Keywords

1 Introduction

Domestic minor sex trafficking (DMST) accounts for a significant percentage of sex trafficking. Of the 600,000–800,000 people trafficked across borders internationally, 70% are women and half of those are children [1]. Since so many sex trafficking victims are minors, sex tourism has grown into a thriving business for pedophiles. A common misconception is that sex tourism only happens in other places like the far East and South America, but pedophiles find opportunities in America as well. In the United States, while some children are sold by their family members and a few are kidnapped, any child is vulnerable and most are recruited by friends or people they perceive to be friends.

Many are runaways who arrive in a strange city penniless. Recruiters hang out at bus stations waiting to befriend arrivals with promises of food and a safe place to stay. They are then “broken in” either by seduction or violence until they believe they have no other choices. A fortunate few are identified by police or health care practitioners and placed in shelters. Others commit suicide or are killed by their pimps or “johns.” If the rescued victims receive treatment, they can manage to become thriving survivors and often work in shelters helping others as peer support counselors. This chapter summarizes the problem in the United States in terms of the children, the traffickers, treatments, and prevention tips.

2 Terminology

The general public, media, and law enforcement particularly have the unfortunate tendency to refer to victims as child prostitutes. The term implies choice, but little kids do not dream of becoming a prostitute when they grow up. Therefore, the precise term is prostituted children, indicating that something is done to them, in contrast to their seeking out sexual experiences. In most states-indeed, in most countries—the age of consent for sex is 18. If a minor (under the age of consent) is lured, tricked, or forced into sex, then that child has been raped. Yet, we continue to treat children as offenders rather than victims.

Another confusing term is victim. Legally, children are victims, but it is therapeutic to refer to them in a positive way as survivors, especially when working with them clinically. Whatever happened to them and how awful their lives have been, if they manage to escape the life, they are survivors. Then the job of the clinician or counselor is to help them become what one young woman described herself with pride—“a thriving survivor.”

3 Demographics

Prostituted children are both female and male and represent all races and a range of age from infancy till 18 when they are no longer minors. The average age of beginning is usually stated as 12–14 or 11–13. Both figures are suspect because the population is largely invisible and studies are few and have limited validity and reliability. For all practical purposes, it should be enough to remember that the age of consent is usually 18 and sex with anyone under that age is rape even if the minor believes he or she can consent.

Even this figure is complicated by child marriage, when parents can obtain legal permission to marry off their young children. Child marriage is discussed elsewhere in this book so only a brief mention is made here to emphasize that the reason many parents insist on these marriages is when the child has been raped by an adult and the parents force her to marry her rapist [2].

In 2016, the Tahirih organization collected case stories by survivors to present to the Virginia legislature to document the lives of children forced into marriage. The founders noticed large numbers of girls married to older men and documented their stories in the hope of changing the lax law permitting child marriage. They found that only Delaware and New Jersey set minimum marriage age at 18 with no exceptions. Thirteen states do not set any minimum age [3]. Recent and pending legislation in a few states addresses setting new rules for child marriage but progress is slow and hampered by attitudes of family shame and parental prerogatives.

There is a market for children who are disabled in some way. Disability can be physical or developmental. Offenders can be preferential and choose children by age and/or gender. Some prefer more vulnerable children. They derive their thrills from the particular weakness of the child. Traffickers who use the disabled might find them easier to isolate from their support systems and can control them for their benefits if they receive disability social security or other funding. Traffickers use their level of awareness and cognitive processing against them to lure and trick them into compliance.

4 Cases

4.1 Cassie

Blind and deaf since birth, a 13-year-old Cassie was an orphan raised by an elderly grandmother who employed a caretaker for Cassie. Vulnerable and physically weak herself, the grandmother trusted the woman she employed and gradually turned over financial control to the woman, Mrs. Smith. She was unaware that Mrs. Smith was a trafficker who took Cassie to hotel rooms to meet men under the guise of fun outings like the zoo and museums. The true situation was discovered by the grandmother when Cassie became pregnant. Mrs. Smith disappeared with a substantial amount of money, but Cassie received help and the grandmother was able to make appropriate arrangements for Cassie.

Gay and transgendered children are particularly vulnerable in that they tend to be rejected by their families. They runaway or are forced to leave home and end up in strange cities where they are quickly tricked by pimps. As many as 25%, LBGTQ youth may be rejected by their families and become trafficked as a way of surviving on the street [4].

