Commercial sexual exploitation of children (CSEC) is not a new social problem, but one that has undergone an evolution in its conceptualization. CSEC was first defined in the 1996 Declaration and Agenda for Action for the First World Congress Against the Commercial Sexual Exploitation of Children as “sexual abuse by the adult and remuneration in cash or kind to the child or a third person or persons” (p. 1). CSEC overlaps in definition and meaning with sex trafficking of minors (STM). Sex trafficking is defined in the Trafficking Victims Protection Act (TVPA) of 2000 as “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act…in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age” (22 USC § 7102; 8 CFR § 214.11(a)). To be clear, the TVPA (2000) defines a commercial sex act as “any sexual act for which something of value is given or received.” Unlike other forms of human trafficking, no proof of force, fraud, or coercion is needed when the person in commercial sex is under age 18 because children cannot consent to commercial sex (Boxill and Richardson 2005).

The most consistently found risk factors for CSEC and STM include sexual abuse (Cobbina and Oselin 2011), prior child welfare involvement (Gragg et al. 2007; Nixon et al. 2002), foster care placement (IOM and NRC 2013), running away or being thrown away (Cole et al. 2016; IOM and NRC 2013; Reid et al. 2015; Varma et al. 2015), homelessness (Greene et al. 1999; Nadon et al. 1998; NAEH 2009; Wagner et al. 2001), and substance use/abuse (Cole and Sprang 2015; Cusick et al. 2003).

Some child victims of sex trafficking are trafficked by a parent or other family member (Kennedy and Pucci 2007; Polaris Project 2015). The National Juvenile Prostitution Study surveyed nearly 2,600 law enforcement agencies about cases of juveniles involved in prostitution in 2005, and noted that among the randomly sampled agencies that reported at least one arrest or detention in cases of a juvenile involved in prostitution, 12% were exploited by a family member, caretaker, or acquaintance, 57% of the cases involved a third-party exploiter (i.e., pimp), and 31% were classified as juvenile who offered themselves for sexual services (Mitchell et al. 2010). Of 314 cases of child trafficking reported to the National Human Trafficking Resource Center’s hotline from 2007 to 2012, 49 cases (15.6%) involved allegations that the minor was trafficked by a parent or legal guardian (Polaris Project 2013). In a survey of professionals who worked with at-risk youth and crime victims/offenders, the largest category of victim-trafficker relationship for the three most recent cases they had worked was family member: ranging from 50.0% in micropolitan communities to 82.4% of professionals working in all types of communities (Cole and Sprang 2015).

When one considers child pornography, which fits the definition of commercial sex when it is traded for something of value, the involvement of family members is found in a sizeable minority of cases. Among juvenile victims of child pornography offenses whose offender could be identified in the National Incident-Based Reporting System (NIBRS), 25% were family members of the offenders (Finkelhor and Ormrod 2004). Wells et al. (2012) found that technology-facilitated sex trafficking of minors involved younger children and were more likely to involve a family member or acquaintance compared with non-technology-facilitated cases.

Familial sex trafficking of minors may involve the intergenerational transmission of prostitution (Raphael et al. 2010), or it may involve family members selling sexual access to children to obtain money, drugs, or something else of value (Smith et al. 2009). In a sample of adults involved in commercial sex, 35% of the individuals who were first involved in commercial sex before the age of 18 (n = 115) had family members engaged in sex work (Fedina et al. 2016). In the Fedina et al. (2016) study, there were no questions about if and how family members were involved in the child’s exploitation in commercial sex therefore it is not possible to determine if family members were directly involved in the juveniles’ exploitation in commercial sex. Studies have documented familial sex trafficking cases of parents with substance use disorders trafficking their children to obtain drugs (Cole and Sprang 2015; Heil and Nichols 2015). Other types of familial sex trafficking are parents allowing sexual offenders to sexually abuse children for money, drugs, or a place to stay, and caregivers producing pornography of their children and selling/trading the products (Smith et al. 2009).

