View Dr. Greenbaum`s PowerPoint presentation.

Child Sex Trafficking and Commercial
Sexual Exploitation: A Multidisciplinary
Approach
Jordan Greenbaum, MD
Stephanie V. Blank Center for Safe and Healthy Children
Children’s Healthcare of Atlanta
Children’s Healthcare of Atlanta
1
Objectives
• Describe the nature of child sex
trafficking/exploitation in the U.S.,
and common physical and emotional
consequences
• Recall possible indicators of CSEC
• Recall the advantages of a traumainformed, multidisciplinary approach
to CSEC
PolarisProject.com
2
A word about words….
3
What is Human Trafficking?
Action
Means
Purpose
Recruits
Harbors
Entices
Transports
Provides
Obtains or
maintains a
person
OR
[patronizes
/solicits sex]
Force
OR
Fraud
OR
Coercion
Involuntary servitude
OR
Debt Bondage
OR
Slavery
OR
Sexual exploitation
4
TVPA, 2000; Justice for Victims Trafficking Act, 2015
Sex Trafficking of a Minor
Action
Means
Purpose
Recruits
Harbors
Entices
Transports
Provides
Obtains or
maintains a
person
OR
[patronizes
/solicits sex]
Force
OR
Fraud
OR
Coercion
Involuntary servitude
OR
Debt Bondage
OR
Slavery
OR
Sexual exploitation
5
TVPA, 2000; Justice for Victims Trafficking Act, 2015
Commercial Sexual Exploitation of
Children (CSEC)
• Occurs when a person induces a minor to engage
in a sex act in exchange for remuneration in the
form of money, food, shelter or other valued
entity.
– Survival sex
– Trafficking child for commercial sex act (on account of which
anything of value is given to or received by any person)
– Sexual exploitation material (Pornography)
– Exploitation in travel and tourism
– Use of child in sexually oriented business
• Does NOT require force, coercion, violence, etc
Trafficking in the U.S.
• No reliable estimates of prevalence/incidence
• Majority of identified child sex trafficking victims
are domestic
• Very little information on child labor trafficking
7
Trafficking Examples
• 11 yo boy from a small village near Villa Nueva. He and
his mother arrange to be smuggled into the US to escape
gang violence in Guatemala. They are separated en route
and the boy is approached by a man offering to help.
• 15 yo transgender youth runs away from home to escape
mother’s drug addiction and violent BF. After 5 days she is
hungry, cold and without resources…
• 13 you girl argues with her mother and leaves home. She
meets 2 men who offer her a ride and take her to an
abandoned house where they have sex…
8
Youth at Higher Risk for CSEC/CST
Child welfare involvement
Truancy, school problems
Poverty
Abuse/Neglect
Family Dysfunction
Runaway/Throwaway
Mental health problems
Drug/Alcohol abuse
Gang involvement
Parent with substance abuse
Adult prostitution in home
LGBTQ status
Community violence, upheaval
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STI, HIV, infertility
Physical and Sexual Violence
Substance abuse
Pregnancy/
abortion
Depression/
Suicidality
So, how will I know a victim
when I see one?
11
Challenges to Victim Identification
• Victims don’t self-identify
• Reluctant to disclose
• Few clinically validated quick screening tools and
these are cumbersome
12
Think about risk factors…
Child welfare involvement
Truancy, school problems
Poverty
Abuse/Neglect
Family Dysfunction
Runaway/Throwaway
Mental health problems
Drug/Alcohol abuse
Gang involvement
Parent with substance abuse
Adult prostitution in home
LGBTQ status
Community violence, upheaval
13
Possible Indicators of Trafficking: First
Impressions
• Youth appears afraid of adult, or overly
submissive, anxious
• Youth gives false or inconsistent information,
Youth cannot describe where she/he is staying,
doesn’t know city
• Girl with much older man
14
15
Possible Indicators of Trafficking
• Consider adverse health effects of trafficking….
 Multiple sexually transmitted infections
 Pregnancies, abortions, or miscarriages
 Illicit drug use
 Suicide attempt
 Current or past history of:
• Sexual assault
• Inflicted Injury
• Visible signs of physical abuse
16
What do you say to a potential victim?
How do you act?
17
Exploitation/Trafficking causes traumatic
stress.
Traumatic stress: the physical and
emotional responses to a traumatic
event.
Trauma affects behavior,
beliefs, attitudes
18
What is a “Trauma-Informed
Approach”?
