Recognizing the Risk Factors, Signs, and Symptoms of Domestic Minor Sex Trafficking in Mental Health Clinical Practice


On January 31, 1865, the United States Congress passed the 13th amendment to the U.S. Constitution. It reads: “Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction” (U.S. Const. amend. XIII). Enslaving vulnerable people is a crime against humanity that exists in every country worldwide (United Nations Office on Drugs and Crime, 2009). Human trafficking is the term used to describe human beings (regardless of age, ethnicity, nationality, foreign or domestic) who are coerced into performing labor or becoming sex workers without their explicit consent. Trafficking is considered a modern form of slavery. It is defined by the United Nations’ Palermo Protocol as:

The recruitment, transportation, transfer, harboring, or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs

According to the International Labor Union, 40.3 million individuals are currently enslaved globally (International Labour Office [ILO], 2017). It is estimated that 4.8 million individuals (mostly women and children) are engaged in some form of sexual slavery. Seventy-seven percent of these victims remain in their country of residence (ILO, 2017). This means that 5.4/1,000 individuals are currently enslaved; one in four are children.

For 2 decades, the U.S. government has been working to address modern forms of human slavery. In 2000, the United States Congress passed the Trafficking Victims Protection Act (TVPA) to help enforce the 13th amendment.The TVPA (2000) established the “3 Ps” (prosecution, prevention, and protection) framework. The TVPA has been reaffirmed and updated multiple times (2000, 2003, 2005, 2008, and 2013). Despite this ongoing work, human trafficking is one of the fastest-growing economic enterprises in the world, generating profits of $150 billion globally (ILO, 2017). Trafficking and enslaving children is especially lucrative because, unlike guns or drugs, which must be purchased prior to commodification, children can be resold repeatedly, and are at the mercy of their captors for survival and cannot advocate for themselves (Kotrla, 2010).

Many Americans may erroneously assume that foreign females are the primary victims of sex trafficking inside the United States. But according to a federally funded human trafficking task force, significantly more U.S. citizens and legal residents are enslaved compared to foreign nationals (Banks & Kyckelhahn, 2011). In addition, the law does not require that victims be moved physically from one location (e.g., state or country) to another to be considered a victim of trafficking (Polaris Project, 2015).

Sexual Exploitation Defined

Domestic minor sex trafficking (DMST) is the term used to describe the subset of human trafficking victims who are American citizens (or legal residents) aged <18 years involved in commercial sex (Gibbs et al., 2015). Commercial sex includes prostitution, pornography, escort services, and other sexual services (Kotrla, 2010). Minors are unable to provide consent to any form of commercial sexual activity (Smith et al., 2009).

The term commercial sexual exploitation of children (CSEC) refers to the sexual abuse of a child for economic gain through a range of crimes (Grace et al., 2012), including prostitution, trafficking for sexual purposes, sex tourism, online exploitation, early forced marriage, pornography, stripping, and survival sex (i.e., exchanging sex for food or shelter). The distinction between CSEC and DMST is related to the citizenship status of the victim. DMST victims are legal residents or citizens of the state or nation where the trafficking occurs. CSEC refers to the sexual exploitation of children regardless of citizenship status, legal or otherwise (Office of Juvenile Justice and Delinquency Prevention, 2013). The economic transaction involved in sexual exploitation may be monetary or nonmonetary (e.g., an exchange for food, shelter, drugs). However, even when sex is exchanged for money, the trafficking exchange primarily benefits the exploiter (Franchino-Olsen, 2019; Greenbaum, 2014).

Survival sex is the term used for sexual activity for money to provide food, drugs, and/or shelter, and can occur in the absence of third-party exploitation, such as pimp-controlled sexual exploitation (Fedina et al., 2019) Prostitution is the term used to describe the sale of sexual acts between adults (Moses, 2006). Prostitution can be consensual or non-consensual, legal or illegal, may or may not involve a pimp, and may or may not involve coercion (Kempadoo et al., 2015).

Purpose

Experts and policy makers are encouraging researchers to focus on the role health care providers play in identifying and preventing DMST (Abas et al., 2013; Cole, 2009; Cole & Sprang, 2015; Ernewein & Nieves, 2015; Goldberg et al., 2017; Grace et al., 2012; Ijadi-Maghsoodi et al., 2016; Ijadi-Maghsoodi et al., 2014; Le et al., 2018; Lutz, 2018; Rafferty, 2018). An estimated 87% of rescued trafficking victims had an encounter with a health care provider who failed to recognize the patient as a trafficking victim (Lederer & Wetzel, 2014). Emergency department (ED) providers, school nurses, women’s health clinicians, dentists, and primary care and psychiatric clinics are a few of the types of clinical settings that provide care to DMST victims. Because DMST victims are at increased risk of psychiatric morbidity, psychiatric clinicians are well-situated to help identify those affected by DMST (Goldberg et al., 2017; Kaplan et al., 2018; Moore et al., 2019; Moore et al., 2017; Moore et al., 2016). Educating psychiatric professionals about the risk factors and identifying characteristics of DMST is important for prevention and detection of DMST victimization. Failure to identify these victims is associated with a high risk of continued involvement in the commercial sex industry into adulthood (Kellison et al., 2019).

