Evaluation of Services for the Commercial Sexual Exploitation of Children and Youth: A Scoping Review

Abstract

Commercial sexual exploitation (CSE) of youth is a public health issue with multiple negative consequences. Despite the complexities and comprehensiveness of service needs for youth experiencing CSE, the evidence base of effective services and programs lags far behind. This scoping review seeks to identify the most up-to-date evidence on programs for youth experiencing CSE that have been evaluated and found to be effective. We conducted a scoping review of current literature, including peer-reviewed articles as well as gray literature using a scientific approach to identify programs and service provisions specifically focused on youth experiencing CSE and examine empirical evidence for their effectiveness. A comprehensive search of five databases was completed in September 2020 then updated in April 2021 to identify relevant publications from January 1, 2000 to present. Additional program mining was conducted on evaluations of programs mentioned in the search results. A total of 3,597 citations from the database searches were screened for title and abstract and 190 citations were included for full-text review. The search process yielded 11 eligible articles with one additional report found through program mining. Identified programs targeted youth, providers, and consumers of CSE. While scientific rigor was not high, all included studies reported positive outcomes. Evidence base for effective services and programs is sparse. While more programs and services are being developed, studies should use rigorous research designs to test the effectiveness of these programs and services. Implications for practice and policy are discussed.

Keywords

commercial sexual exploitation of youth child trafficking sexual abuse commercial sexual exploitation

Introduction

Commercial sexual exploitation (CSE) is a public health issue with multiple negative consequences. For youth, CSE involves child sex trafficking, child pornography, child sex tourism, and trading sex to meet basic needs often referred to as “survival sex” (Walker, 2013). Traffickers often prey on already vulnerable children and youth, those who have experienced childhood physical and sexual abuse, violence or chaos at home, foster care and/or juvenile justice involvement, and/or homelessness or running away from home or placements (Hyatt, 2012). Once on the streets, traffickers coerce children and youth into sex for hire using promises of love, drugs, and violence, subjecting children to beatings, rape, and starvation if they do not comply. Others manipulate children into submission with a mix of loving care, violence, and threats or shame, resulting in the children experiencing trauma bonding with their traffickers (Sanchez et al., 2009; Smith, 2009). Not all youth experiencing CSE have a trafficker. Some instead find themselves trading sex for a place to stay or a warm meal; many are exploited by their own peers and family members.

Enumerating youth impacted by CSE remains difficult to ascertain due to various reasons such as few studies collecting data on the same regions or some studies estimating the number of individuals who are at risk versus having a history of CSE experiences (Franchino-Olsen et al., 2020). In a scoping review investigating the prevalence of CSE across the United States, Franchino-Olsen et al. (2020) was unable to provide synthesized information around prevalence. For example, one study estimated 244,000 to 325,000 children are at risk for CSE (Estes & Weiner, 2001; Franchino-Olsen et al., 2020) while another study estimated that 3.5% of youth in Grades 7 to 12 across the United States—approximately 808,500—exchanged sex for drugs or money during their lifetime (Edwards et al., 2006). Some studies were specific to smaller locales—Williamson et al. (2010) found that approximately 3,000 Ohio youth were at risk for CSE annually and among those, 1,078 youth have experienced CSE. Overall, several issues remain with estimating the true extent of CSE among youth in the United States. Given the hidden nature of the problem, prevalence rates generally cover small locales and rates covering larger geographic areas are based on arrest data (i.e., of buyers or prostitution charges on minors depending on jurisdiction) or youth self-report, and there is heavy reliance on high-risk samples (e.g., Ashley, 2008; Edwards et al., 2006; Swaner et al., 2016). Nevertheless, the estimates are alarming and illustrate a great demand for services.

The service needs of youth impacted by CSE in the United States are both unique and complex ranging from short-term, emergency, and/or basic needs such as housing and medical care to long-term needs such as legal assistance, trauma-informed mental health and substance use treatment, and life skills training (Hounmenou & Grady, 2019; O’Brien et al., 2019). Youth impacted by CSE are different from their peers who have been victimized in other ways. For instance, they are more likely to have contact with the juvenile justice system, report gang involvement, and more likely to engage in risk behaviors such as reckless driving or getting into cars with strangers (Hickle & Roe-Sepowitz, 2018). They are also more likely to use drugs or alcohol, struggle academically, exhibit running away behaviors (Cole et al., 2016; Varma et al., 2015), and experience violent victimization such as intimate partner violence and child sexual abuse (Franchino-Olsen et al., 2022). Finally, when compared to other youth involved in the child welfare or juvenile justice systems, youth impacted by CSE have more referrals due to child maltreatment, arrests, and frequent placement changes causing significant housing instability (Dierkhising et al., 2021).

