Abstract
Domestic minor sex trafficking (DMST) is an increasingly recognized traumatic crime premised upon the control, abuse, and exploitation of youth. By definition, DMST is the “recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act” within domestic borders, in which the person is a U.S. citizen or lawful permanent resident under the age of 18 years. The present study described the demographics, psychosocial features, and trafficking experiences (e.g., environments of recruitment, relationship to trafficker, solicitation) of DMST victims. A total of 25 medical records of patients under the age of 18 who disclosed their involvement in DMST to medical providers between August 1, 2013, and November 30, 2015, were retrospectively reviewed. The majority of patients were female, and the mean age was 15.4 years old. Most patients lived at home and/or were accompanied at the evaluation by a parent/guardian. High rates of alcohol or substance use/abuse (92%), being placed in a group home or child protective services (CPS) custody (28%), a history of runaway behavior (60%), and/or exposure to other child maltreatment (88%) were identified. Our data indicated variation in reported trafficking experiences; however, patients commonly reported an established relationship with their trafficker (60%) and recruitment occurred primarily as a result of financial motivation (52%). Patients were prevalently recruited in settings where there were face-to-face interactions (56%), whereas the solicitation of sex-buyers occurred primarily online (92%). Victims who disclosed involvement in DMST had complicated psychosocial histories that may have rendered them susceptible to their exploitation, and reported a variety of DMST experiences perpetuated by traffickers. Although preliminary in nature, this study provided empirical evidence of the predisposing factors, motivations, and experiences of victimized youth uniquely from the perspective of patients who sought medical care.
Introduction
Domestic minor sex trafficking (DMST) is an increasingly recognized traumatic crime premised upon the control, abuse, and exploitation of youth. By definition, DMST is the “recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act” within domestic borders, in which the person is a U.S. citizen or lawful permanent resident under the age of 18 (Trafficking Victims Protection Act [TVPA], 2000). Child victims engage in acts such as survival sex, prostitution, and stripping in exchange for money, food, shelter, or another valued entity. There are currently no reliable national statistics on the incidence and prevalence of this issue due to the exceptional challenges associated with victim identification. However, it is conservatively estimated that 100,000 American juveniles are victimized through sex trafficking each year, and the average age a child is recruited is 12 to 14 years old (Smith, Vardaman & Snow, 2009).
Prior research has indicated that most sex trafficking minors are recruited and controlled by traffickers (Flowers, 1998; Giobbe, 1993; Smith, 2009; Williamson, 2002), and more often than adult sex workers (May, Harocopos, & Hough, 2000). Traffickers, also known as pimps, are those persons who profit by receiving cash or other benefits in exchange for the sexual use of a minor (Smith et al., 2009). By virtue of age, youth are vulnerable to exploitation by traffickers due to their limited life experience and capacity to think critically, fewer coping mechanisms, and smaller social support systems (Smith et al., 2009). At increased risk are children with a history of maltreatment, substances use, and child protective services (CPS) involvement. Runaway, homeless, and group home youth are also at high risk because they commonly experience environments with impaired parental supervision, poverty, neglect, and abuse (Institute of Medicine [IOM] & National Research Council [NRC], 2013; Williamson & Cluse-Tolar, 2002). Traffickers strategically prey on children with these aforementioned risk factors due to their emotional, physical, and financial vulnerabilities, and subsequent susceptibility to engage in risk-taking behaviors (IOM & NRC, 2013).
Traffickers often create an enticing reason to become involved in sex trafficking for both minors and adult victims: fast and large sums of money, exciting lifestyle, feeling empowered, and having a sense of belonging (Williamson & Folaron, 2003). Literature has shown that some traffickers have close relational ties to the victim, such as being a family member or romantic partner, whereas others may not have a prior relationship with the victim (e.g., stranger, kidnapper; May et al., 2000; Williamson, 2002). Regardless of the relationship and methods of recruitment, traffickers commonly instill a sense of loyalty and/or fear in victims through the development of complex psychological and emotional relationships. Thus, victims rarely self-identify or endorse their sex trafficking involvement (Clawson & Dutch, 2015), consequently making empirical research on youth controlled by traffickers difficult to obtain (Williamson, 2002).
