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Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States (2013)

Chapter:3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors

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Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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3


Risk Factors for and Consequences
of Commercial Sexual Exploitation
and Sex Trafficking of Minors

Identifying risk factors for commercial sexual exploitation and sex trafficking of minors is necessary to understand the etiology of these problems and to inform interventions for preventing and addressing them. Understanding the various short- and long-term consequences of commercial sexual exploitation and sex trafficking of minors also is necessary to guide future prevention and intervention strategies. This chapter describes what is known about individual, family, peer, neighborhood, and systems-level risk factors associated with victims and offenders of commercial sexual exploitation and sex trafficking of minors. In addition, to clarify the impact of these crimes, the chapter describes what is known about their physical, emotional, and behavioral health consequences, as well as their developmental, social, health, and legal implications. Because the existing evidence base for these subjects is extremely limited, the discussion draws heavily on related research literatures (e.g., on child maltreatment, sexual assault/rape, and trauma), as well as evidence from secondary source materials (e.g., the committee’s workshops and site visits). Finally, this chapter aims to connect the dots between these sources of evidence to provide guidance for future research efforts on commercial sexual exploitation and sex trafficking of minors in the United States.

RISK FACTORS

Commercial sexual exploitation and sex trafficking of minors are multiply determined with causes at several levels, ranging from individual characteristics to family, peer, and neighborhood factors. Community and

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

societal norms and expectations about sexual behavior and coercion, as well as societal and cultural standards and expectations regarding minors, gender, sexual orientation, race/ethnicity, and power, also contribute to commercial sexual exploitation and sex trafficking of minors. Adding to this complexity, each of these factors interacts within and across levels to increase risk or protection. Because of the multiple forces involved, prevention and intervention efforts targeting only single risks may have limited utility. Moreover, a comprehensive understanding of risk factors for commercial sexual exploitation and sex trafficking of minors requires awareness that the processes associated with these problems, from beginning to end, are dynamic (see Figure 3-1).

The ecological model depicted in Figure 3-1 highlights the complex and interconnected forces that contribute to initial and continued commercial sexual exploitation and sex trafficking of minors. It should be noted, however, that the factors included in this schematic are likely only a subset of the risk factors for these problems. Moreover, some of those factors may be necessary but not sufficient contributors to the commercial sexual exploitation and sex trafficking of minors. For example, the presence of risk factors would not result in the commercial sexual exploitation and sex trafficking of minors without the presence of an exploiter or trafficker. Of note, the contributing and maintaining factors depicted in Figure 3-1 may function independently or in combination. In addition, risk factors in one sphere may trigger a cascade of effects or initiate pathways into or out of commercial sexual exploitation and sex trafficking. Because many of the factors in Figure 3-1 also may be risks for other types of adverse youth outcomes, readers are cautioned not to assume that the presence of any single risk factor necessarily signals commercial sexual exploitation and sex trafficking of minors. Instead, the presence of one or more of these factors should be considered as part of a more comprehensive assessment to determine youth at risk of or involved in commercial sexual exploitation and sex trafficking. Each domain included in Figure 3-1 is detailed in the following sections.

Risk Factors for Victims

Individual-Level Factors

At the individual level, a number of factors may increase boys’ and girls’ vulnerability to commercial sexual exploitation and sex trafficking. These include sexual abuse, physical abuse, and other forms of maltreatment; disruptions in normative development; the experience of running away or being homeless or thrown away; being placed in foster care or otherwise systems involved; being lesbian, gay, bisexual, or transgender (LGBT); substance use/abuse; psychogenic factors and impaired cognitive

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

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FIGURE 3-1 Ecological model adapted to illustrate the possible risk factors for commercial sexual exploitation and sex trafficking of minors.
NOTE: LGBT = lesbian, gay, bisexual, or transgender.

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

function; having a disability; earlier pubertal maturation; and the experience of early adversity.

Child maltreatment Child neglect, physical abuse, and sexual abuse are commonly thought to be risk factors for commercial sexual exploitation and sex trafficking of minors (Dalla et al., 2003; Williams and Fedderick, 2009). Support for this perspective originates in studies reporting that youth identify the sexual abuse they experienced as a child as a major influence on their becoming involved in commercial sexual exploitation. For example, 70 percent of the subjects in a U.S. study conducted by Silbert and Pines (1981) and 73 percent of those in a Canadian study conducted by Bagley and Young (1987) reported that childhood sexual abuse affected their path to involvement in commercial sex work. Silbert and Pines (1981) found that 78 percent of the 200 San Francisco prostitutes in their sample were prostituted as juveniles. In that study, the majority of those interviewed were under age 21, and one subject was only 10 years old. Sixty percent of the sample reported that they had been or were being sexually exploited; 67 percent reported sexual abuse during their childhood by a father figure (33 percent by their biological father), 28 percent by a brother, and 31 percent by friends of the family. In 82 percent of the episodes of abuse, some sort of force was used. Because the results of these studies are based on retrospective data, however, one cannot conclude that child maltreatment played a causal role in the youth’s commercial sexual exploitation.

In one of the few prospective studies on this subject, Widom and Kuhns (1996) examined the relationship between childhood maltreatment and promiscuity, prostitution, and teen pregnancy. The study used a prospective cohort design in which victims of child maltreatment were matched with nonabused children and followed into adulthood. Child neglect and sexual abuse were found to be associated with later prostitution among females. Although male victims of child abuse and/or neglect had a higher prevalence of being prostituted (12.54 percent) than females (8.93 percent), the study did not find an association with later prostitution for males. In another prospective study, Wilson and Widom (2010, p. 18) found that victims of maltreatment were more than twice as likely as nonvictims to report involvement in prostitution as adolescents or adults, as assessed through participants’ positive response to a question about whether they had “ever been paid for having sex with someone.” Stoltz and colleagues (2007) found a significant association between child maltreatment (sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada. On the other hand, Nadon and colleagues (1998) compared a sample of 45 female adolescents involved in prostitution and recruited from service organizations in areas known for prostitution

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

with a sample of 37 female adolescents not involved in prostitution and recruited from the same service organizations. Surprisingly, the adolescents involved and not involved in prostitution did not differ in terms of child sexual abuse: rates of child sexual abuse were similar in the two groups, as were the circumstances surrounding the abuse, including the relationships between perpetrators and victims. Notably, the commercially sexually exploited youth had significantly higher rates of running away from home (see the discussion of this factor below); this finding suggests that it may not be the child sexual abuse alone but its consequences that heighten the risk for commercial sexual exploitation and sex trafficking of minors. In fact, Jesson (1993) and Nadon and colleagues (1998) argue that early maltreatment, family dysfunction, and running away are so closely linked that it may well be the running away that puts youth directly at risk. Thus the literature suggests that there are multiple possible indirect pathways to commercial sexual exploitation and sex trafficking of minors.

A number of researchers have offered explanations for why child maltreatment may create vulnerability to commercial sexual exploitation and sex trafficking of minors. Stoltz and colleagues (2007, p. 5) suggest that some “children who are sexually victimized develop psychologically and emotionally in ways that make them vulnerable to continuing sexual predation.” For example, survivors of child sexual abuse may display sexualized behaviors (Putnam, 2003). In addition, according to Stoltz and colleagues (2007), victims of child sexual abuse may have the tendency to engage in risk-taking behaviors (i.e., drug and alcohol abuse, running away from home) that may lead to circumstances in which they perceive survival sex as one of the few remaining resources available to them. While suggesting that child sexual abuse creates a susceptibility to becoming involved in trading sex, the authors emphasize that the abuse does not cause commercial sexual exploitation and sex trafficking. Rather, they posit that the abuse is one component of a generally traumatic negative developmental experience that may weaken resiliency. Similarly, Steel and Herlitz (2005) suggest a possible pathway from child sexual abuse to sexual risk behavior, with psychological symptoms such as depressive mood, poor self-esteem, lack of assertiveness, poor self-worth, and posttraumatic stress disorder (PTSD) leading to future risk behavior (Stein et al., 2002; Swanston et al., 2003). Noll and colleagues (2003) suggest that stigma associated with child sexual abuse may make it difficult for victims to experience nonsexual or emotional rewards from relationships, thereby making victims more likely to engage in risk behaviors and more vulnerable to sexual exploitation (Lalor and McElvaney, 2010; Stoltz et al., 2007). According to several researchers, victims of child sexual abuse may experience poor affect regulation (i.e., how an individual controls his/her experience and/or expression of emotion), experience difficulty in forming relationships, and possess poor coping abilities (Arata, 2002;

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

Cloitre et al., 1996, 2001; Gold et al., 1999; Lalor and McElvaney, 2010; Polusny and Follette, 1995). These outcomes can result in a number of negative consequences for victims of such abuse later in life. For example, victims may engage in emotional avoidance behaviors such as self-harm and substance abuse (Lalor and McElvaney, 2010). These behaviors, in turn, may increase a victim’s risk of future victimization (Gold et al., 1999). Taken together, these propositions highlight emotional and behavioral consequences of child sexual abuse that are associated with commercial sexual exploitation and sex trafficking of minors, suggesting mechanisms that may link child abuse to these crimes.

In support of the above propositions regarding the indirect pathways through which child maltreatment increases the risk for commercial sexual exploitation and sex trafficking of minors, ample evidence documents associations between child sexual abuse and outcomes that have been linked with these crimes. For example, victims of child sexual abuse may begin to engage in sexual activity at earlier ages than nonvictims (Fergusson et al., 1997; Lodico and Diclemente, 1994; Noll et al., 2003; Springs and Friedrich, 1992; Wilson and Widom, 2010). Earlier onset of consensual sexual activity is in turn associated with increased risk for truancy, dropping out of school, and running away, as well as for gang membership (Unger et al., 1998), each of which has been associated with commercial sexual exploitation and sex trafficking of minors. Several studies have found that sexually abused adolescents are likely to have higher levels of alcohol and drug abuse, risky sexual behaviors, depression, trauma, anxiety, and suicidality, as well as poorer sense of self (Negrao et al., 2005; Noll et al., 2006; Sickel et al., 2002). Children and adolescents who experience abuse and/or neglect may use drugs to cope with a negative home environment (Harrison et al., 1989), to enhance self-esteem (Cavaiola and Schiff, 1998), or to relieve symptoms of depression (Allen and Tarnowski, 1989). In older adolescents, child abuse has been found to be associated with heightened sexual risk taking and heightened risks for other adverse behavioral outcomes (Fergusson et al., 1997; Noll et al., 2009). According to Kelley and colleagues (1997), adolescents with a history of child maltreatment were at least 25 percent more likely to experience problems with juvenile delinquency, teen pregnancy, low academic achievement, drug use, and symptoms of poor mental health than those without such a history, which together could increase the risk for commercial sexual exploitation and sex trafficking of minors.

Few studies have examined indirect pathways between child maltreatment, hypothesized mechanisms, and commercial sexual exploitation and sex trafficking in prospective studies. One exception is the work of Wilson and Widom (2010), who explored whether behavioral sequelae of child maltreatment (i.e., early sexual initiation, running away, juvenile crime,

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

school problems, and early drug use) were precursors of commercial sexual exploitation of minors. Each type of child maltreatment (i.e., neglect, physical abuse, sexual abuse) was significantly associated with early sexual initiation, running away, juvenile crime, and school problems; these problems, in turn, were linked with prostitution by adulthood. Initiation of sexual behavior before age 15 emerged as the strongest link between child maltreatment and later prostitution. Other possible mediating factors (e.g., parental conflict, parental psychopathology) that may link child maltreatment with high-risk behavior and/or victimization by commercial sexual exploitation and sex trafficking are discussed below.

While the above studies suggest that child maltreatment, particularly child sexual abuse, may be associated with commercial sexual exploitation and sex trafficking of minors, it should be noted that findings of the few prospective studies available suggest that only an extremely small proportion of children who are sexually abused subsequently become involved in trading sex for money or something of value (Lalor and McElvaney, 2010; Lamont, 2010). For example, while Flowers (2001, p. 82) notes that “nearly all girl prostitutes have been sexually molested, assaulted, or physically abused before entering the profession,” the reverse does not hold. In a study of 2,810 Swedish citizens, Steel and Herlitz (2005) found that very few of the individuals who were victims of child sexual abuse (n = 268) reported having engaged in “sex work” (n = 1). This finding does not suggest a strong predisposition to involvement in prostitution among victims of child maltreatment. Moreover, while child maltreatment, and child sexual abuse in particular, appears to increase the risk for later high-risk behaviors and revictimization for some children and adolescents, this is not the case for all victims of child maltreatment. For example, Widom’s previously described longitudinal studies (Widom and Kuhns, 1996; Wilson and Widom, 2010) found no differences in teen pregnancy or promiscuity between individuals who experienced childhood maltreatment and those who did not. Reasons for such resilience after experiencing child maltreatment are unknown, as studies indicating what may make some victims of child abuse more or less resilient are lacking.