Despite the complexities and comprehensiveness of these needs, the evidence base of effective services and programs is lacking (Hounmenou & Grady, 2019; Institute of Medicine & National Research Council, 2013). In the last decade, programs and services serving youth impacted by CSE have proliferated yet rigorous evaluations of those programs and services have lagged behind (Greenbaum et al., 2020). One systematic review of the literature published in 2018 only found 21 out of over 4,300 publications in the peer reviewed literature describing and evaluating services or programs for youth impacted by CSE globally (Moynihan et al., 2018). In addition, many of the evaluated programs did not provide enough information on the research design of the study, making it challenging to ascertain study quality (Moynihan et al., 2018). Of the studies that did provide details, very few used rigorous research designs with validated measures (Moynihan et al., 2018). Thus, while programs and services for youth impacted by CSE are beginning to be described in the literature, they are much less likely to be evaluated and if they are evaluated the details on the evaluation process and/or the rigor of the research is lacking. This scoping review seeks to identify the most up-to-date evidence on programs for youth experiencing CSE that have been evaluated. Therefore, a scoping review of the current literature was conducted to answer the following research questions:

Q1. What type of programs for youth experiencing CSE have been evaluated?

Q2. What did these evaluations find?

Q3. What are the strengths and limitations of these studies?

Methods

We conducted a scoping review of current literature, including peer-reviewed articles and gray literature, to identify programs and service provisions specifically focused on youth experiencing CSE and examine empirical evidence for their effectiveness.

Search Strategy

We focused on services for CSE in the United States for children and youth that were done since the passage of the Trafficking Victims Protection Act of 2000. Therefore, for studies to be eligible for inclusion, studies were: (a) any type of publication (e.g., reports, conference presentations, dissertation); (b) published from 2000 to present; (c) reported in English; (d) included services and/or programs for youth and young adults, aged up to 21; and (e) included all genders. A comprehensive search of five databases (PubMed, PsycINFO, Social Work Abstracts, Google Scholar, and Web of Science) was done from May 2020 to September 2020 by a social work subject librarian. A combination of subject headings and keywords were used for the major concepts: CSE, services and programs, and the United States. Filters were applied (when available) for publication date, language, and age group. Publication date filter was set from January 1, 2000 to present. An additional search was done in April 2021 to capture new publications from September 2020 to April 2021. Citations were managed and shared in Mendeley. See Supplemental Appendix A for full search strategies.

Study Selection and Data Extraction Procedures

We used Covidence (2016), a cloud-based software that facilitates systematic reviews to select and screen study titles, abstracts, and full-text. Studies were screened by title and abstract in Covidence, using inclusion and exclusion criteria. Two groups of two reviewers independently screened and cross-checked the screening; then conducted full-text reviews, again cross-checking one another’s work. Inclusion decisions were compared between the two coders and when the two coders could not come to a consensus after a discussion, a third reviewer was invited to help facilitate a consensus. The extraction elements were developed by all reviewers, and two articles were selected to pilot test the elements; minor edits were made to the extraction elements. Extraction elements included: bibliographic information, methods, program characteristics, sample characteristics, analysis, and outcomes. Two reviewers independently extracted included studies and if there were discrepancies, reached a consensus through discussions. An additional search was completed based on program mining by searching for specific programs referenced in the included articles to find evaluation studies and reports of those programs when possible.

Results

Search Results

A total of 3,597 citations from the database searches were added to Covidence for title and abstract screening. Duplicates (n = 432) and irrelevant citations (n = 2,975) were removed and 190 citations were included for full-text review. At this stage, 179 articles were removed for the following reasons: (1) Approach/framework/model for CSE but not service/program (n = 84); (2) CSE population but not service/program (n = 33); (3) Program/service for CSE referenced but not described or evaluated (n = 28); (4) Child sexual abuse with no mention of CSE (n = 27); (5) Out of age range (n = 5); and (6) International scope only (n = 2). Eleven articles (nine peer-reviewed; two dissertations) were ultimately selected through this process and one report was added after program mining for extraction (See Figure 1), with a total of 12 studies reported in this paper. All studies extracted were published between 2008 and 2020 with nearly 40% of them being published in 2020 (n = 4).

Figure 1.

PRISMA diagram of scoping review process.

