Opinion
VIEWPOINT
Angela Diaz, MD, MPH Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York; and Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. Ellen Wright Clayton, MD, JD Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee. Patti Simon, MPH Institute of Medicine and National Research Council, Washington, DC.
Viewpoint page 793
Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors Health care professionals who routinely interact with young people have an important role to play in preventing, identifying, and responding to commercial sexual exploitation and sex trafficking of minors. These crimes— which include any sexual activity with someone younger than 18 years in exchange for something of value— occur every day in the United States and have serious, long-term consequences for individuals who have experienced this violence and exploitation. Unfortunately, pediatricians may not recognize children and adolescents who are at risk or who may be abused. A recent report from the Institute of Medicine and the National Research Council sheds light on these crimes and provides recommendations designed to increase awareness, advance understanding, and support efforts to prevent and respond to this abuse.
The Problem Commercial sexual exploitation and sex trafficking of minors are serious and frequently overlooked, misunderstood, and unaddressed domestic problems. The report, Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States,1 contends that these crimes should be viewed as child abuse and violence against children and adolescents. As such, survivors of these crimes require support and assistance, not arrest and conviction.
Key Findings and Conclusions Scope
Like other hidden crimes—such as sexual assault and intimate partner violence—the true extent of commercial sexual exploitation and sex trafficking of minors in the United States is likely undercounted. These crimes may be overlooked and underreported because they frequently occur at the margins of society, behind closed doors. Professionals may lack the tools to identify this kind of abuse. Children and adolescents who have been exploited may distrust authority figures, may not view themselves as “victims,” or may be too traumatized to report or disclose the crimes committed against them. Risk Factors
Corresponding Author: Angela Diaz, MD, MPH, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 320 E 94th St, 2nd Floor, New York, NY 10128 (angela [email protected]).
Risk factors for commercial sexual exploitation and sex trafficking of minors have been identified at the individual, family, peer, neighborhood, and societal levels. These include a history of child maltreatment (particularly sexual abuse), family violence, and out-of-home residential placement,2,3 as well as a lack of stable housing and being a lesbian, gay, bisexual, transgender, queer, questioning, and intersex youth.4 Neighborhood context—whether the community is characterized by pov-
erty, crime, police corruption, and adult prostitution— can increase the risk for exploitation. The ability of health care professionals to recognize risk among the youth in their care is an essential part of an overall effort to prevent, identify, and respond to this abuse. Consequences
Although direct scientific data are sparse, there is little doubt that commercial sexual exploitation and sex trafficking of minors are associated with serious, often lifelong, and sometimes life-threatening consequences. These include physical trauma; risk for depression, suicide, and posttraumatic stress disorder; sexually transmitted infections and their sequelae; and substance abuse.5,6 Additional prospective, longitudinal research is needed to better understand the consequences of commercial sexual exploitation and sex trafficking on survivors of these crimes.
The Pediatrician’s Role Pediatricians and other child health professionals can play major roles in increasing awareness, advancing understanding, and supporting efforts to prevent, identify, and respond to the commercial sexual exploitation and sex trafficking of minors in the United States. Pediatricians may encounter children and adolescents who have been exploited and trafficked and who seek treatment for injury or illness in emergency departments, urgent care, and community health centers. Understanding commercial sexual exploitation and sex trafficking of minors as forms of child abuse can help pediatricians acknowledge their critical role in recognizing risk and providing assistance to the young people they treat. Pediatricians who lack the tools may not recognize youth who are in their care who are at risk of, are experiencing, or are survivors of these crimes. Because this is an emerging area of research and practice, few health care settingshaveestablishedscreeningpractices,policies,and protocols related to commercial sexual exploitation and sex trafficking of minors. However, health care professionals can draw lessons from research on related and overlapping issues. For example, programs and practices that serve survivors of child abuse, sexual abuse, and intimate partner violence can be adapted and expanded to include services and support for children and adolescents who have been exploited and trafficked.
Developing an Evidence-Based Practice to Support the Pediatrician’s Role Existing screening tools and trainings have been developed based not on empirical data but on the experiences of professionals working in the field. To date, these
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JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
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791
Opinion Viewpoint
instruments and efforts have not been evaluated. The Office of Juvenile Justice and Delinquency Prevention has announced the Commercial Sexual Exploitation of Children Field-Initiated Research and Evaluation Program, which is based on recommendations from the Institute of Medicine and the National Research Council report. The new program has the potential to identify much-needed evidencebased practices that can inform clinical practice guidelines, standards of care, and undergraduate and continuing medical education— none of which currently exist. Pediatricians, particularly those affiliated with academic institutions, can provide leadership in these efforts.