Existing literature on the context in which sex trafficking occurs relies largely on qualitative interviews of adult and youth survivors, service providers, and law enforcement (IOM & NRC, 2013). There are also a number of quantitative reports that utilize agency or other case review (IOM & NRC, 2013). These studies have contributed to our understanding of a phenomenon that is hidden and poorly understood, and subsequently assisted in victim identification efforts (IOM & NRC, 2013; Smith et al., 2009). Recent research has focused attention on DMST specifically in the medical setting, finding that victims frequently present for medical attention with complex psychosocial histories, and medical and psychiatric needs (Lederer & Wetzel, 2014; Varma, Gillespie, McCracken, & Greenbaum, 2015).
To our knowledge, no data exist on DMST experiences (e.g., methods and environments of recruitment, relationship to trafficker, solicitation) reported to medical providers by victimized patients who sought health care during or after their period of exploitation. Utilizing patient-level quantitative data obtained during clinical interactions with medical providers, the objective of the present study was to describe the psychosocial context and reported trafficking experiences of victims who disclosed involvement in DMST.
Method
Medical records of 25 patients who disclosed their involvement in DMST at a single child protection medical clinic were retrospectively reviewed. Subject identification was obtained from an electronic record database maintained of patients evaluated for child sexual abuse secondary to DMST at a child protection clinic between August 1, 2013, and November 30, 2015. Patients were brought to clinic with concern of DMST involvement either due to confirmatory evidence (e.g., found by law enforcement in a sting operation) or suspected involvement (e.g., Sexually transmitted infections (STIs), running away with friends). Inclusion criteria were all patients under the age of 18 who disclosed involvement in DMST to a health care provider during a medical evaluation. A disclosure consisted of a patient verbally endorsing their involvement in sex trafficking to a physician on their own, or disclosed after being found with evidence by law enforcement or a friend/relative.
An electronic medical record (EMR) review was conducted by a trained research coordinator (J.L.M.) and overseen by the senior author (A.P.G.). Review included inpatient, outpatient, and consultation patient encounters in the emergency department, a child protection clinic, and other medical center clinics (e.g., adolescent health care center). The sources of information consisted of physician notes documenting patient/guardian interviews, demographics, and histories within medical encounters. Data were collected for the period of 1 year prior to and including their medical evaluation when a disclosure of DMST involvement was made. Trafficking experiences were abstracted from medical charts that documented patient interviews in medical encounters. Patient demographics (e.g., age, gender), trafficking experiences (e.g., relationship to trafficker, methods of recruitment), and psychosocial variables (e.g., substance abuse, history of maltreatment) were selected based on a comprehensive literature review and clinical practice. Descriptive statistics and exploratory analyses were calculated. The Institutional Review Board approved all research procedures.
Results
Of the 25 patients included in this analysis, the majority of patients (17/25, 68%) disclosed involvement to a medical provider after being found by law enforcement or a relative with confirmatory evidence (e.g., found in a Federal Bureau of Investigation (FBI) sting operation). One third of patients (8/25, 32%) disclosed involvement on their own.
Table 1 describes the demographics of patients involved in DMST, including patients’ living environment and who accompanied them at their evaluation when a disclosure was made. The majority of patients were female (24/25, 96%) and White (16/25, 64%). The mean age at the medical visit where patients disclosed DMST involvement was 15.4 years old (range = 11-17). Most patients lived at home (18/25, 72%) at the time a disclosure of DMST involvement was made.
Demographics and Psychosocial Characteristics of Patients Who Disclose DMST Involvement (n = 25).
Note. Psychosocial variables are not mutually exclusive. Unavailable/unsure is the result of missing or unclear data from patient medical charts. DMST = domestic minor sex trafficking; CPS = child protective services; DV = domestic violence.
All 25 patients included in our cohort presented to an outpatient child protection clinic specifically with a referral for DMST involvement, and therefore were accompanied by a parent/guardian (17/25, 68%) and/or child welfare agency representative (7/25, 28%). Furthermore, patients also presented to the medical visit with the police (9/25, 36%) ordinarily after being found sex trafficking and referred to the child protection clinic. More than one individual accompanied some patients, most commonly including both a parent/guardian and the police (6/25, 24%). We specifically asked patients alone about their relationship with the person they presented with, especially if the individual was a nonprofessional. Within the child protection clinic setting, the child’s sense of safety in their living environment and with the adults who take care of them is routinely assessed and documented. A safe disposition is created by asking the child if they feel safe in their current living situation and with the individuals who accompany them to their child safe evaluation, involving CPS and police when appropriate. Information about whether this person played a role in the patient’s exploitation, however, was not specifically asked.
Psychosocial characteristics identified in prior literature to render youth susceptible to involvement in DMST (IOM & NRC, 2013) were revealed in the current cohort. There were high rates of alcohol or substance use/abuse (23/25, 92%), being placed in group homes or CPS custody (7/25, 28%), a history of runaway behavior (15/25, 60%), and/or exposure to other child maltreatment (88%).