Program and Study Overview

Of the 12 studies extracted, the majority (58.3%) targeted youth for their sample while three studies focused on both youth and providers (25%). Most interventions focused on adolescents with most participants identifying as female. One study focused on providers only and one study focused on consumers of commercial sex. Study design and sample sizes varied. Of the programs solely targeting youth, interventions were focused on improving outcomes in youth who had already experienced CSE. Only two programs focused on preventing CSE (Murphy et al., 2016; Rothman et al., 2020). Table 1 summarizes included studies and Supplemental Appendix B provides a program brief describing each program in further detail.

Table 1.

Summary of Included Studies.

Authors	Target population	Gender	Program name	Study design	Sample size	Study findings
Bath et al. (2020)	Youth	Female: 360; Male: 2; Transgender Female: 2	Succeeding Through Achievement and Resilience(STAR) Court	Pre- and Posttest	364	Increase of new medication prescriptions
						Increased linkages to mental health and substance use treatment
						Decreased child welfare allegations, runaway episodes, criminal involvement, and placement changes
Criswell (2014)	Youth	Female: 10	Positive Youth Development Program/mentoring Intervention	Pre- and Posttest	10	Increased self-worth and job competence
						Increased future orientation
						Increased self-regulation
Gibbs et al. (2015)	Youth	Female: 53; Male:1; Transgender: 1	SAGE: The Standing Against Global Exploitation Everywhere	Process Evaluation	55	Identified diversity across trafficked minors
						Met the needs of youth including crisis intervention, food or clothing, and safety planning
						Service gaps identified in long-term housing, employment, vocational assistance, and education.
		Female: 33; Male: 1; Transgender: 1	STOP-IT: Salvation Army Trafficking Outreach Program and Intervention Techniques		35	Identified strategies to maintain engagement
		Female: 67; Male: 39; Transgender: 5	The Streetwork Project at Safe Horizon		111	Identified strategies to maintain engagement
Hickle and Roe-Sepowitz (2014)	Youth	Female: 10	Putting the Pieces Back Together	Qualitative	10	Increased knowledge about CSE
						Reduced shame and addressed stigma
						Fostered mutual aid through validation and support
						Managed strong emotions
Rothman et al. (2020)	Youth	Female: 39; Male: 1; Other: 1	My Life My Choice	Pre- and Posttest (6 months & 12 months)	41	Decreased: CSE at 6 months and 1 year Sexually explicit behavior at 6 months
						Delinquent behavior at 6 and 12 months
						Illicit drug use at 6 months
						Improved: Coping skills for 6 months and 1 year and social support at 6 months
Twill et al. (2010)	Youth	Female: 22	Group Home Treatment Program	Posttest	22	50% of the participants did not commit a new offense after discharge
Twill et al. (2010)	Youth	Female: 22	Group Home Treatment Program	Posttest	22	No new prostitution-related offenses
Murphy et al. (2016)	Youth	Female: 46; Male: 2	yourworth.org	Pre- and Posttest	48	Increased awareness and knowledge of areas in Atlanta where one can access resources
Kim et al. (2018)	Providers	Female: 25; Male: 4	Protection for Abused and Trafficked Humans Task Force	Mixed Methods Study	32	Increased coordination among law enforcement, key agencies, and service providers.
Kim et al. (2018)	Providers	Female: 25; Male: 4	Protection for Abused and Trafficked Humans Task Force	Mixed Methods Study	32	Improved quality of service provision.
Kinnish et al. (2020)	Youth and Providers	N/A	Project Intersect	Pre- and Posttest	29	Positive feedback from participating therapists 96% of youth no longer meet Post-Traumatic Stress Disorder (PTSD) criteria at the completion of the program.
Miller et al. (2020)	Youth and Providers	Female: 357; unknown: 4	The Law Enforcement First Responder Protocol (LA County)	Posttest	361	509 total recoveries across 361 youth
						59% of identified youth received a medical evaluation within 72 hours
						85% of cases had a prior child welfare referral
Sutherland (2014)	Youth and Providers	N/A	Child and Adolescent Psychiatric Residential Facility	Pre- and Posttest	97 (staff members)	Program implementation and pre-services assessment scores were critical to overall program effectiveness
Shively et al. (2008)	Consumers of Commercial Sex and Human Trafficking	Male	The First Offender Prostitution Program (FOPP)	Quasi-Experimental (Interrupted Time Series)	198	Reduced recidivism among men arrested for soliciting.
						Cost effective and provides revenue for programs supporting victims of CSE.
						Used for 25 other programs across the United States

Note. Gibbs et al. (2015) evaluated three separate programs but study findings were reported as an aggregate across all three programs.

