Children`s Healthcare of Atlanta

Child Sex Trafficking and
Commercial Sexual Exploitation
In America
Jordan Greenbaum, MD,
Stephanie V. Blank Center for Safe and Healthy Children
Children’s Healthcare of Atlanta
Objectives
• Be familiar with risk factors and possible indicators of child sex
trafficking
• Be aware of trauma-informed techniques used to speak with
suspected victims and to gather information while
maintaining the safety and well being of the child
• Be aware of how to make a report of suspected victimization
as appropriate, and knowledgeable of available resources for
victims and healthcare providers.
2
What is Sex Trafficking?
• Involves the recruitment, harboring,
transportation, provision, or obtaining of a
person for the purpose of a commercial sex act
– (any sex act on account of which anything of value is
given to or received by any person.)
– If person is >18 yo, must show force, fraud, coercion
– If person <18 yo, no force, etc required
TVPA, 2000
3
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)
– Pornography
– Sex tourism
– Use of child in sexually oriented business
• Does NOT require force, coercion, violence, etc
Trafficking and CSEC in the U.S.
• No reliable estimates of prevalence/incidence
• Majority of identified child victims are domestic
5
When we think of child sex trafficking and
commercial sexual exploitation, we think of…..
Girls and ‘Pimps’
6
But, there’s more to it….
• Girls and
• Direct exchange of sex for item of value
• Survival sex
• Luxury items
• Pornography
• Sex-oriented businesses
• What about boys?? What about LGBTQI youth?
7
The “Invisible Boy”
• Boys largely ignored in articles, studies of HT
• Why?




Some studies show predominance of girls
Public discomfort with male-to-male sex
Males not viewed as powerless, vulnerable
Males are not objectified
Friedman, 2013; US Dept. of State, TIP, 2013; UNODC, 2014; Dennis, 2008
8
What Are The Consequences?
‘Offender’ vs ‘victim’ status
Lack of services
9
Children At Increased Risk for Sex
Trafficking
Child welfare involvement
Looking for love
Poverty
Abuse/Neglect
Family Dysfunction
Runaway/Throwaway
Increased Risk
Parent with substance abuse
‘Easy money’
Mental health problems
Drug/Alcohol abuse
Gang involvement
Adult prostitution in home
LGBTQI status
IOM, 2013; Smith 2009; Edinburgh, 2015; Greenbaum 2015; Gragg 2007; Bigelson 2013
Risks for Transgender Youth
• Family and societal rejection
• Seek acceptance
• Job discrimination
• Substance use to cope
• Need money for treatment
• High risk survival sex
11
Grossman,
2006
Pathways to Entry
• Seduction and coercion (boys and girls)
• False advertising for modeling, acting, or
dancing
• Internet : Chat rooms or social media
• Offered food, safety while en route to U.S.
• Mechanism for survival
Pathways to Entry
• Peer recruitment
• Parents selling children
• Violence and force, kidnapping
• Drugs/alcohol
13
How can the child be a victim
when they freely agree to sell
sex?
14
How can you have a ‘compliant’ victim?
• Children have needs, just like adults.
• Easily manipulated.
• Lack experience and maturity to understand
implications.
• Lack psychological, cognitive ability to ‘consent’.
• Lack legal ability to consent.
When you think of a ‘typical’ adolescent,
what do you imagine?
Rebellious
Curious
about
sex
Easily
sexually
aroused
Adolescent
Needing to
break
away from
parents
Influenced
by social
media
Unsure
of self
Eager to
‘grow up’
Eager for
acceptance
What do we know about adolescent
behavior?
• Show increased risk-taking behavior.
• Increased impulsive behavior.
• Not so good at…
– Suppressing inappropriate thoughts or actions.
– Favoring goal-directed behavior.
– Delaying gratification.
