents and help them make better decisions at the individual level. One such pilot program, the iSeeMe Society, uses a curriculum that engages adults in the community to empower youth to make better life decisions based on the man or woman they hope to become (Taylor, 2017). Through partnerships with two community organizations in Atlanta, Georgia, a series of in-person workshops led by three adult leaders were offered to at-risk youth. The goals of the program are threefold: to provide inspiring and thought-provoking experiences; to provide information and resources for choices in the areas of scholastic achievement, community service, and healthy habits; and also to improve time and money management. The program supports the development of peer-to-peer mentoring groups designed for support after the workshop series ends (Taylor, 2017). Taylor (2017) reported that participants experienced an increase in both the perceived and actual use of the positive decision-making skills. These results have increased interest to broaden the applications in the prevention of CSEC and are gaining traction within the international community (Taylor, 2017).

 

Parents play a crucial role as a protector of their children via two pathways: directly by strengthening external barriers, or gatekeeping through supervision, involvement, and communication, and indirectly by promoting their child's competence, well-being, and self-esteem (Rudolph, Zimmere-Gembeck, Shanley, & Hawkins, 2018). There is an extensive body of knowledge that suggests that involved, caring, and communicative parenting and strong familial relationships may decrease the likelihood that a child becomes a target for CSEC. Parents need to pay attention to what their children are doing online. Some red flags that may indicate a child may be in danger include showing obsessive and secretive behaviors about being online, showing signs of anger when not allowed to be online, or getting phone calls, messages, and/or gifts from a stranger. Parents and forensic nurses can directly ask the child if a stranger has tried to befriend him or her online, asked for personal information, asked for pictures, talked about sex, or texted anything to make him or her feel uncomfortable. Enough-Is-Enough is an Internet safety program for children and families that provides information for parents on how to protect their children from online predators ("Internet Safety 101," 2018). Finally, wide dissemination of CSEC information can enact a change in parental behavior through the use of mass media campaigns and public service announcements along with school-based information that can reach a large number of parents (Sanders, Montgomery, & Brechman-Toussaint, 2000).

 

Educating Pediatric Healthcare Professionals

Children and adolescents who are subjected to sex trafficking are often seen by pediatric healthcare providers for physical and mental health problems; however, pediatric healthcare providers often lack knowledge and information regarding the nature and scope of human trafficking (Grace et al., 2014). There must be universal education of all forensic nurses regarding human trafficking and CSEC. As potential first responders, forensic nurses need to be fully educated on the risk factors, recruitment practices, and identification of and interventions for CSEC victims. Forensic nurses must recognize that victims can present in different healthcare facilities such as emergency departments, outpatient clinics, urgent care settings, and family planning clinics. They may be seeking medical attention for infections (STIs), complications of substance use, pregnancy testing, contraceptive care, sexual assault, and physical injury (Lederer & Wetzel, 2014). Forensic nurses also recognize that the identification of victims requires education of all members of the pediatric healthcare team.

 

Implications for Forensic Nurses

Forensic nurses can play a vital role in addressing CSEC; they provide a vital resource to healthcare systems and contribute to the delivery of crucial CSEC education. Supporting programs and public policy that aim to eradicate poverty and increase economic opportunities for families and teens is crucial to the elimination of CSEC. By increasing personal awareness of and educating other pediatric healthcare providers regarding human trafficking and CSEC, forensic nurses can make a huge impact on the health of some of the most vulnerable children in our society. As patient advocates for children and their caretakers, it is essential that forensic nurses become familiar with community resources and services available to victims of CSEC. Forensic nurses often play fundamental roles as members of community and statewide human trafficking task forces. In addition, forensic nurses are compelled to become directly involved in community campaigns against all types of exploitation of children and to increase public knowledge of this important topic. Rachel Lloyd (2017), a prominent CSEC advocate, writes:

 

We can significantly decrease the commercial sexual exploitation and trafficking of girls and young women, but it will not come through salacious news coverage, huge stings or rescue-focused work, but through the infinitely less sensational work of building resilience in the lives of vulnerable children, creating resources and support for under-served communities and ultimately addressing the inequities that girls and young women face. (p.3)

 

References

 

American Professional Society on the Abuse of Children. (2017). APSAC practice guidelines. Retrieved from https://www.apsac.org/single-post/2017/12/05/APSAC-Practice-Guidelines-Now-Free[Context Link]

 

Anthony B. (2018). On-ramps, intersections and exit routes: a Roadmap for systems and industries to prevent and disrupt human trafficking. Washington, DC: Polaris. Retrieved from https://polarisproject.org/human-trafficking-and-social-media[Context Link]

 