Study 1: Bath et al. (2020)

Description of study and findings

Bath et al. (2020) sought to understand the role of STAR (Succeeding Through Achievement and Resilience) Court, a specialty juvenile justice court, in identifying mental health and substance use treatment needs, providing linkages to services, and facilitating stability for youth with histories of CSE. The study identified 364 youth, mostly cisgender female youth aged 16, who participated in STAR Court on average for 16 months. Using administrative case records (baseline, 6 months, 12 months), the study found that once youth entered STAR Court, there were significant decreases in child welfare allegations, reported runaway episodes, criminal involvement, and placement changes—compared to baseline. Youth demonstrated significant increases in linkages to mental health and substance use treatment services across the duration of STAR Court involvement, and for varying exposure lengths, youth had a substantial increase in being prescribed medications while under court supervision.

Strengths and limitations noted by Bath et al. (2020)

This is one of the first studies to examine the processes and outcomes of a specialty court for probation youth impacted by CSE. Specialty court eligibility criteria, however, could have excluded relevant youth. Due to the voluntary nature of participating in the specialty court, the findings are subject to possible self-selection bias. Moreover, no causal claims can be made without a comparison group. Finally, participants were primarily girls.

Study 2: Criswell (2014)

Description of study and findings

This pilot study (N = 10) evaluated the role of a Positive Youth Development (PYD)-oriented mentoring and therapy program, developed for youth impacted by domestic minor sex trafficking, on three key PYD outcomes (i.e., self-perception, future orientation, intentional self-regulation). Using a pre- and posttest design (baseline, 11-week program completion), the study found a significant increase in the global self-worth subscale, job competence subscales, and future orientation.

Strengths and limitations noted by Criswell (2014)

While preliminary, this study provides promising support for inclusion and expansion of PYD-oriented programming for youth impacted by CSE as well as diverse at-risk urban youth. The individualized program that provided opportunities for fostering positive relationships with significant adults reinforced the importance of focusing on growth and strengths in this vulnerable population. Despite some promising results, Criswell (2014) noted that the study was limited due to high turnover and low-retention rates (e.g., aging out, inappropriate behaviors, individual choice, program incompletion), which resulted in a small sample size with little statistical power. Participants were not randomly selected and the evaluation did not have a comparison group. Criswell (2014) also noted that adherence to the intervention was not formally assessed.

Study 3: Gibbs et al. (2015)

Description of study and findings

Gibbs et al. (2015) reported selected findings from evaluations of three programs: The Standing Against Global Exploitation Everywhere (SAGE) Project (N = 55); The Salvation Army Trafficking Outreach Program and Intervention Techniques (STOP-IT) program (N = 35); and the Streetwork Project at Safe Horizon (N = 111). This process evaluation was conducted to identify minor trafficking victims’ characteristics and needs, document disseminated services, and understand the program staffs’ experiences with the dissemination of services. Gibbs et al. (2015) identified a diverse client population across the three programs, including 55% of clients who were confirmed victims of CSE. Clients served by these programs were primarily female (76%), Black (65%), and had some system involvement (i.e., 38% child welfare, 24% juvenile justice). Clients across all programs primarily received case management to address three of the four highest areas of need including crisis intervention, food or clothing, and safety planning. Program staff also identified strategies to promote engagement such as respecting clients’ boundaries, emphasized services clients preferred and maintained an “open door” to support clients should they need to return.

Strengths and limitations noted by Gibbs et al. (2015)

This article was unique in that it combined data from three different programs. The use of multiple data sources, diverse programs and client populations, and program staff perspectives served as notable strengths for this study; however, it did limit their ability to look at individual outcomes between the programs. The authors also acknowledged the reduced generalizability due to small program sample sizes and possible bias related to selective disclosure of interviewed staff, limited disclosure of information by clients to program staff, or selection of clients for case narrative interviews by program staff.

Study 4: Hickle and Roe-Sepowitz (2014)

Description of study and findings

Hickle and Roe-Sepowitz (2014) adapted and piloted a group intervention called Putting the Pieces back Together, a 12-week psychoeducation program initially developed for female inmates, for youth who have been victimized by domestic minor sex trafficking (DMST; N = 10). This observational case study demonstrated group participants displaying mutual aid, reducing shame, addressing stigma, and managing strong emotions.

Strengths and limitations noted by Hickle and Roe-Sepowitz (2014)

Hickle and Roe-Sepowitz (2014) assert that while youth impacted by CSE need mental health and substance use treatments, programs also must provide a safe and supportive space for youth to address CSE-specific trauma. While a formal outcome evaluation was not conducted, lessons learned from this pilot contribute to the slim literature on group work with young people experiencing CSE. No limitation is noted by the authors; however, the small sample size and observational approach to evaluation reduce generalizability and impede any causal inferences being made from the data.