17
Homeless Youth and Survival Sex
• Very common behavior: ~10-50%
• More likely if live on street (rather than shelter)
• Boys more likely than girls? Study results
conflict
Walls, 2011; Greene, 1999; Chettiar, 2010
18
Homeless youth and survival sex
Older youth
Antisocial
behavior
More time on
the street
Drug use (esp.
injection drugs)
Hx sexual or
emotional
abuse
Young age when
first ran away
Increased
Risk of
Survival Sex
Hx psychiatric
hospitalization
Hx suicide
attempt
Hx STI or
pregnancy
LGBTQI
19
Wall, 2011; Greene, 1999; Stoltz, 2007; Kerr, 2009, Chettiar, 2010; Whitbeck, 2004
Conditions in “the Life”
• Lots of variation
–
–
–
–
–
–
–
Survival sex on the streets
Work alone or with group
Live at home
Live with trafficker
Involvement with gang
Freedom may vary
Brothel vs motel vs trailer in field vs street
20
Case example- Paul
Paul is a 15 yo boy who ran away from home
because his mother told him that his being gay
disgraced the family. He started out living with a
friend, but this did not work well and he ended
up on the street. He slept in the park for a few
days but his money ran out and he didn’t know
what to do. He was approached by some other
boys who allowed him to join their group. He
watched Joel ‘turn some tricks’ and Joel told him
what he needed to do. It seemed like all the
boys were doing it so Paul did, too.
21
Paul
Paul had been using marijuana for years but
when living on the streets he began using
cocaine and alcohol. After awhile he could
only see clients if he was ‘high’. He seldom
used a condom although he saw up to 4
clients per day. He and his friends went to the
public STI clinic every few months to get
tested, although Paul did not agree to HIV
testing.
22
Case Example: Sherise and Elsa
• Sherise is 17 years old, has a 6 month old baby, and is living on the
streets after being thrown out of the house because of her pregnancy.
She dropped out of school and is struggling to support herself. She is
staying with a female friend, who suggests she work as an exotic
dancer. She does this for a few months and one night is approached by
a man who tells her he loves her dancing. He invites her outside on her
break and kidnaps her. He rapes and beats her and tells her now she is
working for him. She works at his club and eventually is told she must
engage in prostitution as well as dancing.
• Elsa is 14 years old, and an A and B student. She loves track and
painting. She meets a 17 year old boy on Facebook and they become
friends. She tells him everything, all about her frustration with her
mother and her abandonment by her father. After 2 months he asks to
meet her. But before he does, he wants her to know that actually he’s
25 years old. She is shocked but she is in love…..she goes to meet him.
23
CSEC in New York City
Boys (n-111)
Girls (n-119)
Transgender (n-19)
‘Living on the
street’
44%
24%
11%
Family home
16%
29%
5%
Friend’s home
19%
26%
11%
Another home
6%
18%
16%
Shelter
28%
18%
42%
Market facilitator
home
0%
4%
0%
Living alone
52%
26%
42%
Living situation
Curtis, 2008
24
CSEC in New York City
Boys (n-111)
Ave age of initiation 15.28 years
Girls (n-119)
Transgender (n-19)
15.15 years
16.16 years
How recruited?
Friends
44%
46%
68%
Relative
3%
1%
0%
Trafficker
1%
16%
0%
Customer
approached child
32%
16%
11%
Internet
4%
3%
5%
Curtis, 2008
25
New York City Study
•
•
•
•
Extensive peer networks for boys/girls
Most had <5 clients per day
Violence a way of life
Drugs of choice
 Marijuana>alcohol>cocaine>heroin
 None: 24% girls; 12% boys; 53% transgender
Curtis, 2008
26
“Why Don’t they just leave?”
• Threatened by trafficker
• Loyal to trafficker, feel indebted
• Trafficking life perceived as preferable
• ‘Perks’, sense of belonging,
• May feel that is only skill they have
• Home is worse
What are the consequences
of child sex trafficking?