Basson D., Fernando A. D., Geltman E., Haley H., Langs J., Ritter L., & Rosenblatt E. (2016). Identifying commercially sexually exploited children. Oakland, CA: West Coast Children's Clinic. Retrieved from http://www.westcoastcc.org/wp-content/uploads/2016/09/CSE-IT2.0user-manual_9.15.[Context Link]

 

Berliner L., & Kolko D. J. (2016). Trauma informed care: A commentary and critique. Child Maltreatment, 21(2), 168-172. doi:10.1177/1077559516643785 [Context Link]

 

Centers for Disease Control and Prevention. (2014). Positive parenting tips. Retrieved from https://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/index.html[Context Link]

 

Centers for Disease Control and Prevention. (2018). HIV pre-exposure prophylaxis. Retrieved from https://www.cdc.gov/hiv/basics/prep.html[Context Link]

 

Chaffee T., & English A. (2015). Sex trafficking of adolescents and young adults in the United States: Healthcare provider's role. Current Opinion in Obstetrics & Gynecology, 27(5), 339-344. doi:10.1097/GCO.0000000000000198 [Context Link]

 

Chang K. S. G., Lee K., Park T., Sy E., & Quach T. (2015). Using a clinic-based screening tool for primary care providers to identify commercially sexually exploited children. Journal of Applied Research on Children: Informing Policy for Children at Risk, 6(1), 15. Retrieved from http://digitalcommons.library.tmc.edu/childrenatrisk/vol6/iss1/6/[Context Link]

 

Chisolm-Straker M., Richardson L. D., & Cossio T. (2012). Combating slavery in the 21st century: The role of emergency medicine. Journal of Healthcare Poor Underserved, 23(3), 980-987. [Context Link]

 

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 [Context Link]

 

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 [Context Link]

 

Clawson H., Dutch N., & Williamson E. (2008b). National symposium of the health needs of human trafficking: Background document. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. [Context Link]

 

Clawson H., & Grace L. (2007). Finding a path to recovery: Residential facilities for minor victims of domestic sex trafficking. Washington, DC: U.S. Department of Health and Human Services. [Context Link]

 

Clawson H., Salomon A., & Grace L. (2008). Treating the hidden wounds; trauma treatment and mental health recovery for victims of human trafficking. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. [Context Link]

 

Clawson H. J., Dutch N., & Williamson E. (2008a). Evidence-based mental health treatment for victims of human trafficking. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. [Context Link]

 

Cole J., Sprang G., Lee R., & Cohen J. (2016). The trauma of commercial sexual exploitation of youth: A comparison of CSE victims to sexual abuse victims in a clinical sample. Journal of Interpersonal Violence, 31(1), 122-146. doi:10.1177/0886260514555133 [Context Link]

 

Clayton E. W., Krugman R. D., & Simon P.Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States, Board on Children Youth and Families, Committee on Law and Justice (2013). Confronting commercial sexual exploitation and sex trafficking of minors in the United States. In Press T. N. A. (Series Ed.) Institute of Medicine (Ed.). Retrieved from http://www.nap.edu/catalog.php?record_id=18358[Context Link]

 

Covenant House. (2013). Homelessness, survival sex, and human trafficking: As experienced by the youth of Covenant House New York. Retrieved from https://humantraffickinghotline.org/sites/default/files/Homelessness%2C%20Surviv[Context Link]

 

Dank M., Yahner J., Yu L., Vasquez-Noriega C., Gelatt J., & Pergamit M. (2017). Pretesting a human trafficking screening tool in the child welfare and runaway and homeless youth systems. Washington, DC. Retrieved from https://aspe.hhs.gov/system/files/pdf/257786/Pretesting.pdf[Context Link]

 

Davies B. R., & Allen N. B. (2017). Trauma and homelessness in youth: Psychopathology and intervention. Clinical Psychology Review, 54, 17-28. http://dx.doi.org/10.1016/j.cpr.2017.03.005[Context Link]

 

Deshpande N., & Nour N. (2013). Sex trafficking of women and girls. Reviews in Obstetrics & Gynecology, 6(1), e22-e27. [Context Link]

 

English A. (2017). Mandatory reporting of human trafficking: Potential benefits and risks of harm. AMA Journal of Ethics, 19(1), 54-62. doi:10.1001/journalofethics.2017.19.1.pfor1-1701 [Context Link]

 

Grace A. M., Lippert S., Collins K., Pineda N., Tolani A., Walker R., [horizontal ellipsis] Horwitz S. M. (2014). Educating health care professionals on human trafficking. Pediatric Emergency Care, 30(12), 856-861. doi:10.1097/PEC.0000000000000287 [Context Link]

 