Study 5: Rothman et al. (2020)

Description of study and findings

Rothman et al. (2020) evaluated a CSE survivor-mentor program, My Life My Choice, using a longitudinal one-group repeated design (baseline, 6-months, 12-months) with 11 to 18 year old youth who were victims of or at-risk for CSE (N = 41). The sample included 95% female, 58% heterosexual, 29% White, 29% Hispanic, and 42% other races/ethnicities. Multivariate models, adjusting for age, race, and baseline level of outcome of interest, showed that participants were less likely to have experienced CSE, engaged in delinquency, and been arrested or detained by police; and exhibited improved coping skills, at 12-month follow-up.

Strengths and limitations noted by Rothman et al. (2020)

The study included a hard-to-reach population in multiple follow-ups allowing longitudinal assessments of youth participating in the program. To ensure CSE victimization was measured accurately, the study used both self-report and third-party report of victimization experiences. The authors also developed a new assessment tool that can be used for this particular population. Rothman et al. (2020) noted the lack of control/comparison group and the small sample size. The reliance on self-reported data on highly personal outcomes could have been affected by social desirability bias.

Study 6: Twill et al. (2010)

Description of study and findings

Twill et al. (2010) used a retrospective posttest design to evaluate a secure group home treatment program for adolescent girls who were identified as CSE. Outcomes specifically focused on recidivism, indicated by newly charged offenses. Archival data were matched to 28 months of juvenile court data to identify newly committed offenses 4 to 13 months after discharge from group home for 22 youth (average age = 15 years). Results indicated that posttreatment, none of the youth were charged with a prostitution-related offense.

Strengths and limitations noted by Twill et al. (2010)

The evaluation was based on a convenience sample and was limited to only participants who were eligible to be placed in the group home treatment program. Twill et al. (2010) stated that this baseline data could be used as a foundation for future research. In regard to the new crimes committed by the youth, most of the crimes were status offenses. However, the study did not examine the possible relationship between status offenses and CSE. Limitations of this evaluation include a narrow focus on justice outcomes, due to measuring success through recidivism, rather than individual well-being outcomes.

Study 7: Murphy et al. (2016)

Description of study and findings

Murphy et al. (2016) developed and evaluated an educational prevention website tool (yourworth.org) specific to the issue of CSE of youth. Using a mixed methods pre- and posttest design, youth (N = 48) were asked for general knowledge about CSE followed by feedback, once they reviewed the website. Paired sample t-tests indicated that the website increased knowledge of CSE and decreased tolerance for CSE among adolescents. A thematic analysis of open-ended items of the survey also supported these findings.

Strengths and limitations noted by Murphy et al. (2016)

The website tool reached adolescents who have not experienced CSE, a group largely left out in prevention of CSE. This can facilitate and foster awareness for those at risk. Video content, however, included exclusively cisgender female victims with male exploiters, which leaves out victims who identify as male or transgender as well as female exploiters. The study did not have a comparison group. Murphy et al. (2016) stated that it is unclear whether or not this tool would help those already experiencing CSE. The website was also only intended for Georgia teens due to information provided for CSE service referrals being tailored to the state of Georgia.

Study 8: Kim et al. (2018)

Description of study and findings

Kim et al. (2018) used mixed methods research design to evaluate the impact of the Protection for Abused and Trafficked Humans Task Force (PATH), a citywide anti-trafficking coalition model. Based on a web-based survey administered to service providers (n = 32) and focus groups with key PATH members (n = 10), Kim et al. (2018) found that the coalition model had increased coordination among key agencies, law enforcement, and service providers and improved quality of service provisions for youth impacted by CSE.

Strengths and limitations noted by Kim et al. (2020)

This is one of the few studies to implement and evaluate a coalition model building on collaborative work for human trafficking victims. With the use of mixed methods, the authors were able to assess perceived impact of PATH and provide specific recommendations on what works and what areas need improvement. The limitation includes small sample size due to low response rate limiting generalizability and the lack of inclusion of victims’ voice as a hard-to-reach population. Finally, the study instruments have not been validated for this population.