In addition to a limited understanding of factors associated with resilience in victims of child sexual abuse, several factors limit understanding of the overall impact of child maltreatment on the risk for commercial sexual exploitation and sex trafficking of minors. In many studies, the timing of involvement in prostitution is unclear, nor is it possible to distinguish between prostitution and commercial sexual exploitation and sex trafficking of minors. Moreover, studies have examined associations between child sexual abuse and later engagement in high-risk sexual behavior, including having multiple sexual partners, engaging in commercial sex work, and being sexually promiscuous; however, methodological issues—such as sam-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

pling women and girls already involved in commercial sex work, relying on retrospective reports of maltreatment, and using instruments that have not been psychometrically tested—limit the conclusions that can be drawn from this research. Other methodological problems include failure of most studies to distinguish among different types of maltreatment, as well as vast differences in definitions of abuse, differences in methodologies for identifying abuse, and the fact that most studies fail to measure the intensity and duration of the abuse or the relationship between perpetrator(s) and victim (Briere, 1992; Hastings and Kelley, 1997; Hulme, 2004; Kelley et al., 1997). These types of problems limit the ability to make comparisons across studies with regard to type of abuse, prevalence, and sequelae, in turn making it difficult to determine the risks associated with each form of abuse. Furthermore, Lalor and McElvaney (2010) report that nonresponse rates of 30 percent are common in surveys on abuse, calling into question the generalizability of the responses of the 70 percent of people who typically agree to participate. In attempting to establish associations between child sexual abuse and commercial sexual exploitation and sex trafficking of minors, moreover, it is important to recognize that, like other forms of abuse, child sexual abuse is an extremely complex phenomenon (Hulme, 2004). The individual experiences of victims, including the number of incidents, the age at onset, the frequency and duration of the abuse, and the relationship between perpetrator(s) and victim, vary greatly (Hulme, 2004, 2007). In some cases, the boundaries between child abuse and commercial sexual exploitation are blurred, as when a parent or other family member coaches a child to be sexually involved in return for money (Saphira, 2001).

Despite these methodological concerns, because commercial sexual exploitation and sex trafficking of minors are extreme forms of child sexual abuse, it is widely assumed that their victims will exhibit behaviors similar to those of victims of child sexual abuse. However, additional prospective, longitudinal research is needed to demonstrate more explicitly whether causal links exist between child sexual abuse and commercial sexual exploitation and sex trafficking of minors.

Disruptions in normative development The terms disrupted development and disrupted transitions have been used to describe precocious transitions to adulthood, or the “rush to adulthood” perspective developed by Wickrama and other researchers (Wickrama and Baltimore, 2010; Wickrama et al., 2003, p. 63, 2005a,b). Disrupted transitions can be defined as life events that either interrupt normative developmental patterns or occur prematurely. For example, Wickrama’s work demonstrates links between precocious transitions, such as early sexual activity, teenage pregnancy, early cohabitation, and early marriage, and negative long-term emotional, behavioral, and physical health outcomes. Similarly, earlier oc-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

currence of physical maturation (e.g., puberty) has been associated with greater health risks occurring in adolescence (Fergusson et al., 1997; Noll et al., 2003). Explanations for this association include the greater stress experienced by early maturers, the short-circuiting of certain developmental tasks of early adolescence, and the greater social pressure to which early developers may be exposed (Tschann et al., 1994). Wickrama and Baltimore (2010, p. 3) summarize the impact of these early transitions as follows:

Certain early life events may create “damages” that may multiply and continue into the young adult years. For example, youths who engage in early sexual activities get a “head start” and are more likely to engage in other unhealthy behaviors (Browning et al., 2008; Steinberg, 2005; Tubman et al., 1996).

Research has not yet focused on early transitions as predictive of commercial sexual exploitation and sex trafficking of minors. However, a number of studies have identified adolescent life experiences that may be potential precursors to commercial sexual exploitation and sex trafficking of children and adolescents. Regardless of race or class, for example, those who become involved in the commercial sex trade (both juveniles and adults) are more likely to have a history of parental abuse and neglect, incest, rape, interrupted school activity (including early dropout), running away, and early sexual experiences (including early first intercourse) (Adlaf and Zdanowicz, 1999; Bracey, 1982; Chesney-Lind and Shelden, 1992; Gibson-Ainyette et al., 1988; Hernandez et al., 1993; Kidd and Kral, 2002; Macvicar and Dillon, 1980; Newman et al., 1982; Raj et al., 2000; Schaffer and Deblassie, 1984; Silbert and Pines, 1981; Vigil et al., 2005). It should be noted, however, that most studies of victims of commercial sexual exploitation and sex trafficking are based on retrospective reports, which are subject to errors of memory and are not verifiable; the result may be underreporting or overreporting of experiences such as sexual abuse and other maltreatment (Hulme and Agrawal, 2004). Additionally, associations between childhood experiences and commercial sexual exploitation and sex trafficking of minors do not necessarily indicate a causal link; other factors may account for the commercial sexual exploitation and sex trafficking of minors. Thus, care must be taken in concluding which, if any, of these factors may be predictive of involvement in these crimes.

Runaway, thrown-away, and homeless youth Of the many factors that may increase vulnerability to commercial sexual exploitation and sex trafficking of minors, especially among adolescents, homelessness is widely considered the most direct contributor (Estes and Weiner, 2001). Homeless youth may include runaways (i.e., children who leave home without permission) and so-called thrown-away children (i.e., children and adolescents

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

who are asked or told to leave home). According to the U.S. Interagency Council on Homelessness, approximately 5 to 7 percent percent of U.S. youth under age 18 (about 1.6 million) may experience an episode of homelessness each year (Ringwalt et al., 1998; USICH, 2010). The experiences of these youth vary widely, ranging from being in adult shelters to sleeping outdoors, in abandoned buildings, or with strangers (Gilmore, 2012; Greene et al., 1999; Holzman, 2012; Ringwalt et al., 1998). Causes of homelessness vary widely as well. For example, youth who have been in foster care are at particularly high risk for becoming homeless (NAEH, 2009). Approximately 40 to 60 percent of homeless youth have experienced physical abuse, and 17 to 35 percent have experienced sexual abuse. Once homeless, young people experience greater risk for violence, sexual assault (NAEH, 2009), and commercial sexual exploitation and sex trafficking (Barnardo’s, 2002, 2012; Estes and Weiner, 2001). The risk of commercial sexual exploitation and sex trafficking among homeless youth increases with a prior history of sexual abuse, as does greater sexual risk taking (e.g., having multiple partners, having unprotected sex) (Raj et al., 2000; Rotherham-Borus et al., 1996) (see also the section on child maltreatment above). Once homeless, young people are at significant risk of commercial sexual exploitation and sex trafficking for reasons ranging from a lack of resources for basic needs, such as food and shelter, to the need for social connection when separated from the family unit and other social supports. Not only are homeless youth victims of commercial sexual exploitation and sex trafficking, but older homeless male youth may recruit their peers into involvement in these crimes (Rotherham-Borus et al., 1992). In addition, homeless and thrown-away youth are at particularly high risk for substance abuse (Gleghorn et al., 1998), which has been linked with involvement in commercial sexual exploitation and sex trafficking.

A number of studies have examined engagement in the commercial sex industry and transactional or survival sex among homeless youth (Curtis et al., 2008; Estes and Weiner, 2001; Greene et al., 1999; Gwadz et al., 2009; Miller et al., 2011). While estimates of such engagement vary greatly (between 2 percent and 46 percent), a cluster of studies suggest a figure of 15 to 30 percent (Adlaf and Zdanowicz, 1999; Greenblatt and Roberson 1993; Greene et al., 1999; Kipke et al., 1995, 1997; Milburn et al., 2006; NAEH, 2009; Rotherham-Borus et al., 1992; Unger et al., 1998; Wagner et al., 2001; Yates et al., 1991). In another example, a study in Seattle by Wagner and colleagues (2001) found that 41 percent of a sample of 272 Seattle homeless youth had been sexually exploited through survival sex and/or commercial sex work, and that 47 percent of females and 37 percent of males had been propositioned to sell sex. Estes and Weiner (2001) research found that homeless youth “are subject to an extraordinary range of risks of engaging in commercial sex that are not experienced by ‘at risk’

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

housed youth” (Estes and Weiner, 2001, p. 63). They suggest that homelessness puts young people at “special risk” for commercial sexual exploitation, not only because life on the streets puts them at greater risk from those who might prey on them, but also because homelessness among young people often is a result of other risk factors, such as family poverty, family dysfunction, or serious mental illness (Estes and Weiner, 2001).

The United Kingdom’s Barnardo’s, a social service organization with a long and deep involvement in working with homeless and thrown-away youth and victims of commercial sexual exploitation and sex trafficking, notes that commercial sexual exploitation and sex trafficking of minors occur gradually and incrementally, not suddenly (Barnardo’s, 2012). Young people at risk become more vulnerable simply if they are spending a great deal of time away from home, from their care placement, or from school, even for short episodes (Barnardo’s, 2012). Similarly, Gwadz and colleagues (2009) found that initiation into the “street economy” is a gradual process and that many homeless youth reveal connections to both the conventional economy and the street economy, but that over time, the conventional economy becomes viewed as foreign. It is important to note that not all homeless youth are involved in prostitution or engage in survival sex, however. Yates and colleagues (1991) found that among homeless youth, those involved in prostitution were more likely to live on the street, more likely to have dropped out of school, less likely to be involved in sports, more likely to have been sexually abused, and more likely to have engaged in survival sex.

Greene and colleagues (1999) criticize many studies of survival sex among homeless and shelter youth because they are based on extremely small sample sizes. To address this gap, they conducted a nationally representative study of homeless and sheltered youth across both urban and nonurban settings, and found that 27.5 percent of street and homeless youth and 9.5 percent of youth in shelters engaged in survival sex. Research on adolescent survival sex remains difficult, however, given the constantly changing circumstances surrounding such activity, as shown by an extensive study conducted in New York City (Curtis et al., 2008). This study found constant variations in the neighborhoods in which survival sex occurred, as well as who “controlled” the market—for example, with increasing gang involvement in recent years. Frequent displacement of sexually exploited youth also was found in a study by Miller and colleagues (2011), which showed that young people involved in survival and exchange sex may move into and out of homelessness over time.

Foster care placement and other systems involvement During its San Francisco site visit, the committee heard that young people who are placed in foster care have backgrounds that include many of the factors thought to contribute to the risk for commercial sexual exploitation and sex traf-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

ficking of minors, including fragmented families, poor parental supervision, and poverty, as well as neglect, physical abuse, and sexual abuse. Therefore, children in foster care should be considered at high risk for commercial sexual exploitation and sex trafficking. In a San Francisco study of 149 youth identified as commercially sexually exploited children, Brantley (2009) found that 55 percent were foster care youth from group homes, and 82 percent had previously run away from home multiple times. In the United Kingdom, the experience of youth in residential placement has been linked with vulnerability to commercial sexual exploitation for boys as well as girls (Mathews, 2000). Some studies have indicated that children placed in nonkinship foster care are more likely to experience physical punishment and be sexually abused and less likely to feel safe in their placement compared with children placed in kinship foster care (Benedict et al., 1996; Fanshel et al., 1990; Wilson and Conroy, 2001). Other studies have shown an association between child sexual abuse and polyvictimization and transactional sex among adolescents in foster care (Ahrens et al., 2012; Turner et al., 2010). Further studies are needed to determine whether commercially sexually exploited minors also are at increased risk of being reexploited or revictimized when placed in foster care or otherwise systems involved.

Lesbian, gay, bisexual, and transgender youth Evidence suggests that LGBT youth may be at increased risk for commercial sexual exploitation and sex trafficking. A number of factors contribute to this potential vulnerability. Among samples of youth who are homeless, for example, as many as 20 to 40 percent are sexual minority youth (Ray et al., 2006), whereas fewer than 10 percent of youth in the general population identify as sexual minority (CDC, 2011). Given that, as discussed above, homelessness is considered one factor contributing to commercial sexual exploitation and sex trafficking of minors, it is not surprising that studies show both a disproportionate experience of homelessness and a disproportionate experience of commercial sexual exploitation among LGBT youth (Adams, 2012; Eastman, 2012; Gilmore, 2012; NAEH, 2009; Polenberg and Westmacott, 2012; Westmacott, 2012). While homeless, LGBT youth are at higher risk for sexual victimization than heterosexual homeless youth (Cochran et al., 2002; Rew et al., 2005; Whitbeck et al., 2004). Yates and colleagues (1991) report that among homeless youth, commercially sexually exploited youth were five times more likely to identify as LGBT. Even prior to homelessness, rates of physical and sexual victimization are higher among LGBT youth than among youth in general (IOM, 2011). Several studies have found that after disclosing their sexual orientation, LGBT youth experience physical and emotional abuse and family rejection (IOM, 2011), both of which are risk factors for these youth becoming homeless. Yates and colleagues (1991) report that the emotional and physical abuse often experienced at home and

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

in school frequently causes LGBT youth to feel isolated and alone, leading them to run away. LGBT adolescents also are at higher risk of being “thrown away” by their families (Palmer, 2001).

Substance use/abuse Research shows that substance use/abuse makes young people extremely vulnerable to a range of poor outcomes. Because substance use/abuse is highly interwoven into the sex trade, it is difficult to determine whether it is a cause or effect of sex work; nonetheless, substance use/abuse itself is one of the main reasons cited by adult women for entering into commercial sex work (Gossop et al., 1994; Kuhns et al., 1992; Weeks et al., 1998). British studies provide evidence that youth who are commercially sexually exploited and trafficked for sexual purposes have higher levels of drug use than other youth (Cusick et al., 2003).

