By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director
School-Based Health Centers
New York-Presbyterian Hospital
Columbia University Medical Center
New York City
Commercial sexual exploitation of children (CSEC) is a serious public health concern that results in immediate and long-term negative health consequences for affected youth. According to the federal Trafficking Victims Protection Act, sex trafficking of a minor does not require the use of fraud, force, or coercion to be deemed illegal. It includes pornography; trafficking of minors for a commercial sex act; street prostitution; exotic dancing; escort services; internet-based exploitation; and the exchange of sex for food, clothing, shelter, or other survival needs, also referred to as “survival sex.”
As many as 325,000 U.S. children are estimated to be at risk of CSEC annually. However, there is no uniform method for data collection on this practice, and it is cited as the most under-reported form of child abuse.1 Medical visits afford providers the opportunity for direct communication with CSEC youth, but most receive little training on their appropriate role in addressing this crisis.2 One study assessing the CSEC population in New York City found that 75% of sexually exploited youth had accessed medical care within the last six months, primarily for general check-ups (42%), testing for sexually transmitted infections (STIs) (34%), and HIV tests (21%).These youth present to EDs, family planning clinics, urgent care, and community health centers.3
Risk factors for CSEC victims can include physical and sexual abuse; substance use; homelessness; foster care placement; juvenile justice involvement; identification as lesbian, gay, bisexual, transgender, or questioning; poor self-esteem; gang involvement; and poverty.4 The presence of risk factors does not clearly indicate CSEC, but CSEC should be considered as part of a more comprehensive medical assessment when these factors are present.
Sexually exploited youth are at greater risk for STIs, pregnancy, uncontrolled asthma, pelvic inflammatory disease, and drug abuse.5 Other common problems include traumatic injuries, wound infections, posttraumatic stress disorder, depression, and suicide.6
Indicators of CSEC include depressed mood or flat affect; malnutrition; poor dentition; physical evidence of abuse, tattoos, or branding; and STI symptoms. Priority areas of focus during a visit with CSEC youth should be reproductive health, physical injuries, substance use, and mental health. Confidentiality concerns can have a deterrent effect on disclosure, which makes it imperative to know local laws and reporting requirements.
The National Human Trafficking Resource Center operates a hotline (888-373-7888) through which victims can seek help, and providers can request to be connected to local resources or training. HEAL Trafficking and Physicians Against the Trafficking of Humans (PATH) are led by clinicians working to address CSEC and human trafficking.
In March 2015, the American Academy of Pediatrics urged pediatricians to work to increase recognition of CSEC, provide direct care and resources, and engage in a multi-disciplinary effort with medical and nonmedical colleagues to meet the needs of CSEC patients.7 Screening tools instituted by Asian Health Services and the Native American School Based Health Center in Oakland, CA, along with the Sexual Assault and Violence Intervention (SAVI) program at Mount Sinai Hospital in New York City, provide potential models for identifying CSEC youth. These organizations have implemented universal screening questions such as: “Over the years, we’ve noticed that more and more young people are turning to the streets to make money for themselves or for other people. Sometimes students tell us that they’re trading sex or ‘going on dates’ for money, clothes, a place to stay, or drugs. Other students say they’ve been asked or forced to let other people do sexual things to them. Has this ever happened to you or to a friend?” This question is part of a larger protocol that involves multi-disciplinary staff, written assessments for risk factors, intervention steps, confidentiality guidelines, and community resources and referrals.4,8
Screen patients only when they are alone, and always offer hotline numbers and other resources directly to the patient.
Starting a dialogue allows patients to disclose if they are ready to do so, and it lays groundwork for patients to seek help in the future.
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Greenbaum J, Kellogg N, Isaac R, et al. The Commercial Sexual Exploitation of Children: The Medical Provider’s role in Identification, Assessment and Treatment. APSAC Practice Guidelines. Columbus, OH: The American Professional Society on the Abuse of Children; 2013.
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Estes RJ, Weiner NA. The Commercial Sexual Exploitation of Children in the U.S., Canada and Mexico. Philadelphia, PA: Center for the Study of Youth Policy, University of Pennsylvania; 2001.
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Curtis R, Terry K, Dank M, et al. The commercial sexual exploitation of children in New York City: Volume 1: The CSEC population in New York City: Size, characteristics and needs. National Institute of Justice, US Department of Justice; 2008.
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IOM (Institute of Medicine) and NRC (National Research Council). Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press; 2013.
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Yates GL, Mackenzie RG, Pennbridge J, et al. A risk profile comparison of homeless youth involved in prostitution and homeless youth not involved. J Adolesc Health 1991; 12(7):545-548.
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Lederer L, Wetzel C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014; 23(1):61-91.
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Greenbaum J, Crawford-Jakubiak J. Child sex trafficking and commercial sexual exploitation: Health care needs of victims. Pediatrics 2015; 135(3):566-574.
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Mays A. Sexually Exploited Children Screening Protocol: A Multidisciplinary Model Designed for the Clinical and School Health Setting. UCSF Elevate Conference. Oakland, CA; 2013.