Study 9: Kinnish et al. (2020)

Description of study and findings

Kinnish et al. (2020) used a pre- and posttest design to evaluate Project Intersect, a system of care for youth experiencing CSE that trains mental health professionals to provide service linkages and high-quality evidence-based mental health treatment. Established by Georgia Center for Child Advocacy, Project Intersect aimed to streamline mental health treatment for youth victims of CSE. As part of the project, 200 therapists from 80 organizations received training in delivering Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) for youth victims of CSE. Providers felt TF-CBT was acceptable to youth clients. Client level outcomes using standardized measures suggest significant reductions in posttraumatic stress symptoms.

Strengths and limitations noted by Kinnish et al. (2020)

The training program is grounded in evidence-based practice, utilizing TF-CBT. All the trainings were created and supported by national trainers, researchers, and developers of TF-CBT. Additionally, Project Intersect has created a strong statewide system of care for youth who may have been identified as experiencing CSE. However, client evaluation was based on a small sample size and thus, the positive results should be interpreted with caution.

Study 10: Miller et al. (2020)

Description of study and findings

As alternatives to arrest and detention, the Law Enforcement First Responder Protocol (FRP) was developed to provide coordinated, multidisciplinary, youth-centered, strengths-based, and trauma-informed services to children identified by law enforcement as possible victims of CSE. Through a multiagency collaboration and tracking of monthly statistics for CSE cases identified through the FRP, an evaluation of possible benefits and areas for improvement was conducted. Using administrative data, Miller et al. (2020) provided detailed descriptions of youth (N = 361) identified through FRP (i.e., demographics, child welfare history, CSE identification route, placement situation, medical evaluation). The data revealed how critical it is to provide youth, who have been identified as experiencing CSE, with time-sensitive services in a coordinated and supportive manner. Additionally, the data also revealed possible differences in accessing care after the determination of placement has been made.

Strengths and limitations noted by Miller et al. (2020)

FRP provides a specified and coordinated effort to address urgent needs of youth identified as victims of CSE in a time-sensitive manner at initial law enforcement contact. In doing so, FRP seeks to expand access and utilization of trauma-informed care. The evaluation, however, was limited to administrative data without important feedback from youth and families regarding access to care.

Study 11: Sutherland (2014)

Description of study and findings

Sutherland (2014) examined program components that contribute to the effectiveness of treatment for youth impacted by CSE in a child and adolescent psychiatric residential treatment setting in the southeast. Individual program components across clinical, educational/vocational, medical, and milieu domains were examined using mean group differences in program implementation, client-pre-service assessment, program characteristics, and staff characteristics from archival data collected across disciplines from staff teachers, clinical therapists, milieu support staff, psychiatrists, and nurses (n = 97).

Strengths and limitations noted by Sutherland (2014)

As first of its kind to examine the effectiveness of a residential treatment facility housing youth impacted by CSE, Sutherland (2014) asserts that the findings of the study contribute to a gap in the literature to consider a holistic treatment approach within group homes. Sutherland (2014) also notes that the use of the Commercial Sexual Exploitation Program Assessment Battery across disciplines allows for the identification of discipline specific contributions to overall program effectiveness for youth impacted by CSE within a psychiatric residential treatment setting. The main limitation noted by Sutherland (2014) is that individual outcomes were not included in this analysis and thus fully connecting effectiveness scores to actual program effectiveness is limited.

Study 12: Shively et al. (2008)

Description of study and findings

Shively et al. (2008) evaluated a program created in San Francisco that was designed to reduce the demand for commercial sex by educating those who were arrested for soliciting sex. A mixed methods study design was used to evaluate the effectiveness, transferability, and return on investment of the First Offender Prostitution Program (FOPP). Using interviews, observations, pre- and posttests, and site visits, the evaluation concluded that the program was effective in producing positive shifts in attitudes and reducing recidivism.

Strengths and limitations noted by Shively et al. (2008)

FOPP was not the first program to target solicitors of prostitution; however, it led to the creation of 25 other programs across the United States. The program was low cost and generated revenue that supported survivors of CSE. Although the data showed the effectiveness of the program, the authors suggested the need for an evidence-based curriculum update. Additionally, the findings did not examine which program elements contributed to reduced recidivism.

Types of Programs Evaluated

Across the 12 articles, 13 programs were identified. The evaluated programs included three case management, three multiagency collaboration, three psychoeducation, two mentorship, and two treatment in congregated setting (See Supplemental Appendix B, for further description). In the review conducted by Muraya and Fry (2016), one of the most frequently identified service needs for individuals impacted by CSE was case management, from intake and crisis management to ongoing support for service linkages. While only 3 of the 12 programs designated their program as case management, other programs also included elements of case management, such as the Group Home Treatment Program (Twill et al., 2010) and STAR Court (Bath et al., 2020), further highlighting the importance of case management in servicing youth impacted by CSE.