Even though there is an acknowledgement in the literature that familial sex trafficking of minors occurs (Smith et al. 2009), when researchers describe the ways in which traffickers exploit children they almost always describe methods that are used by boyfriends, pimps, and strangers such as guerilla pimping, finesse pimping, boyfriend pimping, and business pimping (Hammond and McGlone 2014; Kennedy et al. 2007; Kotrla 2010; Mones 2011; Smith et al. 2009; Walker 2013; Williamson and Prior 2009; Wilson and Dalton 2008). This is likely because most of the commercial sexual exploitation is perpetrated by paramours or involves survival sex; however, it remains to be seen how commercial sexual exploitation perpetrated by family members is similar and different from exploitation perpetrated by the more common types of perpetrators.

Recognizing and understanding the variability in youths’ experiences in commercial sexual exploitation is needed to ensure appropriate detection and service provision for all victims (Fedina et al. 2016). There is a need for agencies and individuals to acknowledge that family members profiting off of and/or facilitating the commercial sexual exploitation of children is human trafficking (Smith et al. 2009). Limited attention has been given in assessments to the possibility that the trafficker may be a parent/caregiver. For example, in a comprehensive assessment provided by Polaris Project (2011), questions about the sex trafficker are clearly based on the assumption the trafficker is a boyfriend/pimp and not a parent. The purportedly first developed, validated screening tool to identify adult and minor victims of sex and labor trafficking victims (Simich 2014) was validated on a predominately foreign-born sample, and does not include any questions that would appear to uncover sex trafficking of a child when the trafficker is a parent/guardian (Vera Institute of Justice 2014). Labeling familial sex trafficking of minors as child sexual abuse without acknowledging the commercial element may allow perpetrators to be charged with offenses that carry less severe penalties (Smith et al. 2009).

Exploitation in commercial sex results in significant psychological trauma and negatively impacts development. Children exploited in commercial sex are at high risk of continued involvement in commercial sex in their adulthood (Ventura et al. 2007). Prior research has found associations of CSEC with posttraumatic stress disorder (PTSD; Heilemann and Santhiveeran 2011), complex trauma (Graham and Wish 1994), anxiety and depression (Middleton et al. 2016; Trickett et al. 2011; Tsutsumi et al. 2008), suicidality (Trickett et al. 2011), substance abuse (Middleton et al. 2016; Nadon et al. 1998; Varma et al. 2015), distrust of others (ECPAT 2006), and social isolation (Heilemann and Santhiveeran 2011). The commercial and public nature of CSEC and STM may compound the trauma of the sexual exploitation (Leary 2014). In a clinical sample of youth who had all experienced sexual abuse/assault, youth who had been exploited in commercial sex had higher clinically significant scores for the avoidance subscale on the UCLA PTSD-RI when compared to a matched sample of youth who had experienced sexual abuse/assault but not CSE (Cole et al. 2016). Additionally, significantly more youth exploited in commercial sex had developmentally inappropriate sexualized behavior and substance abuse when compared to the matched group of youth.

The type of psychological and social damage inflicted by parents /other relatives exploiting children in commercial sex may be even more severe and enduring. Households in which children are exploited in commercial sex by family members likely have multiple adversities, dysfunctions, and stressors that create a household dynamic of coercion and chronic stress. Van der Kolk (2005) stated, “When trauma emanates from within the family children experience a crisis of loyalty and organize their behavior to survive within their families” (p. 6). Children who experience this form of trauma exposure can have difficulties with self-regulation and social interpersonal relatedness, and may experience short and long term problems such as physical and psychiatric disorders, addiction, and problems with socio-environmental functioning (Cook et al. 2005).

The purpose of this pilot study is to describe the clinical presentation of juvenile victims of commercial sexual exploitation perpetrated by family members in a sample of clients receiving assessment and/or treatment related to child maltreatment. Specifically, this research focuses on: (1) victim, trafficker, and trafficking characteristics, law enforcement classifications for trafficked youth, clinical profiles of victims, and service system involvement of children and youth involved in familial sex trafficking; (2) gender differences in clinical outcomes of commercially exploited youth; and (3) geographical differences in the severity of the victimization experience.