• Has a basic knowledge of trauma and its impact
• Understands trauma triggers and the need to minimize retraumatization
• Supports emotional safety for victims, family and staff
• Empowers victims to manage feelings; give input on
program/services
• Builds resilience in victim, caregiver
• Provides information about trauma to victims and
caregivers
Zimmerman & Borland 2009
SAMHSA 2014
SOAR TWG Meeting 2014
19
NCTSN
Potential Signs of Traumatic Stress
• Physical
– Nightmares, sleep problems
– Altered appetite, eating patterns
– Chronic pain complaints
• Emotional
–
–
–
–
PTSD
Depression, withdrawal
Anxiety/panic
Dissociation, numbness
Potential Signs of Traumatic Stress
• Behavioral
–
–
–
–
–
–
–
Hyperarousal
Aggression, antisocial behavior
Hypervigilance
Lack of control of mood, behavior
Misinterpretation of others’ intentions
Distrust of others
Difficulty with authority, criticism
Trauma-Informed Approach
• Ensure safety
• Treat youth with respect
– Explain what you want to do
– Ask permission
– Review limits of confidentiality early on
– Survivor, not offender
22
Trauma-Informed Approach
• Sensitivity to victim’s reactions and to
possible stress
• Allow victim control when feasible
• Offer resources
• Have trained interpreter
23
What questions should I ask?
24
Keep in mind….
• Only seek information that you need to know
• What is my role?
• “Why am I asking this question?”
– To assess physical and emotional health?
– To assess safety at home?
– To determine appropriate services and
referrals?
– To provide important information to the child?
– To investigate a crime?
Types of Questions
Openended
Leading
Specific/
Direct
Suggestive
Multiple
Choice
Yes/No
What type of question is this?
“How many
times did it
happen?”
“Were you in the
motel, the
apartment or
somewhere else?”
“Are you hurting
anywhere now?”
“Tell me all
about …..”
“Didn’t you try
to leave?”
“What did he
say after he
was done?”
Youth only reports
having sex with a
man. You say,
“How much did he
pay you?”
“So, then what
happened?”
More Tips
•
•
•
•
•
A little silence can be good
Listen respectfully
Be open, nonjudgmental
Clarify terms
Avoid interrupting
Suppose you think the child in front of you
is a victim of sex trafficking….What now?
29
Reports and Referrals
• Know the mandated reporter laws in your state
– Report to Law Enforcement
– Child Protective Services
• Emphasize victim status
30
Reports and Referrals
• National Human Trafficking Resource Center
Hotline
 (1-888-3737-888)
• U.S. Immigration and Customs Enforcement
 (1-866-872-4973)
31
Complex Needs of Victims
•
•
•
•
•
•
•
Housing, food, clothing, etc.
Emotional support
Legal advocacy (immigration issues, T visa…)
School enrollment
Life skills and job training
Family services, potential reunification
Transition services
• Multidisciplinary approach!!!
32
Health-Related Needs
Child Advocacy Center
or SANE exam: ASAP
Behavioral health assessment
and treatment: ASAP
Substance abuse assessment
and rehab
Primary care provider
STI testing
Family planning
HPV vaccine
Anticipatory guidance
Immunizations
?Human trafficking clinic?
OB/GYN care
33
34
Advantages to Multidisciplinary Work
• Efficient
• Pro’s do what they are good at
• Minimize re-trauma to child
• Better outcomes
35
Challenges to Multidisciplinary Work
• Lots of cooks
– Confusion over responsibilities
• Need to communicate (HIPPA, other problems)
• Different goals
– But can agree on victim-centered approach
• Players change over time
36
What happens to victims after
discovery?
• Many return to exploitation
• Trafficker may make contact, apply
pressure
• Trafficking life perceived as
preferable
• ‘Perks’, sense of belonging,
• May feel that is only skill they
have
• Home is worse
37
• Trauma bonds & the
cycle of violence
38
High Risk of Re-trafficking…
• Resources
–
–
–
–
–
–
–
–
–
–
Anticipatory guidance (harm reduction)
LGBTQ
Homeless shelters
National Human Trafficking Center hotline
• 888-3737-888
Crisis hotlines
Teen clinics
Mental health services
Drug rehab
Reproductive health
Food pantries
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Case 1:
You are a law enforcement officer. You pull over a
car with a broken headlight and find an older male
driver and a younger teen passenger. The girl does
not look at you and appears nervous. The man
provides minimal information to your questions and
keeps staring hard at the child.
What, if anything, do you do?
40
Case 2:
• 14 yo male is in your office. While you talk to him
you discover he is gay and having many
problems with discrimination and rejection by
parents and peers. He ‘meets’ men online and
arranges to have dates with them. He has had
sex with many men but denies any exchange of
money or other valuables. He reports the sex is
‘consensual’.