Greenbaum J. (2016). Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine, 17(4), 241-248. [Context Link]

 

Greenbaum J., Bodrick N.[horizontal ellipsis] Committee on Child Abuse and Neglect Section on International Child Health (2017). Global human trafficking and child victimization. Pediatrics, 140(6), pii: E20173138. doi:10.1542/peds.2017-3138. [Context Link]

 

Greenbaum J., Crawford-Jakubiak J. E.[horizontal ellipsis] Committee on Child Abuse and Neglect (2015). Child sex trafficking and commercial sexual exploitation: Health care needs of victims. Pediatrics. 135(3), 566-574. doi:10.1542/peds.2014-4138 [Context Link]

 

Greenbaum V. J. (2014). Commercial sexual exploitation and sex trafficking of children in the United States. Current Problems in Pediatric Adolescent Health Care, 44(9), 245-269. doi:10.1016/j.cppeds.2014.07.001 [Context Link]

 

Hardy V., Compton K., [horizontal ellipsis] McPhatter V. (2013). Domestic minor sex trafficking: Practice implications for mental health professionals. Journal of Women and Social Work, 28, 8-18. [Context Link]

 

Hassain M., Zimmerman C., Abas M., Light M., [horizontal ellipsis] Watts C. (2010). The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American Journal of Public Health, 100(12), 2442-2449. doi:10.2105/AJPH.2009.173229 [Context Link]

 

Hom K. A., [horizontal ellipsis] Woods S. J. (2013). Trauma and its aftermath for commercially sexually exploited women as told by front-line service providers. Issues in Mental Health Nursing, 34(2), 75-81. doi:10.3109/01612840.2012.723300 [Context Link]

 

Hornor G. (2015). Domestic minor sex trafficking: What the PNP needs to know. Journal of Pediatric Health Care, 29(1), 88-94. doi:10.1016/j.pedhc.2014.08.016 [Context Link]

 

Hornor G., [horizontal ellipsis] Sherfield J. (2018). Commercialized sexual exploitation of children: Healthcare utilization and case characteristics. Journal of Pediatric Health Care, 32(3), 250-262. doi:10.1016/j.pedhc.2017.11.004 [Context Link]

 

Institute of Medicine & National Research Council (2014). Confronting commercial sexual exploitation and sex trafficking of minors in the United States: A guide for the legal sector. Washington DC: National Academies Press. [Context Link]

 

Internet Safety 101. (2018). Retrieved from https://internetsafety101.org/trafficking[Context Link]

 

Jimenez M., Jackson A. M., [horizontal ellipsis] Deye K. (2015). Aspects of abuse: Commercial sexual exploitation of children. Current Problems in Pediatric Adolescent Health Care, 45(3), 80-85. doi:10.1016/j.cppeds.2015.02.003 [Context Link]

 

Kalergis K. (2009). A passionate practice. Journal of Women and Social Work, 24, 313-324. [Context Link]

 

Kassam-Adams N., Rzucidlo S., Campbell M., Good G., Bonifacio E., Slouf K., [horizontal ellipsis] Grather D. (2015). Nurses' views and current practice of trauma-informed pediatric nursing care. Journal of Pediatric Nursing, 30(3), 478-484. doi:10.1016/j.pedn.2014.11.008 [Context Link]

 

Klein D., Goldering J., [horizontal ellipsis] Adelman W. (2014). HEEADSSS 3.0: The psychosocial interview for adolescents updated for a new century fueled by the media. Contemporary Pediatrics, 4, 1-16. [Context Link]

 

Kotrla K. (2010). Domestic minor sex trafficking in the United States. Social Work, 55(2), 181-187. [Context Link]

 

Kramer L., [horizontal ellipsis] Berg E. (2003). A survival analysis of timing of entry into prostitution: The differential impact of race, educational level, and childhood/adolescent risk factors. Sociological Inquiry, 73, 511. [Context Link]

 

Lederer L., [horizontal ellipsis] Wetzel C. (2014). The health consequences of sex trafficking & their potential implications for identifying victims in healthcare facilities. Annuals Health Law, 23(91), 61-91. [Context Link]

 

Lloyd R. (2017). A world for girls. The Huffington Post. Retrieved from https://www.huffpost.com/entry/a-world-for-girls_b_3947673[Context Link]

 

Mays G. P. (2014). Untangling desirable and undesirable variation in public health practice: Accreditation and research working together. Journal of Public Health Management Practice, 20(1), 149-151. doi:10.1097/PHH.0000000000000035 [Context Link]

 

Mendelson T., [horizontal ellipsis] Letourneau E. J. (2015). Parent-focused prevention of child sexual abuse. Prevention Science, 16(6), 844-852. doi:10.1007/s11121-015-0553-z [Context Link]