Table 2 describes trafficking experiences reported by patients during a medical evaluation when a disclosure of DMST involvement was made. The majority of patients reported only male traffickers (15/25, 60%), 20% (5/25) reported having solely a female trafficker, and 12% (3/25) had both male and female traffickers. The role of female traffickers, such as whether they were same-aged peers acting as recruiters, was not available. Many patients had a previously perceived relationship with their trafficker before their period of exploitation, including as a friend (7/25, 28%), acquaintance (4/25, 16%), or intimate partner (4/25, 16%), as opposed to a stranger (6/25, 24%). Patients reported a variety of reasons for engaging in DMST; most common were promises of economic opportunity (13/25, 52%), threatened or coerced with physical/sexual violence (7/25, 28%), and/or to escape their current living situation (5/25, 20%). A smaller number of patients (4/25, 12%) reported promises of an intimate relationship with their trafficker to be a reason for their involvement. The majority of patients (23/25, 92%) reported the solicitation of sex-buyers/clients occurred online, primarily on Backpage.com (14/25, 56%) followed by a dating website (5/25, 20%). Of the 14 patients for whom this information was available, 11/14, or 79% communicated to a physician they have received monetary compensation in exchange for engaging in sexual acts.
Patient Reported Trafficking Experiences.
Note. Variables are not mutually exclusive. Unavailable/unsure is the result of missing or unclear data from patient medical charts.
Exploratory analyses using chi-square tests were conducted to obtain further detail on the context in which DMST occurred in our cohort of 25 patients (Table 3). The interrelationships of trafficking experiences (e.g., relationship to trafficker, trafficker gender, solicitation of clients) presented in Table 2 were examined by race, living situation, and who brought the patient in to the evaluation (Table 1). No statistically significant differences were found (p > .05).
Interrelationship Between Patient Features and Their Reported Trafficking Experiences.
Note. No statistically significant p values (p > .05).
Discussion
The current investigation provides important contextual data on 25 DMST victims, including the reported mechanisms of recruitment and solicitation, their traffickers, and the psychosocial context that may have rendered them vulnerable to exploitation. Overall, our data indicate variation in trafficking experiences; however, patients commonly reported an established relationship with their trafficker and recruitment occurred primarily as a result of financial motivation. Patients were prevalently recruited in settings where there were face-to-face interactions and, conversely, the solicitation of sex-buyers occurred primarily online. The empirical data generated from this study contribute to an understanding of DMST experiences from the perspective of victimized youth who endorse their involvement to medical providers.
Traffickers are skilled in identifying the weaknesses and needs of youth and exploit those vulnerabilities to lure, entrap, and control their victims (Anderson, Coyle, Johnson, & Denner, 2014). Although our cohort revealed that victims lived at home (18/25, 72%) with a parent/guardian and/or were accompanied to their medical visit by a parent (17/25, 68%), a large number of patients (22/25, 88%) in our study had experienced a form of child maltreatment, including prior sexual abuse (12/25, 55%). These data are consistent with two previous studies that found approximately 70% of subjects self-reported a childhood sexual abuse history preceding their sex trafficking victimization (Bagley & Young, 1987; Silbert & Pines, 1982). Based on these findings, it is not surprising that our patients (5/25, 20%) endorsed the need to escape their home life as reason for their involvement. Furthermore, the majority of our patients had run away from home (15/25, 60%) at least once prior to their presentation for DMST. Children who experience maltreatment at home may feel the need to escape, consequently increasing their risk to engage in survival sex for money or shelter.
Studies have also indicated that substance abuse is intrinsically linked to runaway behavior, child maltreatment, and exchanging sex for money, drugs, and general survival (Chen, Tyler, Whitbeck, & Hoyt, 2004; Edwards, 2006; Stoltz et al., 2007). We found that the majority of our patients (23/25, 92%) reported alcohol and substance use/abuse historically and/or at their medical visit when a disclosure of DMST was made. Preexisting substance use can be a risk factor for youth involvement due to decreased inhibitions and impaired judgment, or a recruitment tactic by traffickers promising to supply their addiction (Kennedy, Klein, Bristowe, Cooper, & Yuille, 2007). Twenty percent reported obtaining drugs or alcohol in exchange for sexual acts as a reason for their DMST involvement. The high rate of substance use in our cohort may be a coping mechanism to dull the trauma experienced during the period of exploitation; a substance using youth also provides opportunity for a trafficker to generate addiction and further control the victim. Our data, in conjunction with the literature, compound the notion that youth who come from dysfunctional environments and poor support systems, and who engage in risk-taking behaviors (e.g., running away, substance use) are targeted for exploitation.