While the connection between substance use/abuse and commercial sexual exploitation and sex trafficking of minors has yet to be demonstrated in the peer-reviewed literature, substance use/abuse may be a major obstacle to finding an exit for both minors involved in commercial sexual exploitation and adults involved in commercial sex work. Researchers describe the complex interrelationship between drug use/abuse and sexual exploitation of young people. For example, some exploiters use young people’s dependency on drugs to control them by managing their drug supply in return for “payment” through commercial sex work (Barnardo’s, 2012; Chase and Statham, 2004; Cusick et al., 2003). Another means of coercion is generating a dependency on highly addictive drugs as a means of controlling youth and ensuring their involvement in commercial sex work. Other reports suggest that substance use/abuse may be a pathway to engaging in survival sex (Chettiar et al., 2010; Edwards et al., 2006; Estes and Weiner, 2001; Greene et al., 1999) or may be used as a coping strategy by victims of commercial sexual exploitation (Cusick and Hickman, 2005; Stoltz et al., 2007).

Psychogenic factors and impaired cognitive function Psychogenic factors, such as poor self-esteem, chronic depression, and external locus of control, in addition to low future orientation, may be individual risk factors for commercial sexual exploitation and sex trafficking of minors (Estes and Weiner, 2001). That child sexual abuse has been shown to have a significant impact on these psychological factors, as described earlier, further supports a potential link between child sexual abuse and risk for commercial sexual exploitation and sex trafficking of minors. Evidence from research with otherwise physically healthy adult women shows that victims of child sexual abuse have long-term impairments in memory and other cognitive and neuropsychological functions (Beers and De Bellis, 2002; Carrey et al., 1995; Perez and Widom, 1994), including deficits in inhibitory capacity directly related to the duration of the abuse. Other cognitive deficits include

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

“lower levels of intellectual ability, academic attainment, abstract reasoning, and executive function” (Navalta et al., 2006, p. 50). Further, research supports the hypothesis that child maltreatment has a deleterious effect on brain development (Bremner et al., 1997; Carrion et al., 2001; De Bellis et al., 1999, 2000, 2002a,b; Driessen et al., 2000; Schiffer et al., 1995; Stein et al., 1997; Teicher et al., 1997, 2004; Vythilingam et al., 2002). Although not enough is known about the direct relationship between impaired cognitive functions and later involvement in commercial sex work, there is some evidence that impaired cognitive functions may increase vulnerability to high-risk sexual behaviors in adult women (Brewer-Smyth et al., 2007). While there is evidence demonstrating an association between child sexual abuse and mental health conditions, further research is needed to help understand potential links among psychogenic factors, impaired cognitive functioning, and mental health conditions as risk factors for commercial sexual exploitation and sex trafficking of minors in the United States.

Disability The sexual abuse of children with learning disabilities is a relatively undeveloped area of research (Blum et al., 2001; Cooke, 1989; Gunn, 1989; Sullivan and Knutson, 2000), and estimates of its prevalence are unclear. Studies suggest that one in three U.S. adolescents and one in four U.S. young adults with learning disabilities have a history of sexual abuse (Baker and Duncan, 1985; Chamberlain et al., 1984; Gunn, 1989). Children with learning and intellectual disabilities likely are overrepresented among those who have been physically abused, neglected, or sexually abused (Glaser and Bentovim, 1979; Horner-Johnson and Drum, 2006). Thus, vulnerability to sexual abuse among children with learning and intellectual disabilities may reflect their vulnerability to all types of abuse. According to Westcott (1993), children with disabilities are particularly at risk of sexual abuse when they experience physical or social isolation, as in the case of institutionalization; are dependent on others for their personal care; or have difficulty communicating. Despite the lack of studies focused on the association of disability with commercial sexual exploitation and sex trafficking, disability should be considered a vulnerability for involvement in these crimes given its association with child sexual abuse, which in turn is a risk factor for commercial sexual exploitation and sex trafficking of minors and also is associated with school dropout, another factor that may increase risk for victimization by these crimes.

Earlier pubertal maturation There is evidence that sexually abused girls tend to have earlier pubertal maturation relative to nonabused girls (Trickett et al., 2011a; Turner et al., 1999). In addition, the timing of physical maturation may play a role in the earlier initiation of health-risk behaviors among adolescents, although the reasons for this relationship remain

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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unclear (Herrenkohl et al., 1998; Hulanicka, 1999; Kendall-Tackett and Simon, 1988; Kim and Smith, 1998; Romans et al., 2003; Tschann et al., 1994). One hypothesis for this relationship, related to the literature on precocious transitions discussed earlier, is that adolescents who experience earlier puberty are under considerably more stress than their peers and are subjected to increased peer pressure to engage in sexual activity, for which they may be ill prepared (Tschann et al., 1994). One organization reports that the age at which commercial sexual exploitation and sex trafficking typically begin is between 12 and 14 (Shared Hope International, 2009), the same age at which many girls have physically entered or completed menarche. Thus, the early age at which commercial sexual exploitation and sex trafficking may occur is not surprising given the known timing of both physical and sexual development.

Early adversity In the mid-1990s, the Centers for Disease Control and Prevention (CDC) funded the Adverse Childhood Experiences (ACE) Study in Southern California’s Kaiser Health System (CDC, undated) (see also the discussion of this study in Chapter 2). Spearheaded by researchers Anda and Felliti, the study was designed to assess the impact of early childhood adversity on future health (Felitti et al., 1998). Researchers surveyed more than 18,000 participants in the Kaiser Health System—most of whom were white, over the age of 50, and with some college education—about their experience of various forms of childhood exposure prior to age 18, including physical or emotional abuse by parents; sexual abuse by anyone; physical or emotional neglect; growing up in a home with a family member with mental illness, an incarcerated parent, or a family member with substance abuse; seeing one’s mother treated violently; and marital separation or divorce. The researchers also had access to all of the participants’ medical records, including pharmacy, physical health, and mental health services.

The researchers found that only 36 percent of the participants reported no childhood adversity, 38 percent had experienced two or more forms of adversity, and more than 12 percent had experienced four or more (Felitti et al., 1998). They also found that 28 percent of the women and 16 percent of the men had suffered sexual abuse as children. Beyond these prevalence data, the researchers found a direct dose-response relationship between the number of adverse childhood experiences and the following chronic behavioral or medical problems:

•    adolescent pregnancy,

•    alcoholism and alcohol abuse,

•    chronic obstructive pulmonary disease (COPD),

•    depression,

•    early initiation of smoking,

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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•    early initiation of sexual activity,

•    fetal death,

•    poor health-related quality of life,

•    illicit drug use,

•    ischemic heart disease,

•    liver disease,

•    multiple sexual partners,

•    sexually transmitted diseases,

•    risk for intimate partner violence,

•    smoking,

•    suicide attempts, and

•    unintended pregnancies.

These findings are relevant to commercial sexual exploitation and sex trafficking of minors. Victims of chronic abuse and neglect are at higher risk for multiple sexual partners, smoking, and substance use (e.g., Hahm et al., 2010; Rogosch et al., 2010; Topitzes et al., 2010), behaviors that predispose to chronic disease. Because childhood adversity, and sexual abuse in particular, is a risk factor for commercial sexual exploitation and sex trafficking of minors, victims of these crimes also may be at heightened risk for these outcomes.

When considering the findings of the ACE Study, it is important to note that the findings regarding early adversity likely can be generalized only to samples with similar demographic backgrounds (e.g., white, over the age of 50, with some college education). For example, the adverse outcomes reported by the participants in the ACE Study may represent an underestimate of the adverse outcomes experienced by individuals who are racial minorities and have less educational attainment. Future longitudinal research is necessary to determine whether these findings can be applied to different populations.

A note on male victims A challenge cutting across the literature on individual-level risk factors for commercial sexual exploitation and sex trafficking of minors is the notable scant attention to male victims. The overwhelming majority of research with young samples focuses on females, and retrospective studies similarly often sample adult women. The available research suggests that males and females share several risks for involvement in commercial sexual exploitation and sex trafficking, including a history of child maltreatment, family violence, and out-of-home residential placement (Barnardo’s, 2002; Chase and Statham, 2004; Mathews, 2000; Palmer, 2001). One study of commercial sexual exploitation of boys and young men in the United Kingdom found that boys and young men who sold or traded sex were far less visible than their female counterparts, potentially

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

because of greater secrecy due to the added stigma of homosexuality (Chase and Statham, 2004). As a result, the males were less likely to be identified than the females.

Palmer (2001) describes two categories of boys who are victims of commercial sexual exploitation. Vulnerable young boys may be singled out and “conditioned” into prostitution by a “caring figure.” These individuals may have an elevated risk of developing an abusive lifestyle in their late teens and adult life, including exploiting or abusing other vulnerable young people (Palmer, 2001). Boys and young men who become victims of commercial sexual exploitation to escape unsafe or poor living situations, on the other hand, generally end up on the street trying to survive (Curtis et al., 2008).

Family-Level Factors

As discussed earlier, child maltreatment, including child sexual abuse, physical abuse, and neglect, is consistently cited as a primary risk factor for commercial sexual exploitation and sex trafficking of minors (e.g., Flowers, 2001). Several studies have found that youth unable to tolerate the family environment because of child maltreatment, other family conflict, or family disruption are more likely to run away (Flowers, 2001). Runaway youth and those without stable housing as a result of family conflict, disruption, or other dysfunction may exchange sexual activity for something of value, often as a means of survival (Nadon et al., 1998), and are at an elevated risk of commercial sexual exploitation and sex trafficking (Barnardo’s, 2002; Estes and Weiner, 2001; Sereny, 1984). In fact, Cobbina and Oselin (2011) note that 60 percent of their sample of female prostitutes (ages 20-60, mean age 36.5) who were prostituted as adolescents were motivated by a desire to feel in control of their sexuality and escape abuse. In their sample of adolescents aged 10-18, Nadon and colleagues (1998) found that, compared with adolescents not engaged in commercial sexual exploitation, juveniles who were prostituted were more likely to be runaways and homeless and reported lower family cohesion, greater parental alcohol abuse, and more interparental conflict.

Although homelessness is considered a potent risk for commercial sexual exploitation and sex trafficking of minors, Estes and Weiner (2001) note that commercially sexually exploited children living in their own homes also are at substantial risk of exploitation and revictimization. Those risks are greater in families in which the exploitation remains undetected, and no external intervention by either law enforcement or child protective authorities has occurred. In a report on commercial sexual exploitation of minors in London, Barnardo’s notes that more than one-third of young people involved in such exploitation in the United Kingdom and having

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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received that organization’s services since 1995 lived at home with their parents (Barnardo’s, 1998, 2002). Other family risks for commercial sexual exploitation and sex trafficking of minors include domestic violence, drug use, serious mental illness, and sexual promiscuity in other family members, perhaps given their association with child maltreatment and neglect. Some children may be victimized repeatedly in their own homes. Thus, it should not be assumed that living at home always protects against commercial sexual exploitation and sex trafficking of minors (Lew, 2012).

Adequate parental monitoring and supervision may protect against commercial sexual exploitation and sex trafficking of minors by limiting opportunities for involvement in risky behaviors. Walker (2002) suggests that, while it is common for adolescents to question their parents’ values and to experiment with behaviors consistent with the norms of their peers, the risks involved are often mitigated by adequate parental supervision. Walker suggests that through such supervision, parents can discourage adolescents from engaging in high-risk behaviors in several ways: by administering punishment, by limiting opportunities to engage in such behaviors, and by discussing the consequences of engaging in these behaviors. On the other hand, deterrents to engaging in high-risk behaviors may not exist without adequate parental or adult supervision, and as a result, adolescents may make decisions about such behaviors without being cognitively prepared to do so. Along similar lines, in a study of young people involved in commercial sexual exploitation, Jesson (1993) identifies a pattern that often emerges when victims’ families lack structure. When adolescents lack family structure or adequate supervision, they may receive minimal guidance on how to spend their free time or how to define themselves, they may lack consistent guidance on boundaries or limits to their behavior, or they may be treated as adults before being cognitively or developmentally ready for such responsibility (Jesson, 1993; Walker, 2002). These young people may be vulnerable because an exploiter may provide them with a simulated family structure that they lack. Walker (2002, p. 183) posits that the young person first being initiated into commercial sexual exploitation under the “protection” of an exploiter may be able to leave behind a “confusing lack of control and gains protection in return, together with the promise of safety in a caring and structured relationship” (see also Jesson, 1993).

Findings regarding the role of family financial resources in commercial sexual exploitation and sex trafficking of minors are mixed. In one study, for example, family socioeconomic status did not differ between adolescents who were prostituted and those who were not (Nadon et al., 1998). Yet other research supports the assumption that low-income children are at risk because of the lure of money or material possessions they desire (McClain and Garrity, 2011), or because family members may knowingly exploit their own children out of financial necessity (Flowers, 2001). On the other hand,

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

some research suggests that many trafficked minors are from middle-class families (Estes and Weiner, 2001).

It is important to note that the familial risk factors described above also apply to many youth who do not become victims of commercial sexual exploitation or sex trafficking. This observation suggests that other factors, including peer, neighborhood, social, and situational factors, interact with family characteristics. These factors are discussed in the following sections.