4.2 Billie

Billie was a 15-year-old girl who ran away from home when she came out as gay and her parents threatened to send her to a readjustment school. She took a bus to New York from her small town in Alabama and lived on the street for a few days until she was “befriended” by a young man who claimed he also was a gay runaway. She quickly learned that he lied and was just another pimp, but one who specialized to an extent in men who thought they could reverse Billie’s homosexuality. Her life was a living hell until she was arrested and was fortunate enough to be referred to a human trafficking shelter.

What is common to these two stories is that the traffickers were easily able to establish trust with their victims by pretending to care for them. In contrast to the stereotype of sex traffickers as kidnappers, most traffickers, at least in the US, become known and trusted fairly easily until the child is under their control. Even then, survivors report that they do not try to escape from fear of retribution or because they believe they have no other options.

5 Risk Factors

Risk factors are factors, such as genetics or behavior, that place an individual at an increased risk of contracting an illness or being placed in an unsafe situation. In sex trafficking, risk factors can make certain children more susceptible. Although there is no standard profile for sex trafficking victims, it is important to identify the risk factors associated with trafficked victims.

The top five risk factors for human trafficking in the U.S. are children who have recently migrated or relocated to a new region, engage in substance abuse, runaway or homeless youth, history of mental illness, or involved with the child welfare system [5]. In addition, researchers have found that sex traffickers often target children from low-income families, isolated/marginalized/minority communities, or families that have perpetuated abuse (i.e., mental, emotional, and sexual abuse). Children with families that have been sex trafficked or have bought sex are at a heightened risk. It is important to note that an absence of these risk factors does not prevent a child from being trafficked.

6 Recruitment

Recruiters rely on control tactics to target and seduce their victims. Recruiters may establish a sense of trust with their victims through false promises, seduction or coercion, intimate relationships, or monetary payments. Children are susceptible to trusting traffickers who display good intentions even if this is not true. Victims who are in difficult situation may find recruiters reliable and trustworthy, especially if they offer assistance. Once this sense of trust has been built, they will be forced into the sex trafficking ring where they may be sold, broken-in, traded, or killed. Some recruiters may rely on force, coercion, and threats to suppress and control their victims as well. Traffickers may threaten their victim’s family and friends, which forces them to comply with their demands out of fear for their family’s well-being. Other control tactics include restriction of health care, psychoactive drugs, debt bondage, and threat of law enforcement.

There are four main types of pimps or traffickers: Romeo, Gorilla, CEO, and bottom girls. It is important to note that each trafficker may have different grooming tactics that do not fit this specific list. This list is a general guideline to identify traffickers/pimps. In this chapter, the terms pimp and trafficker are interchangeable.

The “loverboy” or Romeo pimp is someone (usually a young, attractive man) that seduces their target and forces them into the sex trafficking trade through romance. Loverboys rely on establishing trust and forming romantic relationships through promises and acts of service. These relationships can be formed through chat rooms, internet rooms, forums, etc. They will promise things like how wonderful a life with them would be, jobs, money, support, or a “real’ relationship. Romeo pimps will twist the perception of their target and try to isolate them from their social support. The relationship may begin as loving or stable, however, it will quickly turn into an emotional and psychological abusive relationship [6].

The Gorilla (or Guerilla) pimp is one of the more violent and intimidating traffickers. They rely solely on intimidation, violence, force, and threats to control their victims. They are seen as the opposite of a Romeo pimp because there is usually no staged love or affection. If it is present, it is seen for a short time period. Their violent nature is hard to subdue. However, they may employ Romeo tactics to entice their target at first and will lash out once they have them trapped in the trade [7]. Victims may feel like they are trapped by the routine violence and intimidation. If the victims do not follow the pimp’s rules, it may result in severe consequences.

The CEO pimp views sexual exploitation as a form of business. Typically, they hold the belief that the prostituted women and children are their property. They run it like a business and may operate other illegal businesses. They display narcissistic tendencies such as grandiose sense of self-importance, entitlement, exploitation of others, and constant need for attention. CEO pimps may brag about themselves and what they can do for their victims.

Traffickers often have an intermediary between themselves and their victims. The intermediary is often called “the bottom.” The bottom or “bottom girl” is typically a victim and has been with the trafficker(s) the longest. She will look over the other children, punish them, report to the trafficker, and transport them. Even with the gained trust of the traffickers, they still fear retaliation and abuse at the hands of the traffickers. Bottom girls are seen in the same light as pimps; however, many bottom girls view their position as a way of survival.