Method

Participants

The sample consists of 31 youth who were referred to an outpatient, academic medical center in a predominately rural state for clinical services related to their child maltreatment experiences (not necessarily sex trafficking experiences). The center is centrally located in the state, and provides assessment and specialized trauma treatment services statewide. Data was extracted from clinical records representing a six-year period, 2011–2017. The sample was young (M = 11.96 years of age, SD = 3.3), with an age range of 6–17. The youth were predominately female (58.1%), and White (83.9%). Comparison of the sample to population statistics from the state reveals similar demographic profiles based on race, and gender (U.S. Census 2010). Approximately 40% of the cases reviewed included sexual exploitation of more than one child in a family unit (M = 2.1 children, SD = 1.7).

Procedure

The current analysis represents a secondary data analysis of a clinical database from an assessment and treatment program. Cases were selected for inclusion in this study if indication of commercial sexual exploitation was identified in the assessment process (i.e., child’s involvement in prostitution, pornography, strip dancing), even if the reason for the referral was for services related to another form of child maltreatment. This was determined by a word search of the clinical database of reports using the terms “prostitution, pornography, strip dancing, sex trafficking, and sexual exploitation.” This resulted in 35 hits, four of which were not included because the terms did not apply to children. To protect the assumption of data independence, only one child from each family was included in the study. This excluded children/youth in a family who witnessed or had knowledge of the sexual exploitation but who were not actively involved. If more than one child was trafficked, the child with the longest history of involvement, or if equal, the child whose involvement resulted in criminal justice involvement was included. This algorithm was successful in identifying inclusion in all cases. Data was extracted by the senior author using a data extraction template that included the aforementioned variables of interest. There were no specific criteria put forth about the relationship of the trafficker to the victim; however, prior clinical work with this population suggested that familial sex trafficking would be one of the more common types of relationships. In fact, all the cases in this study involved familial sex trafficking, even if other types of traffickers were identified. Due to the nature of the clinical setting, all youth had current or past child welfare involvement. The protocol for this proposed project was approved by the appropriate Institutional Review Board (IRB).

Measures

Case Dynamics

Commercial sexual exploitation descriptors were obtained from the existing clinical records database, and included demographic information on the youth and the trafficker (e.g., age, gender, race, where the youth was living when the exploitation occurred, and relationship information); how the trafficker(s) identified the child or youth and the number of children exploited; method of coercion used by the trafficker(s) (e.g., threats and intimidation, kidnapping, drug addiction as determined by a review of the criminal record, child welfare investigation, or clinical interviews); and presence of and nature of any law enforcement involvement (o = no, 1 = yes) and criminal charges (o = no 1 = yes). For purposes of this study, involvement in prostitution, pornography or strip club was endorsed if the child protection record substantiated that the child was engaged in these activities. The federal definition was used to ensure the activities as described in the record were consistent with sex trafficking. This definition states that sex trafficking is “any sex act, on account of which anything of value is given to or received by any person”, and, in minors, does not require proof of force, fraud, or coercion (Citizen’s Guide to U.S. Federal law on the Prostitution of Children 2015, p. 1). In this study, child pornography was considered to be of value even if it was not traded for cash or goods. Additional information on the children/youth included history of psychiatric hospitalizations (no = 0, yes = 1); suicide attempts (no = 0, yes = 1); and/or injury (no = 0, yes = 1).

To further dimensionalize the trafficking experience, a severity of abuse rating was calculated for each child/youth using the Sexual Abuse Severity Score algorithm proposed by Zink et al. (2009). Information collected included age of first sexual abuse, whether there was more than one perpetrator, degree of coercion (high = 4, moderate = 2, none = 0), severity of abuse such as attempted intercourse (4), which is more severe than fondling (2)and requests for sexual favors (0), and the number of occurrences. Scores on this scale range from 0 to 20, with higher scores indicating more severe abuse.