Peer- and Extrafamilial-Level Factors

Davis (1971) proposes an exposure model to explain women’s motivations for entering prostitution. According to this model, women enter prostitution as a result of interpersonal contacts and “inducement” from others involved in prostitution (see also Cobbina and Oselin, 2011). Likewise, contagion and epidemic models highlight the significance of peer influence for youth’s involvement in risk behaviors. These models highlight peer pressure and modeling as the processes through which peers exert their influence on youth’s entry into or avoidance of commercial sexual exploitation.

Peer pressure can sway individuals’ decision making to be consistent with a social norm (Zwane, 2000). Burgess and colleagues (1981) found that peer pressure was one of the factors associated with initiation into a child sex ring among their sample of 6- to 14-year-old boys and girls. Likewise, some studies have found that peer pressure often is a risk factor for entry into prostitution (Bao et al., 2000; Ennett et al., 1999). Raphael and Shapiro (2002), for example, report that nearly one-third of prostitutes in their sample were encouraged to enter prostitution by another individual. At the same time, however, peer pressure can promote adaptive behaviors, including healthy sexual behaviors and avoidance of risk involvement, leading some to propose peer education programs as one means of preventing risky sexual behavior and sexual exploitation of minors (Zwane et al., 2004).

Youth may model peer behaviors, especially when they observe peers being reinforced for those behaviors. In the present context, youth may copy the behavior of others involved in commercial sexual exploitation in order to obtain desired objects (e.g., money, clothing). Thus, peer modeling may be relevant for entry into and persistence of commercial sexual exploitation. Taylor-Browne and colleagues (2002) and Palmer (2001) report that peers’ involvement in prostitution is one of the reasons some young people find it difficult to end their own involvement in prostitution; the significance of peers appears to increase with the amount of time youth have been involved in prostitution as connections with family and prosocial/mainstream peers weaken or become increasingly strained (Chase and Statham, 2004).

Some peer relationships also are associated with other risks for com-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

mercial sexual exploitation and sex trafficking of minors, thus having an indirect effect on involvement in these crimes. For example, negative peer pressure and social isolation from peers have been identified as risks for youth’s running away from home (Flowers, 2001), which as discussed earlier is associated with involvement in commercial sexual exploitation and sex trafficking. It also is possible that after running away or being expelled from their homes, youth may encounter peers who are involved in deviant or delinquent behaviors. The influence of these peers may exacerbate the effects of running away on the risk for commercial sexual exploitation and sex trafficking of minors at different or multiple points along the pathway to involvement in these crimes.

The role of peers as exploiters of children also is important to consider. Lloyd (1992) notes that the use of physical violence or sexual abuse and coercion may be encouraged or sanctioned by the peer group. Gillen (2003) reports that “peer-to-peer” exchanges of children also are common among exploiters. In addition, there is increasing evidence of gang members’ involvement in human trafficking and prostitution as an additional source of revenue. For example, according to a recent report by the Federal Bureau of Investigation’s National Gang Intelligence Center on emerging gang trends (National Gang Intelligence Center, 2011), gang members may operate as pimps, using force, coercion, or false pretenses, including transporting underage females across state lines, to lead victims into prostitution or forced labor. In some cases, gangs have combined human trafficking and drug trafficking with female victims being used as couriers and for prostitution.

Neighborhood-Level Factors

Several models propose links between the neighborhood context and youth risk behaviors. Collective socialization and collective efficacy models highlight the role of neighborhood adults as role models and enforcers of social controls (Sampson et al., 2002). More socially organized neighborhoods and those with more trust, cohesion, and shared beliefs about appropriate behaviors for youth are more likely to institute formal and informal controls to curb risk among adolescents. When neighborhood control mechanisms are lacking, residents may be more tolerant and accepting of delinquency and criminal behavior among youth, including violence in general and males’ violence against females in particular, as well as of sexual exploitation (Popkin et al., 2010). According to Sampson (2001), the degree to which adult neighborhood residents institute informal social controls against particular adolescent risk behaviors depends in part on their having shared values. Therefore, community norms about sexual behavior and what constitutes consent and coercion likely influence youth’s involvement in commercial sexual exploitation and sex trafficking. Community

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

norms regarding sexual conquest and bravado (Anderson, 1999; Bourgois, 2002; Warner et al., 2011) also may be relevant. McLeod (1982) highlights as important for understanding commercial sexual exploitation of minors such local factors as the existence of a number of commercial sex workers already working near the area; the presence of exploiters or sex establishments, such as saunas and massage parlors; and the demand factor of men who will pay for sex. Likewise, communities characterized by crime, police corruption, adult prostitution, and high numbers of transient males (e.g., truckers, members of the military) appear to have an increased risk for commercial sexual exploitation (Clawson et al., 2009; Estes and Weiner, 2001).

As noted by Satcher (2010), research has not thoroughly examined the role of neighborhood characteristics and public and private disinvestment in commercial sexual exploitation and sex trafficking of minors. However, the available research reveals that the neighborhood context has important implications for sexual activity among young people, including sexual risk behaviors and sexual victimization. The main variables of interest appear to be collective efficacy, poverty, community cohesion and support, and community norms and expectations.

Collective efficacy Collective efficacy refers to mutual trust among neighbors and neighbors’ willingness to intervene when problems arise (Sampson et al., 1997). While the level of collective efficacy has not been directly linked with commercial sexual exploitation and sex trafficking of minors, collective efficacy has been found to reduce the likelihood of dating violence (Jain et al., 2010) and may have relevance for other types of victimization, including commercial sexual exploitation and sex trafficking. For instance, communities characterized by high collective efficacy may have less tolerance for sexual coercion, or victimized youth may find resources for help in these settings. It should be noted, however, that the benefits of collective efficacy depend upon the perception that a problem exists. In communities with high rates of deviant behavior, including crime and gang activity, community norms about appropriate and inappropriate behaviors likely differ from those of communities in which crime and gang presence are less prevalent. Thus, a high level of collective efficacy may not always be protective against commercial sexual exploitation and sex trafficking of minors. For example, collective efficacy within gang communities, particularly those in which gang involvement includes prostitution and sexual coercion of minors, could have adverse effects with respect to commercial sexual exploitation and sex trafficking.

Poverty Living in poverty and disadvantaged conditions has been linked to girls’ risky sexual behaviors and earlier onset of sexual activity (see Leventhal et al., 2009), both of which appear to be risks for commercial

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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sexual exploitation and sex trafficking. Other research suggests that girls growing up in neighborhoods characterized by high poverty are at increased risk of intimate partner violence and sexual assault and are more likely to face sexual harassment and pressure to become sexually active at a young age compared with girls in other types of neighborhoods (Popkin et al., 2010). In fact, among urban girls, the risk of sexual victimization is higher among those in high-risk neighborhoods (Popkin et al., 2010). For example, Menard and Huizinga (2001) found that 38 percent of girls in high-risk neighborhoods were exposed to some type of sexual victimization, including being threatened or hurt by someone trying to have sex with them forcibly; moreover, most girls reported repeated victimization. In those neighborhoods, the fear of sexual harassment, coercion, and assault, described by Gordon and Riger (1991) as the “female fear,” may be common and realistic. Of note, girls who moved from impoverished, high-risk neighborhoods reported less female fear (Popkin et al., 2010), and their actual encounters with these feared events may have occurred less frequently after moving. Neighborhood poverty may not be a risk factor in and of itself. Rather, the correlation may be attributable to other, co-occurring conditions (e.g., violence, drug availability and sales) that together increase the risk of commercial sexual exploitation of minors.

Community cohesion and support Some socially isolated communities are characterized by increased pressures for sexual activity, more threats of violence, and higher risk for victimization (see Popkin et al., 2010; Raphael and Shapiro, 2002; Raphael et al., 2010; Renzetti and Edleson, 2008). A lack of neighborhood cohesion and support can lead to increased family strain and its negative consequences. Community cohesion in support of sexually exploitative behaviors is problematic, while community cohesion in support of prosocial behaviors for youth can be protective. For example, communities’ collective or shared socialization of youth can reduce early-onset sexual behavior and the risk for commercial sexual exploitation and sex trafficking by supplementing the supervisory capacity of parents. Several studies link appropriate supervision and monitoring of youth behavior with less involvement in risky behaviors and more adaptive behaviors; a similar process may be at work for commercial sexual exploitation and sex trafficking of minors.

Community norms and expectations Neighborhoods can shape perceptions of the types of opportunities available for social mobility, ideas about legitimate means of employment, and ideas about the acceptability of sexual behaviors and for whom. These norms can influence the behaviors of traffickers and victims, as well as other community residents. In terms of economic opportunities, for example, there may be real and/or perceived

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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barriers to employment based on characteristics of the neighborhood, and there may be few role models using legitimate means to earn money. Cobbina and Oselin (2011) report that 40 percent of their sample of prostitutes (n = 40) described prostitution as “normal” in their neighborhood and a viable option for obtaining income.

Systems-Level Factors

Multiple systems may be involved in the response to victims of commercial sexual exploitation and sex trafficking of minors. These systems include child protection agencies, law enforcement, health care providers, schools, and nongovernmental agencies that serve victims and their families. During its deliberations, the committee heard from a number of organizations that provide services to victims and survivors of commercial sexual exploitation and sex trafficking. The committee learned about barriers that exist within and among these systems that may impede their ability to protect youth from exploitation and help victims rebuild their lives. Involvement with these systems, particularly child protection, often is an appropriate protective response to prior abuse, neglect or maltreatment, poverty, homelessness, and many of the other risk factors for commercial sexual exploitation and sex trafficking of minors documented above. In some cases, however, involvement with these systems may actually pose additional risk for involvement in commercial sexual exploitation or survival sex for vulnerable youth. The following sections review possible risk factors associated with a range of systems. Current and emerging practices, challenges, and opportunities within each of these systems are discussed in greater detail in Chapters 5-10 of this report.

The child protection system Child protection systems are public systems, funded by federal, state, county, and sometimes local resources. These systems are not uniform from state to state, but essentially all are charged with responding to reports of suspected child abuse and neglect. Within the child protection system, the highest premium is placed on protecting the child, whether in the home or in an out-of-home placement. The next priority is provision of services to the child and family to keep the child in the family or reunify the family if the child has been removed from the home for some period of time (Waldfoegel, 2009). Chapter 6 provides additional detail on the roles of child protection systems with respect to child victimization.

In 2011, according to a U.S. Department of Health and Human Services (HHS) report on child maltreatment (ACF, 2010), child protection systems across the United States, including Puerto Rico and the District of Columbia, responded to more than 3.4 million reports of child maltreatment and identified 676,569 children who were victims of maltreatment in

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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the United States, for a unique victim rate of 9.1/1,000 children in the U.S. population (ACF, 2011). Of these victims, 78.5 percent were found to have suffered neglect, 17.6 percent physical abuse, 9.1 percent sexual abuse, 9.0 percent psychological maltreatment, 2.2 percent medical neglect, and 9.6 percent some other form of maltreatment. In the 44 states for which data are available, about one-fifth of all victims were removed from their homes, while approximately two-fifths received in-home services (ACF, 2011).

The child protection system clearly plays a critical role in removing children from adverse circumstances that can serve as risk factors for commercial sexual exploitation and sex trafficking, such as sexual and physical abuse and maltreatment. In this way, the child protection system intervenes to interrupt abuse, even if the abuse was not prevented. Once a child has been removed from the home and placed in foster care or a group home, however, he or she may be subjected to ongoing abuse. The HHS report on child maltreatment notes that fewer than half of the 49 states reporting met the standard of 99.68 percent of children not being maltreated while in foster care (ACF, 2011). In addition to the ongoing risk of abuse while in foster care, such placements may constitute a risk for commercial sexual exploitation and sex trafficking. As Shalita O’Neale, executive director of the Maryland Foster Youth Resource Center, explained to the committee:

A lot of people feel that once they are removed from that situation and they are placed into foster care that it’s a better situation for them, that they’re safe now and that everything is okay. And that may be the case for a lot of foster youth, but for many that isn’t the case…. There’s a lot of sexual, physical, and emotional abuse within foster care itself.

Despite their shortcomings, group homes or foster placements may still be preferable to returning the child to the home. Thus, it is worrisome that participants in the committee’s site visits in Chicago and New York revealed that increasing numbers of reports and caseloads, combined with funding cuts, have caused the child protection system to be overwhelmed (Ashai, 2012). Case managers faced with mounting caseloads often are forced to give priority to the youngest and most vulnerable children while being encouraged to promote family unification or reunification over removal (Ashai, 2012; Polenberg and Westmacott, 2012).

One particularly challenging issue is whether reunification is desirable or even possible. Among the social issues facing youth involved in commercial sexual exploitation and sex trafficking are difficulties with primary social support systems (e.g., family, friends), including interrupted or intermittent contact with their primary social supports, changes in social network dynamics, and challenges in trying to reengage family and social partners as the result of commercial sexual exploitation and sex trafficking. Busch-Armendariz and colleagues (2011) note that reuniting victims

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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of commercial sexual exploitation with their families, social networks, and schools is enormously stressful to both victims and their families, especially after long periods of separation. They suggest that a case management approach is required to help manage all the points and stresses of reconnection and to evaluate whether reunification is in the best interest of the victim.