28
Physical Violence
Fractures, head injury,
Lacerations, bruises,
Beat, choke, whip
Abdominal trauma, Burns
Anogenital trauma
Torture (ice-baths, burns,
suspension, salt in wounds
Physical restraint and/or confinement
Shock, bleeding, infection
Scarring, disfigurement, loss
of function
Deprivation (sleep, food, light)
Malnutrition
Homicide
Exhaustion
Chronic pain
Zimmerman, 2006l Lederer, 2014
29
Sexual Abuse/Assault
Anogenital injury
STI, HIV
Pelvic inflamm. disease
Rape, gang rape
UTI
Forced prostitution
Cervical CA
Forced unprotected sex
Infertility
Pregnancy, abortion
Sex without lubricants
Misuse of contraceptives
Humiliation
PTSD
Chronic pain with intercourse
Chronic pain/IBS
Zimmerman, 2006l Lederer, 2014
30
Sexually Transmitted Infections
• May have to buy condoms from trafficker
•
Problems negotiating condom use
•
May not use condom with trafficker (‘boyfriend’)
•
Client pays more without condom
•
Limited knowledge of STIs, importance of condoms
31
HIV Risk
Economic and Social Commission for Asia and the Pacific. (2000)
CDC website, 2014; Patel et al, 2014
32
Pregnancy
• Contraception is unusual
• Morbidity higher for adolescent
girls than adults
• Many unsafe abortions
 10-50% of women who have
unsafe abortions have complications
• Infants born with acute and chronic
conditions
Willis & Levy, 2002; Deisher, Farrow, Hope, & Litchfield, 1989
33
Psychological Abuse
PTSD
Chronic fear, anxiety
Threats
Intimidation/Terrorizing
Depression
Stockholm syndrome
Blackmail
Suicide
Deception, deceit
Memory loss
Unpredictability
Somatic complaints
Lack of control
Aggression, violence
Isolation
Guilt, shame, hopelessness
Forced dependency
Substance misuse
Zimmerman, 2006l Lederer, 2014
34
Substance Use/Misuse
•
•
•
•
•
Pre-existing use or introduced by trafficker
Method of control, manipulation
Self-medication
Heroin, benzo’s, meth, others
Intoxication, overdose or withdrawal
Untreated Chronic Conditions
• Poorly controlled chronic conditions (e.g. asthma)
• Dental problems
• Chronic pain (HA, abd, pelvic)
• Chronic fatigue
• Problems associated with prior traumatic brain injury
Lederer & Wetzel, 2014; Zimmerman, 2006; Cooper, 2005
36
So, how will I know a victim
when I see one?
Children’s Healthcare of Atlanta
37
Challenges to Victim Identification
• Victims don’t self-identify
• Reluctant to disclose
• Few clinically validated quick screening tools and
these are cumbersome
38
Possible Indicators of Sex Trafficking/CSEC:
First Impressions
• Youth appears afraid of adult, or overly submissive,
anxious
• Youth gives false demographic information,
inconsistent history
• Youth cannot describe where she/he is staying,
doesn’t know city
39
Youth at Risk
Child welfare involvement
Truancy, school problems
Poverty
Abuse/Neglect
Runaway/Throwaway
Mental health problems
Drug/Alcohol abuse
Gang involvement
Family Dysfunction
Parent with substance abuse
Adult prostitution in home
LGBTQ status
40
Possible Indicators of Sex Trafficking/CSEC
• Think about the adverse health effects of
trafficking….




Multiple sexually transmitted infections
Pregnancies, abortions, or miscarriages
Illicit drug use
Current or past history of:
• Sexual assault
• Inflicted Injury
• Multiple expensive items (clothing, jewelry, etc)
• Tattoos
• Visible signs of physical abuse
41
Interview Challenges
Child may:
• Be hostile, uncooperative, manipulative
• Be fearful and untrusting of authorities
• Be afraid of trafficker
• Not see self as victim
42
Sex trafficking and CSEC
cause traumatic stress.
43
Symptoms of Traumatic Stress
•
•
•
•
Symptoms may not manifest immediately.
Variable period to resolution.
Some children don’t show obvious symptoms.
Over control may be as symptomatic as acting out.