Clinical Outcomes

The Child Behavior Checklist (CBCL) (Achenbach and Rescorla 2000) measures emotional and behavioral functioning for children 6–18 years of age, and was completed by the foster or relative caregiver for the identified child/youth during the service delivery period. The CBCL assesses symptoms in the following domains: internalizing behaviors, externalizing behaviors, and total combined problem behaviors. Internalizing behaviors include symptoms of anxiety, depression, and somatic complaints, while externalizing behaviors include symptoms such as aggression and rule-breaking behaviors. The Total Problem Scale score consists of the internalizing and externalizing subscale scores. T-scores of 63 or above exceed the clinical threshold and are considered significant. The CBCL is internally consistent with alphas ranging from 0.78 to 0.97, and has high test–retest values (0.95–1.00; Achenbach and Rescorla 2000). The Trauma Symptom Checklist for Children (TSCC-A) (Briere 1996) is a 44-item child self-report measure of post-traumatic stress symptoms for ages 8–16. The TSCC-A includes an under-response and hyper-response scales, and five clinical scales that measure symptoms of anxiety, depression, anger, post-traumatic stress, and dissociation. TSCC-A T-scores of 65 or higher indicate significant clinical symptoms. The TSCC-A clinical scales have high internal consistency (Cronbach alphas of 0.82 to 0.89) and there is evidence of convergent and discriminant validity (Briere 1996).

The Trauma Symptom Checklist for Young Children (TSCYC) (Briere 2005) is a 90-item caregiver report measure of trauma-related symptoms in children ages 3–12 that was completed by the foster or relative caregiver. The TSCYC consists of a caregiver underreporting and over-reporting symptom scale, and eight clinical scales measuring anxiety, depression, anger/aggression, intrusive thoughts, avoidance, arousal, dissociation, and sexual concerns. A clinical threshold of T-scores equal to or above 70 has been established, and test–retest reliability values for this measure were found to range from 0.68 to 0.96 (Briere 1996). Internal consistency for the clinical scales range from 0.78 (anger subscale) to 0.92 (PTS total subscale (Briere 1996).

Service System Involvement

Service system involvement was classified for each case based on any contact with the juvenile justice, child protection, community mental health, hospital or healthcare facilities, schools, or law enforcement during the period of sex trafficking involvement. Contact with multiple agencies was captured by allowing for multiple codes for each case within this category.

To further elucidate the trafficking experience, law enforcement’s orientation to this phenomenon was described using the categories proposed by Mitchell et al. (2010), which uses an algorithm to classify cases based on who was detained and ultimately charged in the case, and for what offense. Juveniles were categorized as victims if only the trafficker was arrested or detained, or if no charges were filed against the child or youth. The juvenile as delinquent category was used for those youth who were charged or detained, and no treatment services were provided. Juvenile as victim and delinquent refers to those cases where the trafficker was arrested on charges specific to the commercial sexual exploitation, the child or youth was also arrested or detained due to prostitution, but treatment services were provided. This classification provides further detail on how law enforcement engages with youth involved in familial sex trafficking.

Rural–Urban Classifications

Counties where the trafficking occurred were classified based on a continuum of rural to urban codes (USDA 2013). These codes were then used to group the sample into three categories. Metropolitan areas consist of rural to urban codes of 1–3, a micropolitan areas consist of urban populations adjacent to a metropolitan county or a non-adjacent county with a population of over 20,000 (rural to urban codes 4–6), and rural counties are those with less than 20,000 residents, not adjacent to a metro county, or with a county population of less than 2,500 residents (rural to urban codes 7–9).

Data Analysis

Descriptive statistics are used to document the characteristics of the victims, trafficker and trafficking encounters, to describe law enforcement, clinical outcomes, and system involvement for the children and youth. Given the small sample sizes, non-parametric T-test (Mann–Whitney U) and One Way Analysis of Variance (Kruskal–Wallis) were used to assess the impact of gender and rurality on clinical outcomes, and severity of abuse, respectively. There was no missing data on any of the variables of interest.

Results

Case Dynamics

In this sample, all of the cases involved a family member as the trafficker; the mother (64.5% of cases, n = 20), father (32.3% of cases, n = 10), other family member (3.2% of cases, n = 1). In just under one-half of the cases (44.9% n = 14), there was evidence of a non-familial member who assisted in the trafficking, including the parent’s paramour, an acquaintance, or a stranger. In cases where the mother was the trafficker, a second trafficker was involved 65% (n = 13) of the time. This second trafficker was most likely an acquaintance (35%, n = 7) or paramour (30%, n = 6). The traffickers were primarily middle-aged, with parent traffickers being slightly younger (M = 42.6 years of age, SD = 6.6), than their non-familial trafficking partners (M = 42.64 years of age, SD = 13). About two-thirds (64.5%, n = 20) of the traffickers were criminally charged, though only 30% (n = 6) of these were charged with a crime associated with human trafficking. In almost two-thirds of the cases (61.3%, n = 19), victims have/had ongoing contact with the trafficker post-identification of the trafficking.