Traffickers may use manipulative strategies to recruit youth into sexual exploitation; these strategies are termed “grooming techniques,” in which traffickers seduce victims with promises of money, lavish lifestyles and careers, and/or love and security (Kennedy et al., 2007; Raphael, Reichert, & Powers, 2010). Many traffickers approach victims with the ability to earn money quickly (Mones, Rosengard, & Cohee, 2011). Over half of our sample (13/25, 52%) stated that traffickers lured them to engage in DMST based on promises of economic opportunity. While no statistical differences were found, economic opportunity was more frequently reported as a means of recruitment by Black patients (6/9, 67%) as opposed to White patients (7/16, 44%), and patients living in a home (10/18, 56%) versus a group home (3/7, 43%). Furthermore, of the 14 patients for whom this information was available, 11/14 or 79% reported that they received monetary compensation at some point for their involvement. Consistent with these data, prior documentation has found financial reasons as primary motivators for entrance into sex trafficking (Curtis, Terry, Dank, Dombrowski, & Khan, 2008; Silbert & Pines, 1982). In a New York report of 249 interviewed youth, the concern about not finding legal employment was a commonly expressed reason for their subsequent involvement in commercial sex (Curtis et al., 2008).
Previous research has also found that some victims are led to believe that they are in a romantic relationship with their trafficker, and then are forced into highly exploitative situations (Anderson et al., 2014; Curtis et al., 2008). Our data showed that 4/25, or 16% of victims described their trafficker to be an intimate partner, similar to an earlier study that found 25% of recruiters to be boyfriends acting as pimps (Silbert et al., 1982). Older (16-17 years old) patients more commonly reported their trafficker to be an intimate partner (3/14, 21%) as compared with younger (11-15 years old) patients (1/11, 9%). Furthermore, 3/25, or 12% of our sample reported that they became involved in DMST to comply with the request of their trafficker/perceived intimate partner. In a study of 100 adult women controlled by pimps in Chicago, 64 viewed their pimp as a boyfriend and 23 reported that their boyfriend/partner served as their primary recruiter into sex trafficking (Raphael et al., 2010). These data suggest an intersection between the development of intimate relationships and entry into DMST that often leave victims struggling to decipher the perceived love from their exploitation.
Despite the widespread belief that adults are directly responsible for the entry of youth into sexual exploitation, research on recruitment through peer networks shows that this experience is more common than often realized (Adams, Owens, & Small, 2010). Curtis et al. (2008) revealed that 44% to 68% of youth in the sample reported initiation by their perceived friends (Curtis et al., 2008). The current cohort also found that victims commonly reported their trafficker to be a friend (7/25, 28%). While not significantly different statistically, patients living at home (6/18, 33%) versus a group home (1/7, 14%), and Black patients (4/9, 44%) as opposed to White patients (3/16, 19%), more often reported their trafficker to be a friend. Individuals whom victims consider “friends” may work as surrogate recruiters for traffickers by modeling this behavior and normalizing participation in sex trafficking.
Peer-to-peer recruitment methods may also be reinforced by peer pressure and society’s glamorization of the sex industry (Curtis et al., 2008). In addition, victims disclosed that they were recruited in a variety of settings where they may have interacted with friends/peers: home of the victim or a friend (5/25, 20%), school (4/25, 16%), and at social gatherings (5/20, 20%). Our data describe the victim–trafficker dynamic to occur primarily in face-to-face interactions through previously established relationships, opposed to strangers met online. No patients who lived in a group home reported being recruited at school and/or their trafficker to be a stranger, as compared with patients who lived at home. This possibly suggests that trafficking recruitment and a promulgation network are fostered in the group home environment.
While social media was the lowest reported means of victim recruitment in this study (3/25, 12%), the use of Internet websites were the highest reported venues of sex-buyer solicitation (23/25, 92%). Social media had been noted in prior descriptive reports to enable the solicitation of clients (Curtis et al., 2008; Mitchell, Jones, Finkelhor, & Wolak, 2010). The majority of our patients solicited sex-buyers through websites such as Backpage.com (14/25, 56%), Facebook.com (4/25, 16%), and/or dating websites (5/25, 20%). Classified advertisement websites, such as Backpage.com, have been used to advertise commercial sex services with minors (Smith, 2009) and are further supported by our findings. Backpage.com was the most commonly reported venue for soliciting clients. Patients who disclosed their involvement in DMST to a medical provider after being found trafficking with evidence (10/15, 67%) were more likely to report using Backpage.com as a means of soliciting sex-buyers than patients who self-disclosed their involvement (4/10, 40%). Awareness of Backpage.com as a venue for sex trafficking has increased for both victims and those tasked with identifying involved youth.