The current article represents one way to improve DMST victim identification by psychiatric clinicians via education on this topic. The American Nurses Association approved a resolution to address human trafficking through improved identification of victims (Trossman, 2008). Evidence indicates that health care providers lack adequate education/understanding on how to identify potential DMST victims (Ahn et al., 2013; Baldwin et al., 2011; Barnert et al., 2017; Beck et al., 2015; Moore et al., 2016; Ross et al., 2015). Many states (e.g., Michigan, Florida, Texas) are now mandating continuing education on the topic of sex trafficking for RN license renewal. For instance, in 2019, the Texas Board of Nurse Examiners revised Board Rule 216 and will now mandate continuing education competency on human trafficking for licensure renewal (effective September 1, 2020). This change is based on a law HB 2059, passed by the Texas legislature in 2019.

Victims of DMST may present for care in psychiatric EDs, psychiatric hospitals, and community mental health clinics, therefore, psychiatric providers are key stakeholders in the fight to understand, identify, and prevent DMST (Choi, 2015). Advanced practice RNs (APRNs) are particularly important, as they may function as the primary care and/or psychiatric care provider. The purpose of this article is to educate psychiatric clinicians to help prevent and identify DMST victims.

Scope of the Problem

The prevalence of DMST victims has been difficult to ascertain due to lack of a national database, underre-porting, under-identification, misidentification, criminalization of victims, methodological limitations of tracking and counting, the sensitive and covert nature of the topic, and lack of access to the DMST population (Busch-Armendariz et al., 2016; Fedina, 2015; Jimenez et al., 2015; Jordan et al., 2013; Lutnick, 2016; Ross et al., 2015; Shields & Letourneau, 2015). One commonly cited statistic is that 325,000 children/adolescents are at risk for DMST in the United States (Estes & Weiner, 2001).The designation at risk indicates some amalgam of the risk factors (discussed below).

There is no coherent strategy for calculating accurate prevalence rates for DMST. Some states and cities have attempted to determine how many children in its catchment area are affected. A recent study, funded by a $500,000 grant from the Texas Governor’s office (the first phase of the Texas Human Trafficking Mapping Project), generated the benchmark prevalence of overall human trafficking in Texas as 313,000, with DMST victims estimated at 79,618 (Busch-Armendariz et al., 2016). Lifetime economic impact of DMST victimization for the State of Texas was estimated to be $83,125/child × 72,618 victims. Sexual exploitation of children was thus estimated to cost the State of Texas >$6.6 billion (Busch-Armendariz et al., 2016). The costs considered were associated with the care of each individual, in addition to societal costs, and were amortized over several domains, such as social services (foster care), the public health system (mental and physical health care costs), and law enforcement expenses (Busch-Armendariz et al., 2016). Clearly, however, these estimated economic costs are only a small fraction of the personal and psychosocial costs of the sexual exploitation of children. Quantifying the moral, cognitive, spiritual, and overall cost of DMST would be impossible.

The most commonly reported age of entry into DMST ranges from 11 to 15 (Busch-Armendariz et al., 2016; Gibbs et al., 2015; Kellison et al., 2019; Smith et al., 2009), although DMST also affects younger children, including toddlers and babies (ECPAT and INTERPOL, 2018). The stereotypical understanding of a DMST victim involves an underage girl held in captivity against her will (Franchino-Olsen, 2019). The presentation of DMST is far more nuanced and is not limited to a particular gender (e.g., male, female, queer, transgender, intergender) or sexual orientation (Choi, 2015; Clawson et al., 2003; Greenbaum, 2017). Sometimes, the use of the term “victim” versus “survivor” is debated because not all those affected by DMST identify themselves as victims (Reid, 2016; Roe-Sepowitz, 2012). However, according to the law, a minor cannot provide consent to engage in any form of commercial sex (Smith et al., 2009). Therefore, all minors engaged in commercial sex are legally considered victims.