 

National Center for Trauma-Informed Care. (2014). Screening and referral in integrated health systems. Retrieved from https://www.samhsa.gov/health-care-health-systems-integration/screening-referral[Context Link]

 

National Human Trafficking Resource Center. (2018). National human trafficking resource center training. Retrieved from https://humantraffickinghotline.org/nhtrc-hhs-online-trainings[Context Link]

 

Newby A., [horizontal ellipsis] McGuinness T. M. (2012). Human trafficking: What psychiatric nurses should know to help children and adolescents. Journal of Psychosocial Nursing and Mental Health Services, 50(4), 21-24. doi:10.3928/02793695-20120307-03 [Context Link]

 

O'Brien J. E. (2018). "Sometimes, Somebody Just Needs Somebody-Anybody-to Care": The power of interpersonal relationships in the lives of domestic minor sex trafficking survivors. Child Abuse & Neglect, 81, 1-11. doi:10.1016/j.chiabu.2018.04.010 [Context Link]

 

Office of Juvenile Justice and Delinquency Prevention. (2014). Commercial sexual exploitation of children/sex trafficking. Retrieved from https://www.ojjdp.gov/mpg/litreviews/CSECSexTrafficking.pdf[Context Link]

 

Office of Refugee Resettlement (2012). Rescue & Restore Campaign tool kit. Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.acf.hhs.gov/programs/orr/resource/rescue-restore-campaign-tool-kits. [Context Link]

 

Polaris Project. (2015). Sex trafficking in the United States: A closer look at U.S. citizen victims. Retrieved from http://polarisproject.org/resources/sex-trafficing-us-closer-look-us-citizen-vic[Context Link]

 

Polaris Project. (2017). 2017 Hotline statistics. Retrieved from http://polarisproject.org/2017statistics[Context Link]

 

Rudolph J., Zimmere-Gembeck M. J., Shanley D. C., [horizontal ellipsis] Hawkins R. (2018). Child sexual abuse prevention opportunities: Parenting, programs and the reduction of risk. Child Maltreatment, 23(1), 96-106. doi:10.1177/1077559517729479 [Context Link]

 

Sahl S., [horizontal ellipsis] Knoepke C. (2018). Using shared decision making to empower sexually exploited youth. Journal of the American Academy of Child & Adolescent Psychiatry, 57(11), 809-812. doi:10.1016/j.jac.2018.07.873 [Context Link]

 

Sanders M. R., Montgomery D. T., [horizontal ellipsis] Brechman-Toussaint M. L. (2000). The mass media and the prevention of child behavior problems: The evaluation of a television series to promote positive outcomes for parents and their children. Journal of Child Psychology and Psychiatry, 41(7), 939-948. [Context Link]

 

Schapiro N. A., [horizontal ellipsis] Mejia J. (2018). Adolescent confidentiality and women's health: History, rationale, and current threats. Nursing Clinics of North America, 53(2), 145-156. doi:10.1016/j.cnur.2018.01.002 [Context Link]

 

Seay A., Freysteinson W. M., [horizontal ellipsis] McFarlane J. (2014). Positive parenting. Nursing Forum, 49(3), 200-208. doi:10.1111/nuf.12093 [Context Link]

 

Taylor K. C. (2017). Teaching decision-making and building resilience in youth-A case study to reduce the supply of vulnerable youth to sex traffickers in Atlanta, Georgia. European Journal of Operational Research, 268(3), 960-970. [Context Link]

 

U.S. Department of State. (2018). Trafficking in persons report 2018. Retrieved from https://www.state.gov/documents/organization/282798.pdf[Context Link]

 

Varma S., Gillespie S., McCracken C., [horizontal ellipsis] Greenbaum V. J. (2015). Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse & Neglect, 44, 98-105. doi:10.1016/j.chiabu.2015.04.004 [Context Link]

 

West Coast Children's Clinic. (2016). Commercial sexual exploitation identification tool. Retrieved from http://www.westcoastcc.org/wp-content/uploads/2016/09/CSE-IT2.0user-manual_9.15.[Context Link]

 

Williamson E., Dutch N. M., [horizontal ellipsis] Clawson H. J. (2009). Medical treatment of sexual assault and domestic violence and its applicability to victims of human trafficking. Retrieved from https://aspe.hhs.gov/system/files/pdf/76121/index.pdf[Context Link]

 

Workowski K., [horizontal ellipsis] Berman S.Centers for Disease Control and Prevention (2010). Sexually transmitted disease treatment guidelines. MMWR Recommendations and Reports, 59(RR-12), 1-110. [Context Link]