Law enforcement and the criminal justice system Law enforcement agencies have a critical role in responding to reports of commercial sexual exploitation and sex trafficking of minors, apprehending exploiters, and identifying and rescuing youth on the streets who may be victims. Nonetheless, victims may actively refuse to cooperate with law enforcement or other service providers for a number of reasons, including ambivalence about leaving the exploiter, confusing an exploiter’s caretaking activities (e.g., provision of food and shelter) with true caring, or fear of retaliation from the exploiter for engaging with law enforcement. Without sufficient education and training about the multiple factors that contribute to the behavior of victims of commercial sexual exploitation and sex trafficking, victims’ deep mistrust for law enforcement and other systems, and their fear of further victimization while detained, law enforcement personnel may have difficultly knowing best practices for intervening in cases of commercial sexual exploitation and sex trafficking of minors. Further, without training regarding the complex set of forces that perpetuate commercial sexual exploitation and sex trafficking and those that prevent minors from experiencing continued victimization, law enforcement personnel and the law enforcement system may fail to understand what is needed to disengage youth from involvement in these crimes. As described further in Chapter 5, there are two areas of concern: conceptualization of minors who are commercially sexually exploited and trafficked for sexual purposes as criminals/delinquents rather than victims, and the arrest and/or detention of victimized minors.

Law enforcement officers may struggle to conceptualize youth involved in commercial sexual exploitation as victims rather than offenders. Research reviewing case files from six U.S. police agencies found that 60 percent of youth involved in commercial sexual exploitation were conceptualized as victims by the police, while 40 percent were seen as offenders (Halter, 2010). Halter identifies five characteristics associated with a youth’s being regarded as a victim by police: greater levels of cooperation, the presence of identified exploiters, the absence of a prior criminal record, coming to police attention through a report, and being from the local area. Biases regarding these characteristics may be shaped by police practices in dealing with adult prostitution as a crime for which individuals are processed as offenders. In some cases, law enforcement personnel may see few options

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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for intervening other than secure detention. For example, law enforcement officials have described detaining victims as a way to protect them from further exploitation or because they lack appropriate services and shelter for the victims they encounter (Fassett, 2012). Detention may be perceived as a better alternative when other options have failed, or officers have limited community resources for placing victims safely. Halter (2010) found that police often were likely to process youth as offenders in an effort to use criminal charges to “protect” youth whom they viewed as uncooperative, resistant to help, or reluctant to give information about their exploiter or who had a prior record.

Unfortunately, actions and policies that support detention for victims of commercial sexual exploitation and sex trafficking may serve to further traumatize the young victims, even if the intent is to protect them from further harm. As David Nielsen, senior social science analyst in the Office of the Assistant Secretary for Planning and Evaluation at HHS, noted during the committee’s May 2012 workshop:

I think the frustration from our law enforcement officers down in Los Angeles is a lot of times they’ll pick the girls up because they don’t want them on the street, and they’ll take them home. Well, home is where they’ve been running away from. Call Child Welfare and they’ll come pick them up, and on the way to the Command Post for Child Welfare the kid jumps out of the car.

Victims and survivors of commercial sexual exploitation and sex trafficking may distrust official systems and services (e.g., child welfare, law enforcement, hospitals, and shelters) and experience institutional violence (i.e., violence or abuse perpetrated by institutions as opposed to individuals) (Sherman, 2012). For example, qualitative research conducted by Iman and colleagues (2009) found that the individual violence experienced by victims and survivors was exacerbated by the institutional violence they experienced from systems and services. Respondents reported “emotional and verbal abuse as well as exclusion from, or mistreatment by, services” (Iman et al., 2009, p. 30). In addition, respondents reported that they were often denied help by professionals and systems that are responsible for protecting and serving children and adolescents because they were involved in the sex trade, because they were perceived as gender nonconforming, or because they used drugs (Iman et al., 2009).

The health care system While involvement with the health care system is not a risk for commercial sexual exploitation and sex trafficking per se, victims and potential victims of these crimes are likely to have contact with that system, most often in emergency departments, walk-in clinics, or other episodic care locations (Cohen, 2005; Macy and Graham, 2012). The

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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type and quality of care received by victims can have implications for their future or continued involvement in commercial sexual exploitation and sex trafficking. Problems relating to sexually transmitted infections, the need for contraceptives, or treatment for injuries due to violence should alert health care providers to the possibility of commercial sexual exploitation or sex trafficking when the patient is a minor; is in the company of a non-family member guardian; or has other known risk factors for commercial sexual exploitation and sex trafficking, such as homelessness, involvement with the child protection or juvenile justice system, or being LGBT. Health care providers who fail to recognize, report, or address commercial sexual exploitation and sex trafficking of minors may unknowingly contribute to additional exploitation and abuse.

A health care workforce—including school-based nurses, community health center providers, and community health workers as well as physicians and nurses—that is adequately trained can recognize and address at-risk youth to prevent possible commercial sexual exploitation and sex trafficking of minors and intervene with, report, and treat victims to help prevent further exploitation or health consequences (e.g., Goldblatt Grace et al., 2012). Chapter 7 provides a comprehensive discussion of the role of the health care system in assessment and treatment of victims of commercial sexual exploitation and sex trafficking and youth at risk of such victimization.

The education system School staff, including educators, administrators, and health service providers, are uniquely familiar with the range of normative development in youth, including not only academic adjustment but also emotional, behavioral, and physical adjustment, given the vast numbers of students they encounter in their work. Consequently, school personnel can be instrumental in noticing changes in student behavior that may indicate risk for or involvement in commercial sexual exploitation and sex trafficking of minors. The degree to which school personnel are adequately trained about these crimes and are knowledgeable about how to proceed when the crimes are suspected or disclosed can therefore contribute to or mitigate the risk for their occurrence. In addition, most children and adolescents spend a majority of their school days at school; thus, the school is an ideal setting in which to offer education, prevention, and intervention programming for students and families. Additional benefits of providing such services through schools are that it is possible to reach large numbers of youth, less stigma is associated with these services than is the case in other settings, and schools are familiar and generally easily accessible settings for students and families.

Goldblatt Grace and colleagues (2012) suggest that schools should be responsible for increasing staff awareness of commercial sexual exploitation

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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of minors, increasing student and parent awareness, and creating policies for dealing with cases in which students disclose that they are involved in commercial sexual exploitation. For example, the National Center for Missing and Exploited Children (NCMEC) recommends that any individual with access to children in schools receive training in commercial sexual exploitation of minors. In addition, NCMEC urges comprehensive programming on the topic that is grounded in educational theory; developmentally appropriate for students; repeated for multiple years (versus just once); and delivered through multiple components and formats, including role playing, rehearsal of behaviors, feedback, and active participation of students. Schools also should regularly assess their physical structures and surroundings to ensure that they are safe for children, with proper supervision and security in classrooms and throughout the campus and school grounds. Procedures should be in place as well for screening visitors to the school. These efforts should include parents’ and guardians’ role in ensuring that their children are safe while traveling to and from school. Accordingly, NCMEC provides back-to-school safety tips for children and caregivers (NCMEC, 2013). As Bolling and Harper (2007) note, however, there may be barriers to implementing school-based programs focused on sexual health and sexual exploitation as a result of local, state, and federal policies that may limit the discussion of these issues at school. Chapter 8 includes an in-depth discussion of current and emerging practices in the education sector as well as challenges to and opportunities for preventing, responding to, and addressing commercial sexual exploitation and sex trafficking of minors.

Macro-Level Factors

Beyond individual characteristics and circumstances and the immediate settings in which youth live their lives, it is important to consider the broader contexts that surround individuals, families, peer groups, neighborhoods, and systems. Aspects of the macro environment influence standards regarding the types of behaviors that are acceptable and expected from victims, as well as from traffickers and exploiters. Cultural norms and expectations are primary macro-level influences on commercial sexual exploitation and sex trafficking of minors.

The sexualization of children, particularly girls, and its adverse consequences may play a role in the risk for commercial sexual exploitation and sex trafficking of minors. Concerns about the increasing availability and promotion of products intended to make girls look “sexy” at increasingly younger ages focus on the numerous adverse developmental, social, cognitive, and physical consequences for girls (Egan and Hawkes, 2008). Sexualized images and messages appear in television programming, movies,

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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computer games, and print media, as well as toys, clothing, makeup, and other products marketed to both adults and children. Merskin (2004) and others argue that the messages underlying these products suggest that girls should be sexually available, be willing to be gazed upon, and be willing to be dominated and in some cases recipients of sexual aggression. Given these media messages and their implicit societal sanctioning, girls may perceive benefits to appearing “sexy” (e.g., being more popular, getting more attention) without understanding the potential negative consequences (Murnen and Smolak, 2012). The American Psychological Association’s Task Force on the Sexualization of Girls (2010) notes that the media communicate cultural norms, expectations, and values, and media featuring sexualized images of girls and women normalize sexualization. According to the task force, moreover, sexualized images of girls may reflect “social tolerance of sexual violence and the exploitation of girls and women” (p. 2), as well as contribute to these issues. Thus, the sexualization of girls may place them at risk for commercial sexual exploitation and sex trafficking by shaping their own and others’—including potential traffickers’ and exploiters’—expectations for how girls and women should be treated.

In addition, online and digital technologies, such as the Internet, online classified sites, social networking sites, chat rooms, and mobile phones, are parts of a complex social system that can be used by children and adults in ways that can impact both risk and protective factors for the commercial sexual exploitation and sex trafficking of minors in the United States. The committee includes a discussion of online and digital technologies as risk and protective factors for the commercial sexual exploitation and sex trafficking of minors in the United States in Box 3-1.

A Note About Race/Ethnicity

The interactions among race/ethnicity, victimization, and criminalization are important to consider in relation to risk for commercial sexual exploitation and sex trafficking of minors. Given the current state of evidence, however, the committee was unable to draw conclusions about these interactions. As in other areas, such as the child welfare and juvenile justice systems, in which minority youth are disproportionately represented, it is extremely difficult to disaggregate race/ethnicity from many other complex, multilevel, and interrelated factors, including poverty, constricted educational opportunities, and other structural inequities (NRC, 2013). (For an in-depth discussion of these topics, see the National Research Council [NRC] report Reforming Juvenile Justice: A Developmental Approach [NRC, 2013]). The committee strongly believes that the intersections between race/ethnicity and commercial sexual exploitation and sex trafficking of minors in the United States warrant further examination.

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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BOX 3-1
Online and Digital Technologies as Risk and Protective Factors for the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States

Digital technologies pervade the lives of young people today (Lenhart et al., 2010), and research on children’s use of online technologies is abundant (Ito et al., 2009). Recently, debates have emerged about whether digital technologies, such as the Internet, online classified sites, social networking sites, chat rooms, and mobile phones, are exacerbating commercial sexual exploitation and sex trafficking of minors in the United States. While there is little evidence-based research specifically measuring the effect of technologies on risk or safety in relation to these crimes, the literature provides some early indications and lessons on this issue. The findings of this research generally indicate that, as with technology generally, online and digital technologies, combined with other social factors, can facilitate both negative and positive consequences—i.e., both risks and benefits—to children.

Recent studies from the University of Southern California Annenberg Center on Communication Leadership & Policy provide preliminary evidence that the Internet and other digital networked technologies are being used to facilitate the commercial sexual exploitation and sex trafficking of minors in the United States (Latonero, 2011, 2012). Choo (2009) likewise found that exploiters are using online and digital technologies for recruiting, grooming, and advertising victims for the purposes of commercial sexual exploitation and sex trafficking. Researchers at the Crimes Against Children Research Center have produced a series of empirical studies on how technology facilitates specific aspects and instances of commercial sexual exploitation of children (Mitchell et al., 2010, 2011; Wells et al., 2012). For example, Wells and colleagues (2012) examined law enforcement sources and found that domestic cases of technology-facilitated sex trafficking of minors involved younger juveniles and were more likely to involve a family member or acquaintance compared with non-technology-facilitated cases. Researchers at Microsoft have recently explored these issues and have funded a number of forthcoming studies examining the role of technology in domestic sex trafficking of minors (Boyd et al., 2011). However, little to no extant evidence-based research measures or estimates the overall scale, prevalence, or impact of online and digital technologies with respect to the commercial sexual exploitation and sex trafficking of minors in the United States.

Risk Factors for Offenders

This section examines the individual risk factors associated with those who exploit victims of commercial sexual exploitation and sex trafficking of minors. The focus is on two types of exploiters: traffickers and solicitors/purchasers of commercial sexual exploitation (as defined in Chapter 1). Traffickers’ primary role in commercial sexual exploitation and sex traf-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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In their survey of risk and safety factors for children on the Internet, Livingstone and Haddon (2009, p. 5) state, “today these risks . . . are more available and more accessible, readily crossing national borders to reach children anywhere, anytime, too easily escaping local and national systems of child welfare and law enforcement.” Yet not all minors are equally at risk online. Palfrey and colleagues (2009, p. 5) contend that “the psychosocial makeup of and family dynamics surrounding particular minors are better predictors of risk than the use of specific media or technologies.”

It is important to note as well evidence indicating that Internet technologies are being used to identify, monitor, and combat the commercial sexual exploitation and sex trafficking of minors in the United States (Latonero, 2011, 2012). In addition, research suggests that youth’s use of online technology, in conjunction with other social factors, including parents, families, and friends, can become a positive force in their lives (Livingstone and Helsper, 2007, 2008, 2010). According to researchers at the Berkman Center for Internet and Society, a “combination of technologies . . . in concert with parental oversight, education, social services, law enforcement, and sound policies by social network sites and service providers may assist in addressing specific problems that minors face online” (ISTTF, 2008, p. 6). The Internet also offers a number of opportunities for both risk reduction and empowerment for youth. For example, online technologies provide venues that enhance youth education, civic participation, and social connection (Livingstone and Haddon, 2009). However, little to no research has examined how youth can use these opportunities in ways that might prevent or protect against the commercial sexual exploitation and sex trafficking of minors in the United States. Moreover, the available research indicates that technology cannot serve as a panacea for any social ill, including online risks to safety for youth and the commercial sexual exploitation and sex trafficking of minors.