A high percentage of cases (81.8%, n = 25) involved parents who used illicit drugs as the currency to profit from trafficking of their children. In every case the parent resided with the child during the exploitation period. Just under half (45.2%, n = 14) of trafficking cases originated in rural areas, 16.1% (n = 5) in micropolitan areas, and 38.7% (n = 12) occurred in metropolitan areas. In all cases, caregiver threats, intimidation, and parental authority were used to recruit and maintain the victim in prostitution (86.3%, n = 27), pornography (50%, n = 16), and strip club involvement (18%, n = 6)). The victim’s drug addiction (29% of cases, n = 9) was also utilized to engage and sustain the child youth in trafficking.

The overall mean severity of abuse scores were high in the overall sample (M = 14.66, SD = 3.02), with high coercion scores (M = 3.6, SD = 0.81), indicating threats, bribes, physical force and use of weapons were used to coerce the youth in this sample into sex trafficking. There were very high ratings on the most severe abuse ever experienced (M = 3.67, SD = 0.59), indicating this sample frequently experienced attempted or completed intercourse, or object penetration as part of the trafficking experience. There was a statistically significant difference between geographic groups on severity of abuse as determined by one-way ANOVA (F (2,30) = 6.793, p = .011). A Tukey post hoc test revealed that the mean severity scores were statistically significantly higher in the rural group (16.9, p = .01), compared to the metropolitan groups (13.5, p = .118) and those from micropolitan areas (11.9, p = .197). There was no statistically significant difference between the metropolitan and micropolitan groups (p = .767) on abuse severity. Severity of abuse scores did not differ by gender (t = 0.987, p = .261).

Clinical Outcomes

In addition to the exploitation associated with involvement in prostitution, pornography or employment as an underage worker in a strip club, other forms of trauma exposure were common during the period of exploitation and included sexual assault (96.8%, n = 30), physical assault (58.1%, n = 18)), witnessing violence of another (6.4%, 2 cases), or health-related crisis such as contracting a sexually transmitted disease, pregnancy or injury (90.3%, n = 28). Over one-third of the sample (35.5%, n = 11) had a psychiatric hospitalization subsequent to the trafficking, and almost half (48.4%, n = 15) reported they had attempted suicide during their lifetime. Physical injuries due to trafficking involved bruising, factures or cuts (25.7%, n = 8), sexually transmitted diseases (25.8%, n = 8), or in one case being tattooed or physically marked against their will. Approximately 13% (n = 4) reported self-inflicted cutting during this time.

Post-traumatic stress disorder (PTSD) was the most common diagnosis (80.1%, n = 25) documented in the clinical record with Oppositional Defiant Disorder, and Major Depressive Disorder reported in four, and five cases, respectively. Total Trauma PTS scores, as well as CBCL Internalizing, Externalizing and Total scores are displayed in Table 1. There were no statistically significant differences in child trauma scores (t = -1.620, p = .116) and CBCL Externalizing scores (t = 0.045,p = .964) by gender. However, statistically significant differences were discovered in CBCL internalizing scores (t = 3.11, p = .008), with boys reporting higher mean T scores (M = 74.69, SD = 9.13) than girls (M = 66, SD = 6.45), and lower TSCC depression T scores (t = -2.355, p = .029; M = 54.7, SD = 19.8) than girls (M = 69.25, SD = 7.51).

Table 1 Trauma and CBCL T score measures of dispersion
Full size table

Service System Involvement

Identification of sex trafficking was most frequently preceded by a report from the hospital emergency room (51.6% of the time, n = 16)) to child protective services, or uncovered during a police investigation (45.1%, n = 14). However, in six cases multiple emergency room visits yielded no noted suspicion of sex trafficking or subsequent referral. In five of the cases, a law enforcement investigation of the trafficker’s drug related activity uncovered the sexual exploitation of a minor child(ren). Only two cases involved runaway behavior by the child or youth, though 86.4% (n = 27) involved truancy or excessive absence from school. While all the cases had child welfare involvement, 93.5% (n = 29) had a primary finding of neglect, while only three cases had a sexual abuse finding. The youth in this study were involved with multiple service systems during the time the trafficking was occurring; community mental health (54.9%, n = 17), healthcare (51.6%, n = 16), child protection (19.3%, n = 6), and juvenile justice (22.6%, n = 7). The law enforcement orientation toward the juvenile was identified in each case and compared to national norms (see Table 2). For those with law enforcement involvement (n = 23), youth were slightly more likely to be classified as victims, and less likely to be classified as delinquents, or both victim and delinquent than those in the national sample (Mitchell et al. 2010).