7 Markets/Trading

Traffickers have found ways to exploit victims and connect with buyers or other traffickers. The internet has made it easier to sell and trade prostituted children. The three main communication channels to connect with and sell children is advertising (ads selling sex services), hobby boards (sex service review boards), and dating websites (websites that arrange sex services under the guise of a dating app). Hobby boards are used to disguise sexual exploitation as a legal service. These reviews are used to narrow down and market the children and girls to buyers and other traffickers. Dating websites are used as a front to disguise the illegal activity, but within the system lies a network of pimps, buyers, and “watchers” that buy sex services. Traffickers and recruiters rely on markets as well. The black market, or shadow market, is a network of connections, websites, and sources that sell illegal services and items.

8 Outcomes

Once a child is forced into the sex trade, there is a 1% chance of them escaping or being rescued. Once a child has been forced into “the life,” it is extremely difficult to escape it. The conditions of living vary, but are controlled and limited by the trafficker. Some victims live with their trafficker or the related gang, others work within groups or brothels [8].

Similar to domestic violence situations, victims are often asked why they don’t “just leave the situation.” Victims choose not to leave their trafficker for a variety of reasons. They feel like they lack control or power to leave the situation, fear repercussions or retaliation, or lack insight into their victimization [9]. Due to this, many victims stay in the trade and become subject to violent deaths or face jail time. They are forced to endure physical torture and engage in substance abuse which can lead to overdoses. If the victim feels hopeless, they may seek out means to end their own lives. Depending upon their trafficker, they may become involved with gang-affiliated violence that can lead to death by homicide or homicide-suicide. If a trafficker has multiple child victims, they may trade their victims with other traffickers, “madams,” or buyers.

Victims that remain in the trade for several years may age out of the system or go on their own. If the demand of their services or labor decreases or they appear aged, they may be pushed out of the trade. Victims that become “bottom girls” or work with their traffickers may be criminalized and prosecuted by the justice system if they are arrested. The Federal Bureau of Investigation (FBI) has issued a statement from their sex trafficking operation from 2021 that reports their efforts for criminalizing traffickers and liberating their victims. However, local governments still prosecute victims and treat them like criminals.

9 Identifying Sex Trafficking Victims in a Medical Setting

In the last 6 months, more than 75% of victims were seen by a provider for medical treatment [10]. Traffickers may bring their victims to health centers or hospitals to treat broken limbs, sexually transmitted infections (STIs), pregnancy, or overdoses. The victims may not communicate honestly or openly with their health care provider. As a result, health care providers are in a unique position to intervene and implement safety measures for sex trafficking victims.

Sex trafficking victims may seek treatment for a lack of protection (i.e., condom use or contraceptives), increased contact with individuals diagnosed with STIs, unwanted pregnancy, bruising, broken or fractured limbs, head trauma, or depression. Victims are often forced into unwanted sexual acts where protection is unavailable or too expensive, so they face an increased risk of teen pregnancy, STI infection, and unsafe abortions. Key identifiers for trafficked children in a health care setting include:

  • Youth that are afraid of adults or authority

  • Chronic pain without obvious causes

  • Unexplained bruising or injuries

  • Drastic changes in appearance, weight, behavior, or sleep patterns

  • Withdrawal

  • Reluctance to self-identify or disclose past medical history

During the initial assessment, patients may feel hesitant when discussing their prior health history and current visit to the provider. They may decline to self-identify or disclose any health information, especially if their trafficker is in the room with them. If the provider suspects that the patient may be a victim of sex trafficking, ask their guardian to step out of the room to provide privacy. If their guardian declines to leave, explain per your facilities protocols, a patient’s right to confidentiality and privacy during a health assessment. Once their guardian has left the room, begin the health questionnaire to gather more about their visit and their underlying health concerns. Appropriate questions to ask a possible sex trafficking victims include:

  • Has your identification been taken from you?

  • Are you able to leave your job or situation if you want?

  • Have you ever been forced to commit a sexual act even if you refused?

  • Have you performed sexual acts in exchange for money?

  • Have you been physically harmed in any way?

  • Has anyone threatened you, your friends, or your family?

  • Have you been abused by someone close to you?

  • Have you taken illegal substances?

There are several questions that health providers can ask to gauge whether their patient is a victim or involved in an unsafe situation. When a provider is conducting their health assessment, it is important to establish trust and respect. The patient will be more reluctant to seek help if the provider does not establish that foundation of trust. The patient needs to be monitored for signs of distress and uneasiness. A provider can explain every procedure, answer questions or concerns brought up by the patient, and maintain privacy. By ensuring all of these measures are implemented with every patient, the goals of identifying sex trafficking victims are met. A patient’s safety, privacy, and trust are pivotal in identifying sex trafficking victims.