Much of the literature focuses on the importance of coordinated collaboration across multiple agencies to prevent, identify, and service youth impacted by CSE (e.g., Twigg, 2017). While slightly different in the approach, the practices highlighted in STAR Court (Bath et al., 2020), Protection for Abused and Trafficked Humans Task Force (Kim et al., 2018), and the Law Enforcement FRP (Miller et al., 2020) build on coordinated, multiagency, youth-centered collaboration. This model of care allows for sharing resources across agencies to find the best fitting quality service for youth impacted by CSE, in the most efficient and timely manner. Despite this approach being the gold-standard for serving youth impacted by CSE, these three studies are one of the few studies to provide detailed description of the actual implementation and evaluation of the practice, which is a big contribution to the literature.

Psychoeducation is a well-studied approach to treatment and prevention of mental, emotional, and behavioral problems (e.g., Donker et al., 2009; Lincoln et al., 2007), where brief sessions tend to have greater positive effect. Psychoeducation is easily integrated into other programs and evaluated. As such, psychoeducation was one of the more popular approaches evaluated. In the articles included, psychoeducation was used for prevention (e.g., raising knowledge, awareness, recognition), group-based intervention (e.g., dispelling myths, reducing shame, increasing knowledge), and offender re-entry (e.g., education on negative consequences of sexual exploitation).

Muraya and Fry (2016) also identified trauma-informed practice and coordinated multiagency approach for holistic healing as essential for addressing the complex needs of youth impacted by CSE. Trauma was mentioned in most of the programs, centralizing the need for healing, despite different approaches. Mentorship, in particular, focused on positive relationship building with supportive adults that helps address past trauma experiences. While mentoring programs have been criticized for lack of clarity around program curriculum and strategies, reviews have suggested positive effects, especially when built on emotional support (e.g., Tolan et al., 2014). Finally, Rafferty (2018) suggested that high quality culturally-relevant mental health treatment as the most vital component toward recovery for victims of trafficking. Despite its international focus, this is consistent with the programs identified in these evaluations, as most identify the need for mental health services and provide linkages. In fact, two programs primarily focused on mental health treatment within congregated settings, one in a group home and the other in a psychiatric treatment facility. Both were unique in that these settings were primarily servicing youth experiencing CSE, which is much needed since many young people are stigmatized and discriminated against even in treatment settings (Sutherland, 2014).

Scientific Rigor in Assessing Effectiveness

The study conclusions evaluating the programs were mostly favorable but overall evidence is inconclusive. We assessed the scientific rigor of each study using five categories, including study design, comparison group (yes/no), sample size, attrition/response rate, and analytic method. Overall, the level of scientific rigor was low for all studies. No study included a comparison group and with the exception of Shively et al. (2008), which used a quasi-experimental design with interrupted time series, no study used an experimental design. While some (n = 6) studies used a pre- and posttest design, analytic methods such as sample t-tests and chi-square tests were used without controlling for possible covariates (e.g., demographic characteristics) that could be related to the outcomes of interest. One study reported using a multivariate model to adjust for baseline measures and demographics (Rothman et al., 2020). Studies that reported low response rates and/or high attrition rates also showed possible bias in the findings. These limitations in the study design and analytic approaches enhance the risk for selection effects, and while the positive outcomes found in the studies are promising, more rigorous studies are needed to build the evidence base for programs targeting youth impacted by CSE.

Discussion

This study conducted a systematic scoping review of evaluated programs that service youth victims of CSE. The study sought to compile not simply a list of programs developed and implemented for youth victims of CSE but a hub for empirical evidence for program effectiveness. There is certainly a growing body of literature on youth experiencing or at-risk for CSE. In recent years, several review articles specific to this population have been published, including a systematic review on the prevalence of youth experiencing CSE (Franchino-Olsen et al., 2020), qualitative evidence on youth experiences of CSE (Hampton & Lieggi, 2020), and screening tools and response protocols (Macy et al., 2021). While more studies have been published specific to youth experiencing CSE, in our review, we found that very few identified and described actual programs or services to address the complex needs of youth victims of CSE. Much of the literature still focused on describing the needs and risks of youth experiencing CSE with some studies (e.g., Goldman & Goyal, 2019; Greenbaum et al., 2018) highlighting assessment tools to identify victims of CSE and other studies (e.g., Abrams et al., 2020; Chisolm-Straker et al., 2020; Richie-Zavaleta et al., 2021) proposing possible practice models and frameworks that can help facilitate service linkages.