Table 2 Demographic Comparisons with National Sample of Child Sexual Abuse for Payments Cases and Law Enforcement Orientation towards the Juvenile Classifications
Full size table

Discussion

This article addresses a particularly serious form of sexual victimization, the commercial sexual exploitation of children by a family trafficker. Because children and youth involved in prostitution have been traditionally identified as delinquents, much of our contemporary understanding of this phenomenon has been framed by the published research in the domain of criminology, and informed by the conceptual and clinical literature on deviance and delinquency. By further explicating the nuanced and differential experience of family trafficking experience, this pilot study allows for the sex trafficking of children to be understood from a child maltreatment perspective, and creates additional opportunities to consider the most appropriate ways to identify and respond to victims.

Case Dynamics

This sample involved very young children, with no juvenile justice histories prior to involvement in trafficking. Mitchell et al. (2010) notes that family trafficking involves youth who are younger than those exploited by third parties, or who engage in solo sexual activities for payment. Furthermore, in almost two-thirds of these cases, the trafficker was the mother. Although data on familial sex trafficking is in its infancy, this finding is somewhat unusual and contrary to the descriptions of traffickers most predominate in the literature (Kotrla 2010). Raphael et al. (2010) noted that while females were identified as traffickers in up to 25% of domestic sex trafficking cases, only a small percentages (1%) of these female traffickers were identified as mothers. The violation of trust and exploitation from a primary attachment figure creates a condition where complex trauma could become a clinical issue of concern (Cook et al. 2005). Additionally, educational deprivation, exposure to sexually transmitted diseases and early pregnancy, and poor emotional and behavioral modeling may impact the biopsychosocial development of young children who have not yet acquired the requisite gains in sexual, emotional, behavioral, physical and cognitive development to withstand these assaults unscathed (Rafferty 2008). The young age of these children/youth may have contributed to the lower incidence of running away and lack of involvement in the juvenile justice system, which could decrease providers’ opportunities to detect the trafficking victimization.

In this study, over 60% of the child/youth victims were being trafficked in micropolitan or rural areas, where identification and surveillance of this activity may be hampered by lack of awareness, training and recordkeeping (Edwards et al. 2006; Newton et al. 2008), and/or isolation from necessary resources (Castañeda 2000). A previous study by Cole and Sprang (2015) revealed that professionals in metropolitan communities were more likely to receive training on CSEC, were more familiar with state and federal laws, and more frequently identified sex trafficking cases in their communities. The occurrence of family trafficking of young children, in more isolated and under-resourced communities creates a confluence of risk that may hamper the detection and response to these victims. The implementation of Safe Harbor laws in some states (including the study location) places state child protection agencies in charge of the care and protection of these children (Shared Hope International 2015). Unfortunately, these laws have sometimes been implemented before states have trained workers and developed effective protocols (Shared Hope International 2015). Further, in some states these laws have been an unfunded mandate, possibly creating a situation where child welfare personnel are operating in a vacuum, without the support and collaboration from specialized service providers.

The severity of abuse is high in this sample, with a young age of first exposure, significant coercion involving physical force and the use of weapons, sexual intercourse, and object penetration experiences. In fact, the severity ratings indicate that even in cases of pornography or strip club involvement only, these acts of sexual violation were co-occurring. Research has documented that victims of sexual assaults in which the offender was a stranger or relative and where there was a greater amount of violence and perceived life threat, are at most risk for developing psychopathology and functional impairment (Ullman et al. 2007; Swinson 2013). This suggests that these family trafficking victims may be particularly vulnerable to poor outcomes. The rates of higher severity scores in younger, more rural victims’ raises questions about whether lack of surveillance, due to age, geographic or limited socio-environmental interactions, is influencing the exploitation experience in a negative manner. Future research should focus on how age and rurality function as potential predictors or moderators of the occurrence, severity and clinical outcomes of exploited children and youth.