• What do you say? What do you do?
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My contact info:
Jordan Greenbaum, MD
jordan.greenbaum@choa.org
42
Other Resources
• Polaris Project
 (www.polarisproject.org -sponsors the hotline
above)
• Shared Hope International
 (www.sharedhope.org)
• National Center for Missing and Exploited
Children
43  (www.missingkids.com)
References
• The Alan Guttmacher Institute. (1999) Facts in brief: teen sex and
pregnancy. New York: The Alan Guttmacher Institute.
• Bigelsen, J., & Vuotto, S. (2013). Homelessness, Survival Sex and
Human Trafficking: As Experienced by the Youth of Covenant House
New York. Available at:
http://www.covenanthouse.org/sites/default/files/attachments/CovenantHouse-trafficking-study.pdf Accessed June 15, 2014.
• Centers for Disease Control and Prevention. (2014) HIV/AIDS. Available
at: www.cdc.gov/hiv/. Accessed on June 24, 2014.
• Centers for Disease Control and Prevention. (2010) Sexually
Transmitted Diseases Treatment Guidelines, 2010. MMWR 59(No. RR12). Available at http://www.cdc.gov/std/treatment/2010/STDTreatment-2010-RR5912.pdf. Accessed July 21, 2014.
• Center for Adolescent Substance Abuse Research. (2009) CRAFFT
Screening Tool. Available at: www.ceasar-boston.org. Accessed July
4421, 2014.
References
• Chettiar J, Shannon K, Wood E, Zhang R, Kerr T. Survival sex work
involvement among street-involved youth who use drugs in a
Canadian setting. J Pub Health, 2010;32(3):322-327
• Curtis R, Terry K, Dank M, Dombrowski K & Khan B. (2008) The
Commercial Sexual Exploitation of Children in New York City, Volume
One, The CSEC Population in New York City: Size, Characteristics,
and Needs Final report submitted to the National Institute of Justice.
New York, NY: Center for Court Innovation and John Jay College of
Criminal Justice.
• Cooper SW. (2005). The medical expert and child sexual exploitation.
In Cooper SW Estes RJ, Giardino AP. Kellogg VD, & Vieth VI(Eds.),
Medical, legal and social science aspects of child sexual exploitation:
A comprehensive review of pornography, prostitution, and internet
crimes (Vol. 2, pp. 799-834). St. Louis: G.W. Medical Publishing, Inc.
45
References
• Deisher RW, Farrow JA, Hope K, & Litchfield C. (1989) The pregnant
adolescent prostitute. Am J Dis Child, 143(10), 1162-1165.
• Economic and Social Commission for Asia and the Pacific. (2000)
Sexually abused and sexually exploited children and youth in the
greater Mekong subregion: a qualitative assessment of their health
needs and available services. United Nations: Geneva.
• Edinburgh L, Pape-Blabloil J, Haprin SB, Saewyc E. Assessing
exploitation experiences of girls and boys seen at a child advocacy
center. Child Abuse Neg, 2015: in press.
• Gragg F, Petta I, Bernstein H, et al. New York prevalence study of
commercially sexually exploited children: Final report. New York State
Office of Children and Family Services2007.
• Greenbaum J, Crawford-Jakubiak J, Committee on Child Abuse and
Neglect. Child sex trafficking and commercial sexual exploitation:
Health care needs of victims. Peds,2015:135(3).
46
References
• Greene JM, Ennett ST, Ringwalt CL. Prevalence and correlates of
survival sex among runaway and homeless youth. Am J Public
Health, 1999;89:1406-1409.
• Institute of Medicine and National Research Council. Confronting
commercial sexual exploitation and sex trafficking of minors in the
United States. Washington, D.C.: The National Academies Press;
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• Knight JR, et al. A new brief screen for adolescent substance abuse.
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References
• McCann J, Miyamoto S, Boyle C, Rogers K. (2007) Healing of
hymenal injuries in prepubertal and adolescent girls: A descriptive
study. Pediatrics. 119:e1094.
• Polaris Project. (2013) National Human Trafficking Resource Center.
Available at: http://www.polarisproject.org/what-we-do/nationalhuman-Trafficking-hotline/the-nhtrc/overview. Accessed on June 24,
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• Stoltz JM, Shannon K, Kerr T, Zhang R, Montaner JJS, Wood E.
Associations between childhood maltreatment and sex work in a
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48
References
• Walls NE, Bell S. Correlates of engaging in survival sex among
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• Whitbeck LB, Chen X, Hoyt DR, Tyler KA, Johnson KD. Mental
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