10 Treatment

When survivors escape the trade, it is encouraged that they seek treatment and become involved in support resources. The treatment and care for sex trafficking survivors are complex—they require extensive mental health, physical, emotional, and physiological care. Trauma-informed care is crucial to survivor recovery [11]. Survivors may be at their most vulnerable, therefore it is important for health care professionals to provide care that is respectful, informative, and holistic. It can take time for survivors to seek treatment and report improvements in their health. With education and therapy, survivors will be able to reflect upon their trauma without relieving it. Survivors need to be transitioned back into society. Interpersonal care teams can achieve this goal of reintegration.

There are guidelines for the prevention, identification, and immediate treatment for child sex trafficking victims. Yet, there is a lack of guidelines or recommendations for continuous, ongoing care and follow-ups for this vulnerable population. Comprehensive physical examinations, STI testing, prenatal care, psychiatric evaluations, and behavioral assessments are essential for ongoing care for survivors [12].

10.1 Mental Health

Due to the trauma and abuse victims may experience, they are at an extremely high risk of developing mental illness or disorders. The most common mental health concerns include posttraumatic stress disorder (PTSD), anxiety, obsessive-compulsive disorder (OCD), substance-abuse disorder, and major depressive disorder. The treatment of mental health disorders is driven by evidence-based practice (EBP), therapeutic communication, and pharmacological approaches. EBP is guided by the idea that there is scientific evidence that supports the proposed treatment, which could be medication, therapies, support groups, or treatment plans. Therapy may be referred for the survivors to process and cope with the long-term consequences of sex trafficking. Cognitive and behavioral therapy are among the most common forms of therapy offered.

10.2 Physical Health

The physical health of survivors is often affected as well. Survivors may report unintended weight gain or loss, serious injuries, or change in their ability to complete activities of daily living (ADLs). A major concern for survivors is their reproductive health. Traffickers view their victims as property that can be sold and used multiple times. This has a negative effect on the victims reproductive system. Treatment plans for these survivors will consist of pharmacological approaches and medical interventions to promote quality of life and increase their health.

10.3 Spiritual Health

A traumatized brain is mistrustful and paranoid, especially around figures of authority. When a survivor is referred to spiritual services, it may be beneficial to move slowly, calmly, and carefully. Trust, forgiveness, and love must be slowly presented and built so the victim does not revert back to their prior mental state. Spiritual care is offered to survivors to provide them with a source of unconditional love and support during a traumatic time. If the victim is requesting religious interventions, explaining God’s plan for all of His children and the message He has for His followers may promote spiritual healing. However even if this strategy does not seem appropriate for all survivors, faith-based shelters can be quite effective in providing the comfortable environment that comes with a focus on the survivor as a welcome visitor. Churches and other groups can also be a source for education and prevention of sex trafficking. There may be support groups and communities within churches and similar institutions. Survivors can use this as an outlet to engage in social interactions with other survivors of sex trafficking and seek spiritual healing.

11 Legal Resources

Legal efforts can be intimidating and traumatic for survivors. Laws and federally funded groups are available for victims of sex trafficking. The three main laws that have been established and upheld are a follows:

  • Trafficking Victims Protection Act of 2000—Protects victims and prosecutes traffickers, pimps, and buyers

  • The Justice for Victims of Trafficking Act of 2015—Improves the response to human trafficking and changed the criminal liability of buyers

  • The Preventing Sex Trafficking and Strengthening Families Act of 2014—Seeks to reduce incidence of minor sex trafficking in foster care systems

Before 2000, there were scarce resources for survivors and even less criminal prosecution of traffickers. The laws from the early and late 2000s were established to increase the prosecution of traffickers and resources for survivors. However, it can be difficult for survivors when they seek and use legal resources. They are often held as material witnesses which forces them to testify in their own cases. This can be seen as a traumatic situation because the victim has to relive their trauma in front of the perpetrator and the general public. Due to this, there is a discrepancy between the criminal justice system’s defined metrics and the survivors’ wants and needs. Survivors stress the importance of holding their traffickers accountable through criminal prosecution [13].

Discussion Questions

  • Compare and contrast the vulnerabilities of children vs. adults to sex trafficking.

  • For the case studies, describe prevention strategies that might have been implemented.

  • Discuss aspects of the TVPA that relate to domestic minor sex trafficking.