Risk Factors

Researchers have identified the following risk factors for DMST: childhood abuse and maltreatment (physical, emotional, and/or sexual), compromised parenting due to parental substance use or mental illness, witnessing family violence, poverty, conflict with parents, difficulty in school, running away or being abandoned, engaging in survival sex, psychiatric morbidity, child protection involvement, juvenile delinquency, peer/family influence, early sexual initiation, early use of alcohol/drugs, and prior rape experience (Cook et al., 2018; Fedina et al., 2019; Franchino-Olsen, 2019; Kellison et al., 2019; Miller-Perrin & Wurtele, 2017; Shaw et al., 2017; Wilson & Butler, 2014). In addition, being a member of a sexual minority has been identified in some research as a risk factor (e.g., gay, lesbian, bisexual, transgender, queer, intersex) (Estes & Weiner, 2001; Kellison et al., 2019). Children with an intellectual disability have a four to eight times greater risk of experiencing sexual abuse (Reid, 2018). All ethnicities are at equal risk for DMST (Edinburgh et al., 2015; Fedina et al., 2019). How much significance to place on a particular risk factor is debatable and requires more research.

Enculturation into commercial sex may be achieved in numerous ways: finesse pimping (using seduction), guerilla pimping (using threat or force) (McClain & Garrity, 2011), family introduction (Sprang & Cole, 2018), and self-enculturation (Edinburgh et al., 2015). Because of the depth and variety of enculturation entry, these victim/trafficker dyads may vary widely from being highly coercive to mutually cooperative (Weitzer, 2014). For example, in 2008 and again in 2019, Jeffrey Epstein (American financier) was convicted of sexual abuse of numerous underage girls. The girls mostly remained living with their families and attending high school. DMST may thus occur without removing the child from their home, and without any overt signs of violence. Self-enculturation is a form of sexual exploitation that is managed by the minor without a pimp, parent, or partner, and may include advertising and brokering their own sexual services. Parents may be responsible for exploiting their own children for commercial gain. A boyfriend or romantic partner is estimated to be responsible for 50% of commercial sexual exploitation of minors (Kellison et al., 2019).

Health Consequences

The landmark study of adverse childhood experiences (ACE) marked the beginning of studying the long-term health problems stemming from early life trauma (Felitti et al., 1998). Childhood abuse in general (and DMST in particular) is associated with long-term physical, mental, and behavioral health consequences (Banovic & Bjelajac, 2012; Botros et al., 2019; Heim & Nemeroff, 2001; Nemeroff, 2016; Syed & Nemeroff, 2017). DMST is a specific and especially pernicious form of early life adversity resulting in psychiatric and physical morbidity into adulthood (Azevedo et al., 2009; Felitti et al., 1998). DMST survivors face numerous immediate and long-term mental health consequences, such as posttraumatic stress disorder (PTSD), depression, anxiety, suicidality, and drug and alcohol use disorders (Cook et al., 2018; Ijadi-Maghsoodi et al., 2016; Ijadi-Maghsoodi et al., 2014).

Research into the mental health consequences of DMST is limited. However, evidence supports an increased risk of developing numerous psychiatric disorders, such as depression, anxiety, and PTSD (Edinburgh et al., 2015; Ijadi-Maghsoodi et al., 2016; Landers et al., 2017; Ottisova et al., 2016; Ross et al., 2015; Zimmerman et al., 2008). Previously diagnosed psychiatric morbidity (e.g., bipolar disorder, depression) is also a risk factor for DMST victimization (Busch-Armendariz et al., 2016; Cole & Sprang, 2015; Le et al., 2018; Reid & Jones, 2011; Reid & Piquero, 2014). Therefore, psychiatric diagnoses can be both a predisposing risk factor and a consequence of DMST (Goldberg & Moore, 2018).

A 2017 retrospective analysis of presentation indicated that 66% of identified victims of DMST had a previously diagnosed psychiatric condition, and 46% experienced a psychiatric admission in the year before being identified as a victim of DMST (Goldberg et al., 2017). In this same retrospective analysis, 54% described self-injurious behaviors (e.g., cutting), 20% reported current suicidal ideation, and 59% reported a history of suicidal ideation (Goldberg et al., 2017). Psychiatric sequelae post-DMST victimization representationally include complex PTSD, depression, anxiety, suicidal ideation, self-harm, dissociative disorders, eating disorders, and substance use disorders (Le et al., 2018; Lederer & Wetzel, 2014; Oram et al., 2015; Zimmerman et al., 2008).