NCTSN
44
Potential Signs of Traumatic Stress
• Physical
–
–
–
–
Nightmares and sleep problems.
Altered appetite and eating patterns.
Chronic pain complaints.
Irritable bowel syndrome.
• Emotional
–
–
–
–
Post-traumatic stress disorder (PTSD).
Depression and withdrawal.
Anxiety or panic.
Dissociation and numbness.
NCTSN
45
Potential Signs of Traumatic Stress
• Behavioral
–
–
–
–
–
–
–
Hyperarousal.
Aggression and antisocial behavior.
Hypervigilance.
Lack of control of mood and behavior.
Misinterpretation of others’ intentions.
Distrust of others.
Difficulty with authority and criticism.
NCTSN
46
Trauma-Informed Approach
• Sexual abuse/exploitation causes traumatic stress.
• Trauma can lead to variety of behaviors and
reactions.
• Need to interpret child’s behavior in context of
stress.
• Talking can trigger memories and stress.
• Need to take steps to:
– Ensure child feels safe.
– Minimize re-trauma.
47
Safety Issues
• Primary concern during visit (child, yourself and staff)
– Protocol needed
• Interview youth alone
– “Is it okay for you to talk to me?”
– “Is there anything I can do to make you feel more
comfortable while we talk?”
Polaris Project, 2013
48
Tips for Talking to Possible Victims
• Treat child with respect
• Accept child as she/he is
• Don’t forget: she/he is a victim/survivor, not an
offender
• Review limits of confidentiality early on
49
Tips for Talking to Possible Victims
• Be sensitive to child’s reactions and to
possible stress
• Tell her/him what you need to do and
why
• Allow child control when feasible
50
Direct Questions About Possible
Trafficking/CSEC
1) Has anyone ever asked you to have sex in exchange
for something you wanted or needed (money, food,
shelter or other items)?
2) Has anyone ever asked you to have sex with another
person?
3) Has anyone ever taken sexual pictures of you or
posted such pictures on the internet?
51
What Do You Say If….
• Child is obviously not telling the truth
 “I’ve only had sex once before” (police report she has been
trafficked for a year)
 “I don’t do drugs” (child has positive drug screen from
prior ED visit)
• Youth refuses to allow sexual assault kit and curses
out medical staff; LE is insisting on kit
• Youth decides he/she wants to leave
52
What questions should I
ask?
This depends on your situation and your role.
53
Keep in mind….
• Only seek information that you need to know
• Why are you asking?
–
–
–
–
–
To investigate?
To assess physical and emotional health?
To assess safety at home?
To determine appropriate services and referrals?
To provide important information to the child?
Reproductive History
•
•
•
•
•
•
Current anogenital symptoms/signs
Sexual identity (avoid making assumptions)
Prior sexual experiences
Condom use and other contraception
Prior STI’s, pregnancies, procedures
Prior anogenital injuries
55
Questions About Physical Assault/Injuries
• Anyone ever hit, kick, slap, choke, beat you?
• Tell me about what happened
• Who and when?
• What was done about it?
 Investigation?
 Medical care?
56
Safety Issues: Family History
•
•
•
•
•
•
•
•
Family roles
IPV
Mental health issues
Criminal activity
Is family supportive?
Ever run away? Why?
Any gang involvement?
Are you afraid of anyone?
57
If Youth Is Not Living at Home
• Where are you staying?
• How do you get food and money?
• Do you owe anyone money?
• Have you gotten hurt while out on the streets?
• Has anyone approached you and asked you to do
something you didn’t want to do?
58
Safety Issues: Mental Health
• Screen for symptoms/signs
 Depression
 PTSD
 Anxiety, panic
• Thoughts of hurting self, others?
• Prior self-harm?
• Make appropriate referrals
59
Other Good Screening Questions for
Drugs/Alcohol
• CRAFFT, HEADSS screens
• Has anyone ever given you drugs when you didn’t
know about it?
• Have you ever been forced to take drugs, use
alcohol?