Taken together, the available research suggests that the Internet, online technologies, and digital networks are a major component of the lives of children and adolescents, yet these technologies in and of themselves likely are not the only determinants of positive or negative effects. Instead, technologies are part of a complex social system that can be used by children and adults in ways that can impact both risk and protective factors. Clearly, more direct empirical and evidence-based research is needed to examine specifically how digital technologies are used in ways that increase or decrease the risk and safety of youth in relation to commercial sexual exploitation and sex trafficking of minors in the United States.

ficking of minors is recruiting and maintaining control over victims for purposes of profit and other gain. Traffickers may use several factors, such as housing, food, and income, to control their victims, and these manipulative behaviors may make it extremely difficult for victims to exit their situation (Polaris Project, undated; Shively et al., 2012; Westmacott, 2012). Purchasers are essential to commercial sexual exploitation and sex traffick-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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ing of minors as these crimes would not exist were there no demand. Thus, just as important to inform focused prevention efforts as examining factors that contribute to becoming a victim of commercial sexual exploitation and sex trafficking is examining what is known about why people become offenders.

Rigorous studies examining factors associated with the risk of becoming or being an exploiter are extremely difficult to conduct given the hidden nature of commercial sexual exploitation and sex trafficking of minors. Moreover, despite recognition that understanding the risk factors for becoming an exploiter is critical to inform prevention and intervention efforts, the vast majority of research examining risk factors for commercial sexual exploitation and sex trafficking of minors focuses on victims. The limited available research examining exploiters (i.e., traffickers and solicitors) is primarily descriptive in nature, not peer reviewed, and not focused specifically on the exploiters of victims under age 18. In addition, much of the available research describes international but not domestic commercial sexual exploitation and sex trafficking of minors.

Traffickers

Among studies describing traffickers, many rely on data from secondary sources, such as child survivors, service providers, and law enforcement reports, and a large proportion of these data is anecdotal. In terms of demographic characteristics, Shared Hope International’s descriptive report on demand indicates that a growing number of traffickers in the United States are boys or young men who may work with older men (Shared Hope International, 2006). Similarly, most national and international reports indicate that traffickers are primarily men (Busch-Armendariz et al., 2009a,b; Farley et al., 2011; Mitchell et al., 2010; Raphael and Myers-Powell, 2010; Spindle et al., 2006). However, there is some evidence that women engage in trafficking as recruiters (Raphael and Myers-Powell, 2010; Siegel and de Blank, 2010). For example, a study that examined 89 court files in the Netherlands found that women who had become traffickers reported doing so to stop being victimized themselves (Siegel and de Blank, 2010). Comparable evidence in the United States indicates that female traffickers are or once were victims and became recruiters for such reasons as obtaining protection or gaining favor from their traffickers (Busch-Armendariz et al., 2009a,b; Mitchell et al., 2010; Siffermann, 2012; Turner and Kelly, 2009). Unfortunately, no research has examined specific sex differences in the risks associated with becoming traffickers, nor is there information regarding whether the potential pathways to becoming a trafficker may be different for males and females.

With respect to other risk factors associated with becoming a trafficker,

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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many law enforcement and child welfare agencies, as well as nongovernmental organizations serving victims, report that traffickers and victims of commercial sexual exploitation and sex trafficking share several life factors, including coming from a poor economic background; having a history of physical and/or sexual abuse, domestic violence, family prostitution, or family drug and alcohol abuse; and having been a former victim of these crimes (Goldblatt Grace, 2012; Holzman, 2012; Ring, 2012; Siffermann, 2012). A recent review of cases prosecuted in the United States and of existing literature focused on traffickers revealed that some traffickers participate in activities that can contribute to becoming a trafficker, such as gang and/or organized crime activities that may include sex trafficking (Busch-Armendariz et al., 2009a,b). However, no studies have examined whether the risk factors associated with becoming a trafficker are similar to those associated with becoming a gang or organized crime member. Given that some traffickers are involved in gangs and/or organized crime networks, examining the risk factors associated with individuals becoming involved in those activities might reveal information about risk factors for trafficking.

No studies to date have prospectively examined factors that contribute to becoming a trafficker of domestic minors. The few studies examining risk factors for becoming a trafficker are descriptive in nature. For example, interviews of a convenience sample of 25 former traffickers (18 male, 7 female) from the Chicago area revealed that risk factors for becoming a trafficker were similar to those identified for becoming a victim of commercial sexual exploitation (Raphael and Myers-Powell, 2010). Specifically, the majority of participants reported a history of physical abuse (88 percent), sexual assault (76 percent), domestic violence (88 percent), drug and alcohol abuse in the home (84 percent), family members’ involvement in prostitution (60 percent), personal use of alcohol as a child (84 percent), and running away from home because of abuse (48 percent). The similarities in risk factors associated with becoming a trafficker and becoming a victim may have been driven, at least in part, by the traffickers’ previous victimization histories. In this study, 68 percent (n = 17) of the traffickers reported that they had been a victim of prostitution before becoming a trafficker. All of the women who were traffickers had a previous history of being exploited, providing further evidence that women who are exploited often go on to become traffickers (Raphael and Myers-Powell, 2010). However, results of this study should be interpreted cautiously and warrant replication given the small convenience sample.

One descriptive report describes three profiles of traffickers—“business pimps,” “boyfriend pimps,” and “guerilla pimps”—to demonstrate the variation in how traffickers use force, fraud, or coercion to control their victims (Mones, 2011). The business pimp approaches victims from a purely economic perspective, promising victims careers in modeling or acting and

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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help in earning money quickly, but often not committing to these promises. Instead, the business pimp creates a sort of debt bond with victims by forcing them to continue to make money to pay off a debt that is unachievable and unrealistic. The boyfriend pimp, described as one of the more common types of traffickers, leads victims to believe they are in love and develops a romantic relationship with them, often described as a trauma bond. The boyfriend pimp promises victims a better life, but begins to isolate them as he “grooms” them for exchanging sex for money. The guerilla pimp uses physical force and fear to manipulate victims, and commonly kidnaps and physically abuses them to maintain control (Goldblatt Grace, 2012; Mones, 2011; Ring, 2012). Future research needs to examine specific factors associated with each of these profiles.

Because some traffickers use sexual and physical assault as forms of force and coercion to control their victims, studies focused on factors contributing to the commission of sexual assault and sexually coercive behaviors are relevant to understanding risk factors associated with trafficking. Although little is known about specific factors that contribute to sexually coercive behaviors such as rape, previous research has shown that experiencing abuse (both physical and sexual) in childhood is associated with the development of sexually aggressive behaviors later in life (Malamuth et al., 1995; Nagayama Hall et al., 2005; Simons et al., 2002; White and Smith, 2004). Two studies examined childhood predictors of sexually coercive behavior using data from the National Longitudinal Study of Adolescent Health (Add Health), a national longitudinal sample of youth in the United States who were in grades 7-12 during the 1994-1995 school year and have been followed into young adulthood (Harris, 2011; Harris et al., 2009) (see Chapter 2 for discussion of this study). Casey and colleagues (2009) found that boys who experienced childhood sexual or physical abuse were at greater risk of perpetrating sexual coercion against a partner later in life compared with nonabused boys. Respondents reporting both childhood physical and sexual abuse had a 450 percent greater risk of perpetrating sexual coercion against a partner later in life. It is important to note, however, that of the men who reported coercive sexual behaviors, 55.3 percent had no previous experience of physical or sexual victimization in childhood.

Different behaviors accounted for these associations between child maltreatment and sexually coercive behavior during adulthood. Specifically, these investigators suggest that the effect of child sexual abuse on sexually coercive behavior later in life was partly accounted for by early sexual initiation; on the other hand, the effect of child physical abuse on sexually coercive behavior was accounted for by delinquent behaviors during adolescence (Casey et al., 2009). That the pathways linking child maltreatment and sexually coercive behavior included behaviors (i.e., early sexual initiation and delinquency) but not beliefs (i.e., impersonal sex beliefs) or alcohol

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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use is inconsistent with other research suggesting the importance of these latter factors in sexual coercion. Additional longitudinal research is needed to clarify the multiple possible pathways linking child maltreatment with sexually coercive behavior and the sexual exploitation of children.

Given the overlap of risk factors for victims and traffickers as well as the finding that some victims become traffickers, it is possible that programs focused on early intervention to prevent victimization by commercial sexual exploitation also could prevent individuals from becoming traffickers. Similarly, those factors known to be protective for adolescents, such as having a supportive nurturing adult, may also be factors that can protect children from becoming traffickers. Unfortunately, however, there have been no studies examining factors that are linked to a decreased likelihood of becoming a trafficker. Research is needed to examine the relationship between factors associated with sexually assaultive and coercive behaviors and those associated with the potential for becoming a trafficker. Such research could help support the development of prevention interventions for those at risk of becoming exploiters.

Solicitors/Purchasers

Existing estimates of the percentage of men who purchase sex vary greatly, ranging from 16 to 69 percent in the United States (Farley et al., 2011). A more recent national finding on the rate of adult men in the United States who admit to purchasing sex is 10 to 20 percent of all men (Shively et al., 2012). Given these estimated rates, and if in fact the majority of men do not purchase sex, it is argued that solicitation of sex cannot be considered a normative or intractable problem, but can be addressed by preventive measures (Shively et al., 2012). Unfortunately, most of what is known about solicitors is based on research on purchasers of adults, not minors, for sex. In addition, the majority of research on solicitors has been conducted internationally, not domestically. Nonetheless, the available research does highlight some important factors that may be associated not only with solicitors of sex with adults but also with solicitors of sex with minors in the United States.

Regarding some demographic factors associated with solicitors, a Norwegian study examining solicitors of sex among a random sample of 1,000 men found more demographic similarities than differences between men who have and have never purchased sex (Hoigard and Finstad, 1992). In a 2008 study, the National Council for Crime Prevention conducted 53 international interviews with professionals knowledgeable about human trafficking, including government authorities, law enforcement personnel, representatives of nongovernmental organizations, and social services personnel, as well as facilitators, such as taxi drivers and hotel staff (Englund

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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and Korsell, 2008). According to the descriptive report on this study, sex buyers were a heterogeneous group. While the solicitors described in the report ranged in age, the majority were between 30 and 50 years old, had regular employment, and had a college education; almost half were married or in a long-term relationship and had children.

A few descriptive reports examine solicitors’ behaviors and motivation for purchasing sex. Farley and colleagues (2011) studied the attitudes, behaviors, and demographic characteristics of 110 men who were seeking prostitutes in Scotland. These men, recruited through newspaper advertisements seeking men who were clients of prostitutes, were interviewed about their frequency of purchasing sex and then categorized into those who purchased sex frequently (i.e., more often than once a month) and those who did so less frequently (i.e., once a month or less). Results revealed that men who purchased sex more frequently were more likely to report having committed sexually aggressive acts against nonprostituting women; used pornography more often; and accepted the “rape myth,” or the belief that prostitution prevents rape of nonprostituting women (Farley et al., 2011). Another descriptive study examined the motives and sexual preferences of 584 U.S. men who were seeking an online female service provider for paid sex acts (Milrod and Monto, 2012). Although limited by convenience sampling, this study found that the most of those men were married or partnered (66.3 percent) and had engaged sexually with a prostitute more than once during the last year (66.3 percent). The reasons for seeking prostitutes varied, including “I like to be with a woman who really likes sex” (98.7 percent); “I am excited by the idea of making contact with a prostitute” (86.4 percent); “I like to have a variety of sexual partners” (86 percent); and “I want a different kind of sex than my wife or regular partner does” (66.9 percent) (Milrod and Monto, 2012). Given the variation in characteristics of men who purchase sex, more studies are needed to better understand personal motivations as well as other factors that contribute to men’s soliciting sex, including sex with minors.

Some reports argue that those designing preventive measures to address solicitors must acknowledge that individual factors contributing to the solicitation of sex are strongly associated with societal and cultural attitudes and beliefs about sex and that demand cannot necessarily be addressed at the individual level alone (Claude, 2010; The Schapiro Group, 2009; Shively et al., 2012). Specifically, a review by Ben-Isreal and Levenkron (2005) points out that in some cultures, purchasing sex is a normal sexual behavior of men. In Thailand, for example, it is common for men to have sex for the first time with a prostitute (Ben-Israel and Levenkron, 2005). Similarly, a U.S. study examining the online culture of men purchasing sex found a subculture of men purchasing sex who justify doing so as a normal, nondeviant behavior of men (Blevins and Holt, 2009). In another U.S. study, Milrod and Monto

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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(2012) found that men who solicited sex online were seeking not just sex but companionship and an emotional relationship, which they called “the girlfriend experience.” This finding suggests that some men may be motivated in their exchange by normative relationship qualities rather than just a sex act (Milrod and Monto, 2012). Given the broad range of factors associated with men purchasing sex, additional research is needed to help support or refute the reasons currently proposed for why men buy sex and more important, the motivators for purchasing sex with minors, to better explain the biological, social, and cultural influences on this behavior.