Later this year, the Institute of Medicine and the National Research Council will release a series of guides to the report on commercial sexual exploitation and sex trafficking of minors, including one specifically for health care professionals. This abridged version of the report will include the information that is most relevant to the health care community, such as examples of emerging strategies, challenges to service provision, and sources for additional information. This guide will underscore strategies specific to the health care sector and multisector, collaborative strategies in which health care professionals play a role.
Conclusions Guidance and Leadership Formal guidance for child and adolescent health care professionals is lacking. Few professional organizations have developed policy statements or affirmations of value related to commercial sexual exploitationandsextraffickingofminors.Developingsuchstatementswould demonstrate that these issues have clear relevance to health care professionals who serve youth. Furthermore, disseminating policy statements and affirmations of value help ensure that these issues are recognized in legislative and policy-making processes.
United States and do not necessarily reflect the views of the Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
ARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamapediatrics.2014.1002. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by grant 2011-MC-CX-0004 from the Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The opinions, findings, conclusions, and recommendations expressed in this study are those of the Institute of Medicine and National Research Council Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the
792
Cooperation among agencies and individuals who routinely interact with children and adolescents—including educators, support service providers, health and mental health care providers, legislators, law enforcement personnel, prosecutors, public defenders, judges, and the commercial sector—is needed. It is incumbent upon pediatricians to 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. The status quo is simply unacceptable.
Additional Contributions: We acknowledge the members of the Institute of Medicine and National Research Council Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States for their contribution to this work. REFERENCES 1. Institute of Medicine; National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: National Academies Press; 2013. http://www.nap .edu/catalog.php?record_id=18358. Accessed July 23, 2014. 2. Chase E, Statham J. The Commercial Sexual Exploitation of Children and Young People: An Overview of Key Literature and Data. London,
England: Thomas Coram Research Unit, Institute of Education, University of London; 2004. 3. Mathews P. A Review and a Way Forward: A Report on the Sexual Exploitation of Boys and Young Men. Barkingside, England: Barnardo’s; 2000. 4. Estes RJ, Weiner NA. The Commercial Sexual Exploitation of Children in the US, Canada, and Mexico. Philadelphia, PA: Center for the Study of Youth Policy; 2001. 5. Heilemann T, Santhiveeran J. How do female adolescents cope and survive the hardships of prostitution? a content analysis of existing literature. J Ethnic Cult Divers Soc Work. 2011;20: 57-76. doi:10.1080/15313204.2011.545945. 6. Trickett PK, Noll JG, Putnam FW. The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study. Dev Psychopathol. 2011;23(2):453-476.
JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 05/23/2015
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VIEWPOINT
Angela Diaz, MD, MPH Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York; and Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. Ellen Wright Clayton, MD, JD Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee. Patti Simon, MPH Institute of Medicine and National Research Council, Washington, DC.
Viewpoint page 793
Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors Health care professionals who routinely interact with young people have an important role to play in preventing, identifying, and responding to commercial sexual exploitation and sex trafficking of minors. These crimes— which include any sexual activity with someone younger than 18 years in exchange for something of value— occur every day in the United States and have serious, long-term consequences for individuals who have experienced this violence and exploitation. Unfortunately, pediatricians may not recognize children and adolescents who are at risk or who may be abused. A recent report from the Institute of Medicine and the National Research Council sheds light on these crimes and provides recommendations designed to increase awareness, advance understanding, and support efforts to prevent and respond to this abuse.
The Problem Commercial sexual exploitation and sex trafficking of minors are serious and frequently overlooked, misunderstood, and unaddressed domestic problems. The report, Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States,1 contends that these crimes should be viewed as child abuse and violence against children and adolescents. As such, survivors of these crimes require support and assistance, not arrest and conviction.
Key Findings and Conclusions Scope
Like other hidden crimes—such as sexual assault and intimate partner violence—the true extent of commercial sexual exploitation and sex trafficking of minors in the United States is likely undercounted. These crimes may be overlooked and underreported because they frequently occur at the margins of society, behind closed doors. Professionals may lack the tools to identify this kind of abuse. Children and adolescents who have been exploited may distrust authority figures, may not view themselves as “victims,” or may be too traumatized to report or disclose the crimes committed against them. Risk Factors
Corresponding Author: Angela Diaz, MD, MPH, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 320 E 94th St, 2nd Floor, New York, NY 10128 (angela [email protected]).
Risk factors for commercial sexual exploitation and sex trafficking of minors have been identified at the individual, family, peer, neighborhood, and societal levels. These include a history of child maltreatment (particularly sexual abuse), family violence, and out-of-home residential placement,2,3 as well as a lack of stable housing and being a lesbian, gay, bisexual, transgender, queer, questioning, and intersex youth.4 Neighborhood context—whether the community is characterized by pov-
erty, crime, police corruption, and adult prostitution— can increase the risk for exploitation. The ability of health care professionals to recognize risk among the youth in their care is an essential part of an overall effort to prevent, identify, and respond to this abuse. Consequences
Although direct scientific data are sparse, there is little doubt that commercial sexual exploitation and sex trafficking of minors are associated with serious, often lifelong, and sometimes life-threatening consequences. These include physical trauma; risk for depression, suicide, and posttraumatic stress disorder; sexually transmitted infections and their sequelae; and substance abuse.5,6 Additional prospective, longitudinal research is needed to better understand the consequences of commercial sexual exploitation and sex trafficking on survivors of these crimes.