• Ever felt really bad after you’ve been using drugs, or
when you’re ‘coming down’? (depressed, agitated,
craving drugs, feeling sick)
• Types, frequency of drug use; circumstances of use
60
A suspected victim needs a
medical evaluation promptly.
61
Exam and Diagnostic Evaluation
Focus on:
1. Assessing and treating acute and chronic conditions
2. Documenting acute/remote injuries, genital and extragenital
3. Assessing overall health, nutritional status and hydration
4. Obtaining a sexual assault evidence kit as indicated
5. Testing for pregnancy and sexually transmitted infections
and providing prophylaxis
6. Testing for alcohol and drugs, as indicated
Obtain patient assent for exam, kit, testing
62
Important Considerations for the HCP
Have a chaperone!
Exclude suspected trafficker
Explain steps before doing them
Monitor for signs of distress
Ask if child has any questions/concerns during
exam
• Explain results of your exam
•
•
•
•
•
63
Possible Inflicted Injuries
• Often located in ordinarily protected areas






Cheeks
Neck
Torso
Genitals
Inner thighs
Upper arms
• Restraint injuries
64
There may be no evidence
of genital trauma.
Why?
65
Healing of Hymenal Injuries
• 239 girls, 4 months to 18 years old
• Accidental and inflicted injury
• Left NO residual, except deep lacerations; no scar
tissue seen
McCann, Miyamoto, Boyle, & Rogers, 2007
66
Possible Medical Referrals







Drug rehab
Behavioral health assessment and treatment
Follow up surgical care
HIV PEP monitoring
OB/GYN care
Primary care provider
Child Advocacy Center
67
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!!!
68
Reports and Referrals
• Know your mandated reporter laws in your state
– Report to Law Enforcement
– Child Protective Services
• Potential issues reporting to local authorities
– Victim services available
– CPS understanding of issues facing victims
– Law enforcement response
• Emphasize victim status
69
Reports and Referrals
• National Human Trafficking Resource Center Hotline
 (1-888-3737-888)
• U.S. Immigration and Customs Enforcement
 (1-866-872-4973)
70
Example 1:
•
•
•
•
•
•
•
71
16 yo female comes to ED
Man hanging around outside
CC: bruising, flank pain & blood in urine
Vague history of ped vs. auto incident
What questions do you ask?
Would you ask her about the guy outside?
Eventually she discloses situation
Example 1
• Physical exam:




Bruising to back, upper arms, lip
Chipped tooth
Contusion to right kidney
Trich positive; HIV, other STI & pregnancy negative
 Once you treat her, what do you do?
 Reporting, referrals?
 What about the guy lurking outside?
72
Example 2:
12 yo female comes with her mother to your clinic
for a sports physical. She is a good student and
you have known the family since the patient was
an infant. Mother allows you to speak alone to the
child and the latter tells you she is worried about
‘stuff’ coming from her ‘privates’.
What do you say?
How would you obtain more information?
73
Sample 2:
•
•
•
•
•
Depressed
Tired
Poor grades recently
Abdominal pain, headaches
Vaginal discharge x 2 weeks
74
Sample 3:
• What do you do with respect to referrals and
reports?
• What about the mother (who knows nothing?)
• What kinds of resources might help this child?
75
Sample 3:
• 14 yo male comes to clinic for STI testing. 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’.
76
What do you do???
77
Other Resources
• Polaris Project
 (www.polarisproject.org -sponsors the hotline above)
• Shared Hope International
 (www.sharedhope.org)
• National Center for Missing and Exploited Children
 (www.missingkids.com)
78
My contact info:
Jordan Greenbaum, MD
jordan.greenbaum@choa.org
79
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. RR-12). Available at
http://www.cdc.gov/std/treatment/2010/STD-Treatment-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 21, 2014.
80
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
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81
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83
• McCann J, Miyamoto S, Boyle C, Rogers K. (2007) Healing of hymenal
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84
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85