It is often assumed that trafficking is a male-dominated role. This assumption is supported by prior research that has indicated traffickers to be primarily men (Farley, Golding, Matthews, Malamuth, & Jarrett, 2015; Raphael & Myers-Powell, 2010) and that a growing number of traffickers in the United States are young men trained by older men (Smith, 2009). Our data showed that the majority of reported traffickers (15/25, 72%) were male; however, 8/25 or 32% of our sample reported that their trafficker was either a woman (5/25, 20%) or had traffickers of both genders (3/25, 12%). Black patients more commonly indicated that their recruitment into the sex industry was not forced as compared with White patients. This might be related to Black patients identifying their trafficker as female (4/9, 44%) and/or as a friend, more often than White patients. White patients more often reported having a trafficker who was male (11/16, 69%) and/or an acquaintance (4/16, 25%).
In a case study analysis of 49 female pimps, Roe-Sepowitz, Gallagher, Risinger, and Hickle (2014) identified the various roles women or girls may play in trafficking. Although we were not able to obtain information specifically on the role of patients’ female traffickers, it is possible that many acted as what is termed a “bottom” (Roe-Sepowitz et al., 2014). A bottom is a woman or girl appointed by the trafficker/pimp to befriend other girls and recruit them, train other girls, and provide discipline (i.e., violence; Kennedy et al., 2007; Roe-Sepowitz et al., 2014). The incentive of a bottom may be to gain protection or favor from their traffickers, or as a means to transition from victim to victimizer (Kennedy et al., 2007; Raphael & Myers-Powell, 2010; Roe-Sepowitz et al., 2014).
Limitations
Several limitations need to be considered when interpreting and applying the findings from this study. Due to the small sample and single data collection site, the generalizability of these data is limited. Moreover, only patients who presented for medical attention due to concern for DMST and who subsequently disclosed their involvement were included. Thus, exploited youth who do not come into contact with medical providers or deny engagement in DMST were not represented in our findings. The racial composition of our cohort of DMST patients may not be representative of DMST populations in other geographic locations. In addition, our large percentage of female patients is likely due to substantial difficulties in the identification of male victims.
Existing data do not consistently distinguish events occurring prior to or during the period of exploitation (e.g., substance use), and therefore risk factors of involvement cannot be determined. We did not have information regarding whether the trafficker was a minor or adult, and the role that reported female traffickers played in the exploitation of our patients. Furthermore, nonsignificant associations of the exploratory analyses could be the result of being underpowered due to the small sample available in the current investigation. Future studies with larger samples should examine associations between patient race, gender, and characteristics related to the patient’s living and social support situation and their reported trafficking experiences.
The identification of victims is known to be difficult and rare due to a legion of challenges, and therefore patients involved in DMST do not always disclose their exploitation or provide clear and accurate information (Smith, Vardaman, & Snow, 2009). Thus, the insights provided by our patients who established rapport with physicians offer a glimpse into a phenomenon that remains otherwise invisible and inaccessible.
Conclusion
Victims who disclosed their involvement in DMST to medical providers had complicated psychosocial histories that may have placed them at increased risk for engagement, and reported a variety of victim–perpetrator dynamics and trafficking experiences. Although preliminary in nature, this study provided empirical evidence of the psychosocial characteristics associated with DMST involvement, motivations, and experiences of victimized youth uniquely from the perspective of patients who presented for medical care for DMST involvement. These data suggest a role of peer networks and grooming techniques of traffickers to lure vulnerable adolescents into sexual exploitation. Furthermore, our study highlights the opportunity for health care providers to establish rapport with exploited youth within the medical environment and gain an understanding of their trafficking experiences. Future research on recruitment in congregate care environments (i.e., group homes and residential facilities) may expand our understanding of the role of peer networks and, concurrently, inform interventions in these settings. Further investigation on the correlation between victims’ risk factors and the tactics used by traffickers would provide a more detailed conceptualization of the complex and multilayered methods of recruitment and enmeshment.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: All phases of this study were supported by the Fleet Scholarship Grant, 101-6345.