The Pediatrician’s Role Pediatricians and other child health professionals can play major roles in increasing awareness, advancing understanding, and supporting efforts to prevent, identify, and respond to the commercial sexual exploitation and sex trafficking of minors in the United States. Pediatricians may encounter children and adolescents who have been exploited and trafficked and who seek treatment for injury or illness in emergency departments, urgent care, and community health centers. Understanding commercial sexual exploitation and sex trafficking of minors as forms of child abuse can help pediatricians acknowledge their critical role in recognizing risk and providing assistance to the young people they treat. Pediatricians who lack the tools may not recognize youth who are in their care who are at risk of, are experiencing, or are survivors of these crimes. Because this is an emerging area of research and practice, few health care settingshaveestablishedscreeningpractices,policies,and protocols related to commercial sexual exploitation and sex trafficking of minors. However, health care professionals can draw lessons from research on related and overlapping issues. For example, programs and practices that serve survivors of child abuse, sexual abuse, and intimate partner violence can be adapted and expanded to include services and support for children and adolescents who have been exploited and trafficked.
Developing an Evidence-Based Practice to Support the Pediatrician’s Role Existing screening tools and trainings have been developed based not on empirical data but on the experiences of professionals working in the field. To date, these
jamapediatrics.com
JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 05/23/2015
791
Opinion Viewpoint
instruments and efforts have not been evaluated. The Office of Juvenile Justice and Delinquency Prevention has announced the Commercial Sexual Exploitation of Children Field-Initiated Research and Evaluation Program, which is based on recommendations from the Institute of Medicine and the National Research Council report. The new program has the potential to identify much-needed evidencebased practices that can inform clinical practice guidelines, standards of care, and undergraduate and continuing medical education— none of which currently exist. Pediatricians, particularly those affiliated with academic institutions, can provide leadership in these efforts.
Later this year, the Institute of Medicine and the National Research Council will release a series of guides to the report on commercial sexual exploitation and sex trafficking of minors, including one specifically for health care professionals. This abridged version of the report will include the information that is most relevant to the health care community, such as examples of emerging strategies, challenges to service provision, and sources for additional information. This guide will underscore strategies specific to the health care sector and multisector, collaborative strategies in which health care professionals play a role.
Conclusions Guidance and Leadership Formal guidance for child and adolescent health care professionals is lacking. Few professional organizations have developed policy statements or affirmations of value related to commercial sexual exploitationandsextraffickingofminors.Developingsuchstatementswould demonstrate that these issues have clear relevance to health care professionals who serve youth. Furthermore, disseminating policy statements and affirmations of value help ensure that these issues are recognized in legislative and policy-making processes.
United States and do not necessarily reflect the views of the Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
ARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamapediatrics.2014.1002. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by grant 2011-MC-CX-0004 from the Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The opinions, findings, conclusions, and recommendations expressed in this study are those of the Institute of Medicine and National Research Council Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the
792
Cooperation among agencies and individuals who routinely interact with children and adolescents—including educators, support service providers, health and mental health care providers, legislators, law enforcement personnel, prosecutors, public defenders, judges, and the commercial sector—is needed. It is incumbent upon pediatricians to 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. The status quo is simply unacceptable.
Additional Contributions: We acknowledge the members of the Institute of Medicine and National Research Council Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States for their contribution to this work. REFERENCES 1. Institute of Medicine; National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: National Academies Press; 2013. http://www.nap .edu/catalog.php?record_id=18358. Accessed July 23, 2014. 2. Chase E, Statham J. The Commercial Sexual Exploitation of Children and Young People: An Overview of Key Literature and Data. London,
England: Thomas Coram Research Unit, Institute of Education, University of London; 2004. 3. Mathews P. A Review and a Way Forward: A Report on the Sexual Exploitation of Boys and Young Men. Barkingside, England: Barnardo’s; 2000. 4. Estes RJ, Weiner NA. The Commercial Sexual Exploitation of Children in the US, Canada, and Mexico. Philadelphia, PA: Center for the Study of Youth Policy; 2001. 5. Heilemann T, Santhiveeran J. How do female adolescents cope and survive the hardships of prostitution? a content analysis of existing literature. J Ethnic Cult Divers Soc Work. 2011;20: 57-76. doi:10.1080/15313204.2011.545945. 6. Trickett PK, Noll JG, Putnam FW. The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study. Dev Psychopathol. 2011;23(2):453-476.
JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 05/23/2015
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