With respect to U.S. demographics, findings are contradictory regarding the differences between men who buy sex and those who do not. One study, conducted in Chicago, included 129 men, 81 percent of whom were classified as “users” who had patronized a sex trade venue at least once in their lifetime, and 18 percent of whom were classified as “nonusers” who had never patronized a sex trade venue or exchanged anything of value for sexual services (Chicago Coalition for the Homeless, 2004). There were no demographic differences between the two groups; however, those who were described as more frequent solicitors (i.e., more than 10 times in their life) were more often married and older than those who solicited sex less frequently (i.e., fewer than 10 times in their life). Those who had purchased sex at all had attitudes reflecting indifference to the risk and harm to women who were prostituted (Chicago Coalition for the Homeless, 2004). In contrast, in a study that compared men who had purchased sex in the United States with a nationally representative sample of men, the former men were significantly less likely to be married and were more likely to be unhappy in their marriage if they were (Monto and McRee, 2005).

Although most of the demographic characteristics of men who solicit are not measurably different from those of the general population of men who do not purchase sex (Farley et al., 2011; Shively et al., 2012), one study did find differences in attitudes toward women, toward relationships, and toward commercial sex. Monto and McRee (2005) found that men who had solicited sex were more likely to have liberal attitudes toward sex (e.g., to support premarital sex), to think about sex more often, to have participated in the sex industry, to have served in the military, to have been sexually molested as children, or to have forced women into sexual acts. Further research is necessary to clarify some of these demographic variations.

Most of the research examining demographic characteristics of solicitors (e.g., Shared Hope International’s [2006] summary report; the Department of Justice’s A National Overview of Prostitution and Sex Trafficking Demand Reduction Efforts: Final Report [Shively et al., 2012]) stresses that a primary reason for understanding solicitors is to inform the development of focused prevention efforts and to shift some emphasis toward the solici-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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tors of sex with minors, one of the essential drivers of the problem of commercial sexual exploitation and sex trafficking of minors (Claude, 2010; Shared Hope International, 2006, 2012; Shively et al., 2012). Although a handful of reports focus on solicitors more broadly, few peer-reviewed studies examine specific risk factors that contribute to the solicitation of minors for sex or explore why men may want to purchase sex from underage victims. One exception is the Georgia Demand Study, an attempt to quantify and describe the demand for commercial sexual exploitation of children in Georgia (The Schapiro Group, 2009). Volunteer participants (n = 218) responded to online advertisements for sex with a “young female,” posted on media commonly used to advertise sex services (e.g., Craigslist.com, Backpage.com), and a member of the research team posed as an “operator” to broker the purchase. Respondents were not aware that they were part of a research project. Nearly half of the men who wished to purchase sex were aged 30-39, and just under half expressed willingness to pay for sex with a young female even when they were certain she was an adolescent. Based on these findings, the authors conclude that most men who exploit adolescent females may not know or may be willing to ignore the possibility that they may be having sex with an underage victim. Further, based on the results from their sample, the authors estimate the number of men who purchase sex with females under 18 (The Schapiro Group, 2009).

Several methodological concerns suggest extreme caution in evaluating the conclusions of this study. In addition to being based on a convenience sample of volunteers, the study provides no details about the respondents; thus the generalizability of this research is unclear. The authors note that the sample showed diversity in terms of age, geographic location, experience with purchasing sex, and sex purchase preferences; however, they give no specifics regarding these sample characteristics (The Schapiro Group, 2009). In addition, the interview protocol is not presented; therefore, whether or the degree to which the interviewers’ questions may have encouraged callers to make purchases is unclear. While the study respondents expressed a willingness to pay to the telephone operator (i.e., research confederate), one also cannot know how many would have actually completed the purchase and followed through. Finally, because the method used to estimate the number of men who purchase sex from underage women is not presented, the assumptions underlying the estimate are unknown, and the reliability of the estimate cannot be evaluated.

Evidence indicates that the overwhelming majority of individuals who solicit minors for sex are not pedophiles (i.e., those who have a sexual attraction to prepubertal individuals) or hebephiles (i.e., those who have a sexual attraction to adolescents). Instead, reasons for soliciting sex may be “situational,” and some may be seeking sex with “younger” individuals and not know they are soliciting sex with a minor. Research describing

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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motivations for soliciting sex from younger victims reveals a broad range individuals, including those who perceive a lower chance of contracting sexually transmitted infections, including HIV, with younger individuals; those who do not care about the age of their victims; and those who solicit sex indiscriminately (Ben-Israel and Levenkron, 2005; Shared Hope International, 2006).

A few reports suggest the need to examine potential deterrents to buying sex, but none describe deterrents to soliciting sex with minors. In particular, it is critical to examine the impact of deterrents already in place, such as laws against purchasing sex, existing laws on arresting purchasers, and “Johns’ schools” (i.e., deterrence programs focused on education or treatment for men arrested for soliciting sex [Shively et al., 2012]), as well as deterrents addressing any known risk factors that lead men to purchase sex with minors (e.g., potential deterrents for those who may be soliciting sex with minors unknowingly or indiscriminately) (Chicago Coalition for the Homeless, 2004; Shared Hope International, 2006). Further discussion of laws related to the solicitation and purchase of sex with minors is provided in Chapter 4.

In sum, there is a clear need for additional research examining factors that may contribute to men’s buying sex that can provide guidance on how to focus prevention as well as early intervention efforts to curb demand. In addition, none of the available research conducted nationally or internationally examines women as potential solicitors. Thus, the degree to which factors contributing to behaviors related to soliciting sex are due to biological, social, or cultural factors or a combination thereof is unclear.

CONSEQUENCES

A 1996 report resulting from the first World Congress Against Commercial Sexual Exploitation of Children points out that, although direct scientific data are sparse, there is little doubt that the sexual exploitation of children results in serious, often life-long, and sometimes life-threatening consequences for the physical, psychological, and social health and development of the child (see World Congress Against Commercial Sexual Exploitation of Children, 2002). The report also asserts that the health of victims of commercial sexual exploitation should be defined in terms of complete physical, mental, and social well-being, not just the absence of disease (see http://www.csecworldcongress.org/PDF [accessed April 24, 2013]). Thus, a comprehensive understanding of the impact of commercial sexual exploitation and sex trafficking of minors includes health, developmental, and legal consequences, as well as the risks of reexploitation and further victimization. In addition, commercial sexual exploitation and sex trafficking are themselves a health problem given the physical and emo-

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

tional abuse and the neglect that are inherent in these crimes (Estes and Weiner, 2001). However, a comprehensive understanding of the impact of these crimes remains elusive.

For example, Heilemann and Santhiveeran (2011) conducted a content analysis of existing research on experiences and coping strategies among prostituted female adolescents. Their analysis reviewed 31 quantitative and qualitative studies in 22 countries published between 1997 and 2006. Many characteristics of the studies varied considerably, including sample size, country of origin, and methodologies. Of the 31 studies included in the content analysis, only 5 included U.S. citizens in their samples. The authors identified a range of physical health (e.g., sexually transmitted infections, injuries) and mental health (e.g., depression, PTSD, anxiety) consequences and a number of “social hardships” (e.g., homelessness, social isolation) among the prostituted adolescents studied (Heilemann and Santhiveeran, 2011). In addition, about half of the studies in the content analysis described positive coping strategies (e.g., reliance on social support) and negative coping strategies (e.g., drug and alcohol use, self-mutilation) used by the prostituted adolescents studied. It should be noted that for some of the studies included in the analysis, the samples were small and that, overall, there is no discussion of the statistical strength of the individual study findings. While this analysis offers insights into the experiences and needs of prostituted adolescents and can help inform future research, it also underscores the limitations of the current evidence base on the consequences of commercial sexual exploitation and sex trafficking of minors in the United States.

Physical Health Consequences

Because the few domestic studies of the impact of commercial sexual exploitation and sex trafficking of minors focus primarily on psychological trauma, it is necessary to examine research from related fields to understand the potential physical health implications. For example, research on the impact of child abuse on the developing brain shows an association with mental health problems (i.e., depression, PTSD, suicidality) and behavioral risk taking (i.e., early smoking and sexual activity, illicit drug use) (see IOM/NRC, 2012, 2013; NRC, 2013). Related and relevant research also includes studies of the impact of commercial sexual exploitation and sex trafficking, studies of adults who are or have been involved in the commercial sex trade and survival sex, and international studies of sex trafficking victims. However, care must be taken not to overgeneralize the findings of this research.

In one study, 50 percent of adult women involved in commercial sex work reported having a physical health problem: 14 percent reported arthritis or nonspecific joint pain; 12 percent cardiovascular symptoms; 11

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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percent liver disorders; 10 percent reproductive system symptoms; 9 percent respiratory symptoms; 9 percent neurological symptoms, such as numbness or seizures; and 8 percent HIV infection (Farley and Barkan, 1998). Muftic and Finn (2013) interviewed domestic (n = 22) and international (n = 16) women who had been or were currently involved in the U.S. sex industry; some of the women had been trafficked, and some had not. Women trafficked for sex in the United States had poorer health outcomes than women trafficked internationally and nontrafficked sex workers. While it is difficult to draw any conclusions about underage victims of commercial sexual exploitation and sex trafficking from this research, the long-term health consequences appear to be severe for adult victims who experience continued exploitation (Farley and Barkan, 1998). In addition, many victims of these crimes are subjected to high rates of violence. As a result, victims of these crimes may have many of the same physical health problems associated with beating and rape, including broken bones and the need for wound care (Clawson and Goldblatt Grace, 2007).

Research shows that women who were sexually abused as children experience more negative health outcomes in adulthood than women without such a history (Bonomi et al., 2008; Flaherty et al., 2006). These outcomes can include physical symptoms such as cardiovascular problems, impaired physical functioning, pain, gastrointestinal symptoms, headache, pain syndromes, eating disorders, and disorders characterized as somatization (Arnow, 2004; Drossman et al., 1995, 1996; Fuller-Thomson et al., 2012; Kendall-Tackett, 2000; Leserman, 2005; Leserman et al., 1990; McCauley et al., 1997; Moeller et al., 1993; Sanci et al., 2012; Scarinci et al., 1994; Talley et al., 1994, 1995; Tietjen et al., 2010; Walker et al., 1999). In men, childhood sexual abuse has been associated with cardiovascular problems (Fuller-Thomson et al., 2012). More research is needed to understand whether similar problems will be found for some victims of commercial sexual exploitation and sex trafficking of minors.

Psychosexual dysfunction and reproductive health problems also have been reported among women with a history of sexual abuse, including gynecological disorders, chronic pelvic pain and sexual dysfunction, and sexually transmitted infections (Browne and Finkelhor, 1986; Kinzl et al., 1995; Neumann et al., 1996; Rohsenow et al., 1988; Sarwer and Durlak, 1996; Sutherland, 2011; Talley et al., 1994; Walker et al., 1988, 1997; Williams et al., 2010). Research focused specifically on victims of commercial sexual exploitation has identified health problems that include infectious diseases, reproductive health problems, premature births, and the physical impacts of violence (McClain and Garrity, 2011). In an international study of victims of commercial sexual exploitation, researchers found that these victims are at high risk of many infectious diseases and their sequelae (Willis and Levy, 2002), including sexually transmitted infections and HIV. In a report on

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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domestic trafficking of minors, Clawson and Goldblatt Grace (2007) note that reproductive health problems, including exposure to HIV and other sexually transmitted infections, unplanned pregnancies, and fertility issues, are common among victims of commercial sexual exploitation. The risk of HIV infection in victims of commercial sexual exploitation of minors depends, however, “on several factors, including the local prevalence of HIV infection in sex workers, access to condoms, and attitudes of clients towards their use” (Willis and Levy, 2002, p. 1418).

Mental Health Consequences

Brown and colleagues found that adolescents and young adults with a history of childhood sexual abuse were three times more likely to become depressed or suicidal than individuals without such a history (Brown et al., 1999). Similarly, Schilling and colleagues (2007) found increased rates of depression in young women who had experienced childhood sexual abuse. Studies of adult women who were victims of childhood sexual abuse have shown higher levels of a range of mental health problems and problems in social functioning, including increased rates of PTSD, depression, anxiety, and substance abuse (James and Meyerling, 1977; Rohsenow et al., 1988; Walker et al., 1999); higher rates of promiscuity (Luster and Small, 1997; Wilson and Widom, 2008); and involvement in commercial sex work (Lankenau et al., 2005; Marcus et al., 2011; Stoltz et al., 2007) among victims as compared with nonvictims. Childhood sexual abuse also has been shown to be associated with earlier initiation of injection drug use among adolescent intravenous drug users (Ompad et al., 2005). Evidence indicates that multiple instances of maltreatment, rather than specific types of maltreatment (i.e., neglect, physical abuse, sexual abuse), are more predictive of psychological and psychosocial sequelae (see Berzenski and Yates, 2011).