Clinical Outcomes

To date, there has been limited research on male victims. The available research indicates that male and female victims share risks for CSEC including a history of child maltreatment and out-of-home residential placement (Chase and Statham 2004). This study involves one of the highest percentages of male victims noted in the published literature, and underscores the fact that no child is immune from this form of family exploitation and abuse. The mean T scores on the trauma and behavioral measures were above the clinical thresholds on self-reported anxiety, dissociation, and total post-traumatic stress scores for all victims. Similarly, caregiver reports of symptoms revealed clinically significant levels of avoidance, arousal, as well as internalizing and externalizing behavior regardless of gender. Boys in this study had similar response profiles to girls on trauma and behavioral measures but had lower subscale scores for depression, and higher externalizing behavior. This finding diverges from results of a meta review conducted by Nooner et al. (2012) that documents a similar rate of trauma exposure in male and female adolescents yet a two-fold prevalence of PTSD in sexually abused girls (Breslau et al. 2004). In this study, trauma scores are similar, and noted differences lie in the internalization and externalization of behaviors. These differential response patterns should be explored further as there are social and neurobiological differences that may influence not only the expression and experience of traumatic stress in boys and girls but also their willingness and ability to engage in and benefit from many trauma treatments. Further research with larger samples of boys and girls involved in familial sex trafficking is needed to see if these profiles hold true and if the specific trauma experience may be influencing the expression of distress. Investigating the role of stigma in the help-seeking behavior of boys and girls is an important next step. It is noteworthy, that despite these identified gender differences, both boys and girls are reporting clinically significant trauma symptoms and behavioral distress.

One particularly concerning finding is the prevalence of reported suicide attempts in over 50% of this sample. This rate is extremely high compared to national statistics that place adolescent suicide attempts at a rate of 8–10% in the general population (Evans et al. 2005). The high rate of suicide attempts suggests that the young people in this study were experiencing considerable suffering associated with their life circumstance. Cassell (1952), in the New England Journal of Medicine posits that suffering that leads to suicidal behavior is often preceded by a threat to the person’s existence or integrity, or attempts to maintain his or her role in the family or society, or an assault to the individual’s sense of self or identity. From a developmental perspective, children and youth who are exploited by their parents or family members have encountered an experience that fulfills each of the requirements, and during a time when they may not be cognitively or emotionally capable of extracting themselves from the situation. The fact that almost 60% have ongoing contact with their trafficker speaks to the difficulties these children and youth may have in protecting themselves from ongoing exposure to the perpetrator of the crimes against them, and represents an enduring threat to their psychological and physical safety. Herman (1998) was one of the first to identify the establishment of safety as the first and foremost step to recovery from a psychological trauma. Systems of care designed to protect and treat victims of familial sex trafficking must act decisively to respond to this threat.

Although preliminary, the symptoms of psychological distress are consistent with the findings of Cole et al. (2016) wherein higher rates of arousal and dissociation in youth who were involved in prostitution compared to those who were sexually abused, but not CSEC involved, were found. This finding provides further support for the idea that trafficking can cause additional psychological harm to young people, over and above those associated with sexual abuse.

Service System Involvement

In the juveniles represented in this study, secondary losses and victimization experiences were the norm, and one in five had health-related issues (i.e. sexually transmitted diseases, early pregnancy). Health professionals should screen young people who present with these issues to health clinics or hospital emergency rooms for involvement in sex trafficking, as this may be the initial point of service system contact, and an opportunity for detection and intervention. A study by Beck et al. (2015) of medical providers revealed significant gaps in healthcare professional’s knowledge and awareness of sex trafficking, and lack of organizational policy and guidance regarding screening and intervention, especially in pediatric victims. In this study, these children were less likely to be involved with law enforcement, and more likely to be identified by non-criminal justice such as health care providers, schools or child welfare. A targeted, and collaborative team approach to training, identification, reporting and intervention that includes healthcare professionals, child protection, law enforcement, schools and other child serving providers would increase the probability that surveillance and protection could be accomplished in a more effective and coordinated manner. Further investigation of the circumstances surrounding truant behavior in youth may enhance the detection of commercial sexual exploitation.