In another study that compared sexually abused Indian girls (N = 120) against non-sexually abused girls (N = 120), the prevalence and severity of aggression and poor frustration tolerance differed significantly between the two groups irrespective of age (Deb et al., 2011). Although this study has not been replicated in the United States, it poses the possibility that children with a psychiatric diagnosis related to impulse control and anger (i.e., intermittent explosive disorder, oppositional defiant disorder, conduct disorder, pyromania) might require specific screening related to sex trafficking.

Identification of Potential Victims

DMST victims are difficult to identify, and sometimes do not recognize their own exploitation (Cole, 2009; McClain & Garrity, 2011). Coercive bonding, entrapment, and enmeshment may also contribute to this phenomenon (Reid, 2016; Sanchez et al., 2019). In addition, professionals (e.g., primary care providers or community mental health providers) may misidentify these youths through a maladaptive behavioral lens. They are, in this sense, pigeon-holed as prostitutes, delinquents, drug users, or runaways rather than victims (Ijadi-Maghsoodi et al., 2014; Smith et al., 2009).

Physical signs of DMST victimization can include a tattoo of a pimp’s name, barcode tattoo, ligature marks, bruising, genital harm, self-harm, and traumatic alopecia (Alpert et al., 2014; Avila, 2016; Walker-Rodriguez & Hill, 2011). Mental health providers can begin a dialogue by asking about the meaning of tattoos, whether a patient is a runaway or has stable housing, history of truancy, being threatened, or if clients have ever exchanged sex for food. Failure to read possible signs and symptoms of trafficking and lack of awareness are barriers to help. Because victims may be reluctant to identify themselves as a victim of trafficking, developing a therapeutic bond is essential. It is important to spend at least part of a psychiatric appointment with all children/adolescents without a guardian present to facilitate building a therapeutic alliance between patient and provider.

Discussion and Recommendations

State and federal laws related to DMST vary widely and there is no uniform approach guiding attempts to address this problem (Duger, 2015). Understanding and identifying human rights violations should be included in health care education in the United States (McKenzie et al., 2019; Titchen et al., 2017). The United States has 2.89 million RNs and APRNs (Elflin, 2019). State boards of nursing within the United States are beginning to require continuing nursing education (CNE) to assist with preventing and identifying human trafficking victims/survivors. A small study of nurse practitioner (NP) students in Florida indicated that 1 hour of education on human trafficking (e.g., definitions, identification, prevalence, treatment, referral services) during enrollment in a NP program significantly improved knowledge of trafficking (Lutz, 2018).

Each state, however, establishes its own list of mandatory CNE required at each cycle of licensure renewal. Other State Boards of Nurse Examiners must consider requiring RNs and APRNs to take a mandatory CNE course on the identification and prevention of DMST because currently, APRNs and other health care providers lack the appropriate education and understanding of state laws governing identification and reporting suspected DMST (Atkinson et al., 2016; Egyud et al., 2017). In addition, psychiatric NPs can provide education and guidance for support staff at community mental health centers to improve recognition and referral of DMST victims.

Other recommendations include asking states to mandate community mental health agencies treating high-risk minors to publicly display a sex trafficking hotline number in the clinic (e.g., Shared Hope International at 1-866-HER-LIFE, National Center for Missing and Exploited Children hotline at [800] THE-LOST, National Human Trafficking Hotline at [888] 373-7888). This would be a small, inexpensive, and potentially beneficial policy change that would expose both victims and at-risk youths to access help. Furthermore, mental health practitioners could be asked to begin including questions about personal safety in psychiatric examinations.

Nurses are missing an important opportunity to perceive, protect, promote, and advocate for the healing of DMST victims. Improved education of nurses adds millions of eyes on children and adolescents. Nurses must contribute through better identification of those at risk and those engaged in DMST. Nursing is an act of social justice, so it is the nurse’s responsibility, regardless of education level, to contribute to the growing body of knowledge affected by this hidden humanitarian crisis. Here is the perspective of a survivor in her own words:

To the public, nothing was wrong with me. My life was normal. I was in every single sport and doing UIL [University Interscholastic League] state stuff, and theater. I was very active in school activities, but it was one of those things—if I didn’t do those things, it would look off. The guys that had me were so paranoid that they made me—you better do this, you better do that. That’s where even the control of my cell phone and social media came in so that even there, my life looked normal. – Age 18, Female, Lubbock, Texas

The responsibility of protecting children falls to every adult (e.g., parent, relative, teacher, physician, nurse, coach). Education about DMST is a vital tool for social change. The elimination of commercial sexual exploitation of children requires improved identification of the risk factors as well as the active signs of victimization. Educating psychiatric providers is one way of enabling the identification of victims and at-risk youths, as establishing and incorporating this safety lens builds a more responsible and comprehensive manner of assessment of our collective young patients.

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