Given documented associations between child sexual abuse and commercial sexual exploitation of minors, this research suggests that victims of commercial

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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sexual exploitation may be at risk for depression, suicide, and PTSD (Jeffreys, 2000). Indeed, studies of the psychological impact of commercial sexual exploitation among women and adolescents highlight problems that are similar to the aforementioned problems noted in studies of child sexual abuse (Brannigan and Van Brunschot, 1997). Adolescent victims of commercial sexual exploitation experience more emotional and mental health problems than nonvictims, and several studies indicate that victims of commercial sexual exploitation have long-term psychological sequelae that persist into adulthood (Trickett et al., 2011b), such as low self-esteem, affective disorders (including depression, trauma, anxiety, and panic attacks), suicidality, and attempted suicide (Sickel et al., 2002; Trickett et al., 2011b). In addition, service providers report that victims of commercial sexual exploitation show extremely high rates of fear and anxiety; altered relationships with others, including the inability to trust others; and self-destructive behaviors, including suicidality (Willis and Levy, 2002). They report that victims of commercial sexual exploitation also show changed feelings about themselves, including “profound guilt and shame” (Clawson and Goldblatt Grace, 2007, p. 1).

Addiction and substance abuse are higher among victims of commercial sexual exploitation and sex trafficking as well. Adolescents and young adults who are victims of commercial sexual exploitation have significantly increased rates of nicotine disorder (Al Mamun, 2007) and substance abuse (Diaz et al., 2002). While prior substance use or abuse is a risk factor for some victims of commercial sexual exploitation, for others it may be a coping mechanism or self-medication for their exploitation (Marshall and Hendtlass, 1986). In addition, as discussed earlier, drugs may be used by those exploiting victims of commercial sexual exploitation as a way of increasing their control and the victim’s dependency (Walker, 2002).

Developmental and Social Consequences

A widely accepted clinical literature on adolescents focuses on psychological development and the acquisition of social skills and personal attributes that are necessary to achievement of adult competencies (Feldman et al., 2004; Parker and Asher, 1987; Rutter, 1989). The emphasis is on developmental tasks that should be mastered during adolescence, in particular, the acquisition of greater independence in social functioning and decision making. A typical example of a developmental task is the gradual acquisition of the skills with which to manage one’s own health care.

Failure to achieve key developmental tasks on time may interfere with youth’s ability to navigate subsequent tasks and role expectations successfully, possibly resulting in further adjustment difficulties and compounding the difficulty of successful intervention later in the course of development. For example, research suggests that youth who experience problems in the academic, conduct (i.e., behavioral), and social developmental tasks and expectations of adolescence have difficulty in successfully negotiating the transition to adulthood (Schulenberg et al., 2004).

Schilling and colleagues (2007) found compromised social functioning in such areas as work, education, and intimate relationships in young women who had experienced childhood sexual abuse. They also found that adolescent victims of commercial sexual exploitation were more likely than nonvictims to have difficulties in their relationships, including the ability to trust others.

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Consequences for Access to and Utilization of
Health Care and Support Services

Research has demonstrated the numerous obstacles to accessing health care and support services among all adolescents (IOM/NRC, 2011). These obstacles may be especially pronounced for youth involved in commercial sexual exploitation and sex trafficking. The stigma associated with commercial sexual exploitation and sex trafficking of minors and the criminalization of victims pose significant barriers to victims’ ability to obtain needed services (Clawson et al., 2012; Estes and Weiner, 2001), increasing the likelihood that they will continue to be exploited and likely untreated. In addition, the way the commercial sexual exploitation and sex trafficking of minors are defined and understood affects which young people have access to support services and legal protections and how victims of these crimes are perceived. Phoenix (2002) describes a dichotomous perspective on victims of commercial sexual exploitation. Specifically, young victims who are forced or coerced by third-party exploiters are more likely to be perceived as victims worthy of services and legal protection, while young people who exchange sex for survival are often viewed as willing participants and perceived as unworthy of services and legal protection (Chase and Statham, 2004; Phoenix, 2002). In states where young people aged 16-18 are deemed adults for purposes of the application of criminal laws and transfer to adult criminal court, the risk of a prostitution arrest may serve as a barrier to a young person’s access to health care and support services. Homeless youth face additional challenges in accessing health care and support services. As they often are older adolescents, they are vulnerable to not being offered social services. This vulnerability is compounded by the likelihood that, through being homeless, they may have crossed state or jurisdictional boundaries, so that many social welfare agencies and other entities, including schools, may not accept responsibility for them (Barnardo’s, 2002).

Societal Consequences

Continued involvement in commercial sex work and reexploitation among youth with a history of victimization may increase other youth’s exposure to such victimization through modeling or peer influence, and may overwhelm systems attempting to address commercial sexual exploitation and sex trafficking of minors and their adverse outcomes. It is also possible, at the extreme, that youth’s continued involvement in commercial sexual exploitation and sex trafficking will be taken as suggesting that the problems are chronic and not amenable to intervention because of either

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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characteristics of individuals that appear to be voluntary or a perception of the ease of exploitation by exploiters and traffickers.

Danger of Continued Involvement in Commercial Sex Work

A number of studies highlight the difficulties faced by young people trying to exit commercial sexual exploitation and sex trafficking, including financial difficulties and debt; drug dependency; single parenthood; a lack of education, qualifications, and training for gainful employment; housing problems; criminal convictions (e.g., prostitution); and abusive partners and exploiters (Chase and Statham, 2004; Taylor-Browne et al., 2002). For example, research suggests that the longer young people are commercially sexually exploited, the more intractable the patterns of behavior that contributed to their vulnerability to exploitation become, making it difficult for them to find a way out. This phenomenon is particularly evident among women and girls who have lost contact with family and friends, whose most direct peer groups also are involved in commercial sexual exploitation (Palmer, 2001; Taylor-Browne et al., 2002), and who have an ongoing drug dependency (Cusick et al., 2003).

Risk of Reexploitation

According to Estes and Weiner (2001), the risk of reexploitation for victims of commercial sexual exploitation varies for those still living in their own homes and those who have left home as either runaways or “thrown-away” youth. The former victims are at substantial risk of reexploitation in cases in which families are complicit and in which the commercial sexual exploitation has not been identified by social service agencies, schools, police, or health systems and in which, therefore, no child protection intervention has occurred. Estes and Weiner (2001) note that the risks of reexploitation are especially high in families that move frequently to avoid detection by law enforcement and child protection. In families with high levels of domestic violence, substance abuse, mental illness, and risky sexual behaviors, the risks are even higher, especially for postpubescent girls, who become sexual targets for male family members, family associates, and strangers.

For runaway and homeless youth, the risks of continued exploitation have different sources, arising in part from the influence of peer networks and predatory groups of older adolescents and adults. These youth also are highly vulnerable to various forms of violence. Estes and Weiner (2001) note that children living on the streets “are subject to an extraordinary range of social, emotional, physical, health and economic risks not experienced by other children” (p. 63), including poverty, hunger, and illnesses

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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caused by exposure to the weather and eating garbage. Sexually transmitted infections also are common, especially among street youth who exchange sex for money, food, transportation, and other basic survival needs.

Legal Consequences

The legal consequences for commercially sexually exploited children and adolescents can be multifaceted, long-lasting, and severe. Although this report strongly recommends that these youth be treated as victims and directed away from criminal prosecution and toward effective, long-term, multidisciplinary interventions, these youth may face a variety of criminal charges, including prostitution, delinquency, abuse of illicit substances, burglary, curfew violations, and pandering (Adelson, 2009; Annitto, 2011; Clawson et al., 2009). These charges may result in their involvement with the juvenile justice and child welfare systems, and in some cases, transfer to the adult criminal justice system, none of which may be optimally suited to addressing their complex and long-term needs, and some of which may result in their having permanent records that impede their ability to transition back into normal adolescent social participation. These youth often face a number of legal hurdles independent of criminal charges, including difficulty in obtaining access to benefits available under a number of state and federal programs, such as the Trafficking Victims Protection Act and the Violence Against Women Act. One commonly observed barrier to services for these youth is a lack of adequate identification.

Victims of commercial sexual exploitation often need safe housing and protection from their exploiters (Clawson and Dutch, 2008). Unfortunately, placement with their families of origin may not be optimal given the correlation between early abuse within the home and youths’ subsequent engagement in commercial sexual exploitation, as well as the risks of reexploitation and the stresses of reunification noted above. Victims who feel that they are bound by “contracts” they have signed with their exploiters need to be reassured that such agreements are legally unenforceable (Williamson et al., 2009). Minors who were born in the United States but whose parents are present in this country illegally may be particularly reluctant to seek help for fear of causing their parents to be deported. As a result of these and other complex legal challenges, all victims of commercial sexual exploitation need access to informed and effective counsel, typically working in conjunction with case managers. This sort of assistance, however, is rarely available.

Little research has addressed the specific question of whether child victims of commercial sexual exploitation and sex trafficking are more likely than nonvictims to engage in criminal behavior as adults. However, some research suggests an association between commercial sexual exploitation

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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and future criminal behavior. Research has demonstrated, for example, that after controlling for gender, race, and ethnicity, victims of child sexual abuse are more than twice as likely to be arrested for violent crimes (English et al., 2002). And a recent systematic review of 20 empirical studies focused on child sexual abuse and juvenile and adult offending by victims of commercial sexual exploitation revealed that victims of child sexual abuse are more likely than the general population to be arrested as adults, albeit more for sex crimes than for violent crimes (McGrath et al., 2011).

Summary

In summary, the available literature shows that child maltreatment, particularly child sexual abuse, has significant negative impacts on the physical health, mental health, and social functioning of adult victims and that among adolescent victims, health risk behaviors and mental health problems are increased. While studies focused on consequences for commercially sexually exploited children and adolescents are rare, the data based on child sexual abuse are useful given evidence that these problems are linked in some cases. Overall, research suggests that victims and survivors of commercial sexual exploitation and sex trafficking face developmental, social, societal, and legal consequences that have both short- and long-term impacts on their health and well-being.

FINDINGS AND CONCLUSIONS

The committee’s review of the literature and its careful consideration of expert testimony revealed several themes related to what is known about individual-, family-, peer-, neighborhood-, and systems-level risk factors associated with victims and offenders of commercial sexual exploitation and sex trafficking of minors in the United States. The summary of the evidence in this chapter draws heavily on related research literatures to complement what is known about commercial sexual exploitation and sex trafficking of minors in the United States. Based on its review of the best available evidence, the committee formulated the following findings and conclusions:

3-1 There is a lack of peer-reviewed evidence focused on the causes of commercial sexual exploitation and sex trafficking of minors and consequences for victims, particularly boys. Also scarce is evidence on factors that protect against exploitation and revictimization.

Despite this overall lack of peer-reviewed evidence on causality, the committee found numerous associations of note, including the following:

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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3-2 Child sexual abuse is strongly associated with commercial sexual exploitation and sex trafficking of minors.

3-3 While an unknown proportion of victims of child sexual abuse experience commercial sexual exploitation and sex trafficking, a majority of teenage victims of commercial sexual exploitation report a history of child sexual abuse.

3-4 Off-schedule developmental tasks (e.g., sexual participation, school transitions, work initiation) have negative consequences for youth.

3-5 While commercial sexual exploitation of minors can affect youth across the board, some are groups at higher risk, including those who lack stable housing and sexual and gender minority youth. In addition, some settings and situations—homelessness, foster care placement, and juvenile justice involvement—are particularly high risk under certain circumstances, providing opportunities for recruitment of young people.

3-6 Child and adolescent victims and survivors of commercial sexual exploitation and sex trafficking may not view themselves as victims. In addition, children and adolescents who are at risk for these kinds of exploitation may not recognize their individual risk.

3-7 Substance use is a risk factor for commercial sexual exploitation and sex trafficking of minors and also may perpetuate exploitation.

3-8 The multiple systems that engage youth (e.g., health care, education, juvenile justice) have few models for intervening with youth at risk of commercial sexual exploitation and sex trafficking of minors.

3-9 In general, an integrated public institutional response to commercial sexual exploitation and sex trafficking of minors is lacking.

3-10 The sexualization of children, particularly girls, in U.S. society and the perception that involvement in sex after puberty is consensual contribute to the commercial sexual exploitation and sex trafficking of minors.

Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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3-11 Online and digital technologies are part of a complex social system that includes both risk factors (i.e., recruiting, grooming, and advertising victims) and protective factors (i.e., identifying, monitoring, and combating exploiters) for the commercial sexual exploitation and sex trafficking of minors in the United States.

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Suggested Citation:"3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Every day in the United States, children and adolescents are victims of commercial sexual exploitation and sex trafficking. Despite the serious and long-term consequences for victims as well as their families, communities, and society, efforts to prevent, identify, and respond to these crimes are largely under supported, inefficient, uncoordinated, and unevaluated.

Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States examines commercial sexual exploitation and sex trafficking of U.S. citizens and lawful permanent residents of the United States under age 18. According to this report, efforts to prevent, identify, and respond to these crimes require better collaborative approaches that build upon the capabilities of people and entities from a range of sectors. In addition, such efforts need to confront demand and the individuals who commit and benefit from these crimes. The report recommends increased awareness and understanding, strengthening of the law's response, strengthening of research to advance understanding and to support the development of prevention and intervention strategies, support for multi-sector and interagency collaboration, and creation of a digital information-sharing platform.

A nation that is unaware of these problems or disengaged from solutions unwittingly contributes to the ongoing abuse of minors. If acted upon in a coordinated and comprehensive manner, the recommendations of Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States can help advance and strengthen the nation's emerging efforts to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States.

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