Although child protection was involved in each of these cases, findings of neglect were most common, and may lead to a mischaracterization of the nature and severity of the case. This finding is clinically relevant since professionals (e.g., child protection, court officials, juvenile justice workers, mental health professionals) have limited information at the initial point of contact and may make referral determinations based on these types of descriptors. Clinical services for children who have been neglected (i.e. subjected to acts of omission) tend to be behaviorally focused and case management oriented, while those cases characterized by acts of commission (i.e. physical abuse, sexual abuse, sex trafficking) are more likely to be routed into trauma-specific services (Sprang et al. 2008).

Specifying in child welfare files and referrals for therapeutic services that commercial sexual exploitation may have occurred, rather than labeling the type of exploitation as neglect-only or even sexual abuse in general, is important information to provide behavioral health providers. The finding that no specification of commercial sexual exploitation or sex trafficking of the child was made by child protection in this sample is somewhat unexpected given that in the third year of the data collection period, a safe harbor law was implemented that designated the state child welfare agency with responsibility for investigating reports of human trafficking of minors and “providing appropriate treatment, housing, and services consistent with the status of child as a victim of human trafficking” (KRS. 620.029). Proper identification of cases involving commercial sexual exploitation by family traffickers is needed to facilitate pathways to appropriate treatment, and is consistent with best practice recommendations for improved screening and identification of domestic sex trafficking of minors (U.S. Department of Justice 2016). Current screening tools such as the one developed by Simich et al. (2014) would need to be modified to detect familial sex trafficking cases.

Kotrla’s (2010) paper on Domestic Sex Trafficking in the United States describes the.

“culture of tolerance” that glamorizes involvement in pimping and prostitution, and lures youth into the commercial sex trade business. There was little evidence of this phenomenon in the current study, rather children and youth were exploited by their parents, and in the majority of the cases, parental drug addiction was what precipitated and sustained the sex trafficking. It is noteworthy that most of the literature on sexual exploitation and substance dependence focuses on the youth’s addiction, and the role of illicit drug use by the caregiver is rarely mentioned. Parents, especially mother’s, who are identified as substance dependent by any agency should be screened for involvement in familial sex trafficking. This screening should include others in the life of the parent who may be exploiting their substance dependence as a way of gaining access to their children. Child welfare agencies have a critical role in identifying parents, children and youth who have been or are at risk of being exploited in commercial sex (Walker 2013), and may be most able to identify caregivers whose addictions may lead to trafficking. This risk factor should be included and formalized into sex trafficking screen algorithms during child protection investigations. Concerns about the costs of implementing new screening or assessment protocols are reasonably offset by national estimates regarding the economic burden of child maltreatment on the child serving service sector (Fang et al. 2012), which reached 124 billion dollars in 2010.

Study Limitations

Potential limitations to this study include the self-report, caregiver report and retrospective recall, which contributes to reporting biases associated with memory distortion, misperceptions, avoidance and social desirability. Commercial sexual exploitation of youth is a low frequency, high impact experience and as such the sample size is small, limiting analytic options, and the power associated with the reported findings. However, Bryman and Cramer (1999) identified methods for exploring small sample sizes, which were followed in this study. Furthermore, the data used in this study came from one organization in one state, limiting the representativeness of the sample, yet creating a rural, familial profile of domestic sex trafficking that can be used as a point of comparison in other studies. The focus and scope of this study is consistent with the recommendations from Goździak (2008) who recommends small scale, thematically focused investigations of sex trafficking to further delineate the phenomenon by subpopulation or group. Future research should compare these results to those obtained from a larger, more representative sample to see if the group differences noted are replicable.

Conclusion

Despite the sample size, these findings begin to fill a gap in the literature about child sex trafficking by describing victim and trafficker characteristics, trafficking situations, law enforcement involvement, the clinical presentation of child victims, and involvement of the children in various systems in cases of familial sex trafficking—an understudied and severe form of victimization. Increasing service providers’ awareness and capabilities to recognize and appropriately respond to the unique aspects of familial sex trafficking is necessary to provide effective therapeutic services to victims and to hold traffickers accountable for these serious crimes.