Far fewer studies included evaluations, including process evaluations. Even with the addition of program mining where we conducted a search for evaluation studies or reports for all the programs mentioned in the reviewed articles, only one additional report was added to the list of included articles. This highlights the current lack of evidence-based programs for youth experiencing CSE. While protocols, assessment tools, and frameworks are important in increasing access to services for youth experiencing CSE, tangible services or programs must be developed that specifically target the needs of youth experiencing CSE. Further, evidence of effectiveness is important to ensure that the programs and services provided actually benefit youth experiencing CSE.

Possibly because of legislation changes around CSE identification, many articles focused on identification of individuals experiencing CSE. For example, the Justice for Victims of Trafficking Act of 2015 (P.L. 114-22) amended the Child Abuse Prevention and Treatment Act (CAPTA; P.L. 93-247), requiring states to have procedures in place to identify and assess children who are known or suspected to be victims of sex trafficking. Thus, child welfare systems are statutorily obligated to identify and track CSE among the population they serve and report these numbers to the federal government. Indeed, identification is important and there is a growing body of research (e.g., Middleton & Edwards, 2021) to meet the legal requirement. However, developing identification methods without service options or access to evidence-based interventions is potentially harmful for those identified as experiencing CSE.

Furthermore, nearly half of the studies excluded from the review (84/179) focused on simply describing a framework or model of working with youth experiencing or at-risk for CSE. These studies recommended models and frameworks conceptualizing necessary collaborations and training across various systems and stakeholders (e.g., health care professionals, law enforcement) to address the complex issues related to CSE. While collaborative efforts such as coalition building has been advocated as best practice for working with this population (Walker, 2013), most studies focused on developing and describing these models and frameworks without actual implementation. Two studies (Kim et al., 2018; Miller et al., 2020) included in this review demonstrate an evaluation of a framework/model working to fight against CSE of youth and provide services to those impacted. Both The FRP (Miller et al., 2020) and Protection for Abused and Trafficked Humans Task Force (Kim et al., 2018) seek coordination across key agencies, service providers, and law enforcement to link youth impacted by CSE to services and improve their wellbeing. While neither is a specific service or treatment program, these models and frameworks are important contexts in which services and treatments can be provided. Given the number of articles describing (but not implementing or evaluating) such models, our review highlights the importance of research-practice partnership to implement and evaluate these models and frameworks.

While evaluations specific to victims of child sexual abuse without explicit mention of victims of CSE were excluded, this is a promising area to strengthen evidence that can build off existing literature. When youth who had experienced CSE were grouped youth who had experienced sexual abuse, CSE was not given the appropriate description and how the program/approach could apply to youth experiencing CSE. Potentially many frameworks/programs/approaches developed for victims of child sexual abuse, or childhood trauma more generally, could work for youth experiencing CSE, with some articles suggesting an adaptation. This could expand the evidence-base for victims of CSE, as existing evidence-based programs for childhood trauma exposure can be adapted. One example of an adapted program is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), evaluated in Kinnish et al. (2020), which has been used to treat children and youth who have experienced CSA as well as other childhood traumas. Future research should consider how programs that were not specifically developed for CSE may or may not be appropriate to this population or if adaptations can (or should) be made that tailor treatment to CSE.

Programs identified in this review had various target populations, goals, and outcomes of interest. This may be a reflection that youth impacted by CSE are receiving an array of programs or treatments that target a range of issues and needs. As noted by Gibbs et al. (2015), youth experiencing CSE are often contending with several critical needs beyond exploitation so directing them to other services could be effective. Although evidence across multiple services and programs serving youth victims of CSE is needed, a more intentional understanding of what types of outcomes should be considered as indicators of success for this population would be useful for future evaluations.

The samples included in the studies were by-in-large girls and people of color. Evidence is sparse in general but even slimmer for boys and youth who identify as transgender. More studies and practice models should make a concerted effort to identify victims who identify as transgender as well as cisgender males. Nevertheless, the samples captured in these studies reflect the current systemic and structural inequalities that affect girls, and especially girls of color. This is reflected in some of the studies that continue to refer to youth victims of CSE as “prostitutes” or CSE as “prostitution” which further stigmatizes this population. This may be because different states have different legal responses for youth who are trafficked. For example, Safe Harbor Laws, which are intended to protect children and youth experiencing CSE by providing immunity, diversion, services, and/or decriminalization, are not enacted in all states and for those that have this type of legislation there is significant variation in how it is operationalized (Gies et al., 2019). Policymakers should carefully consider nationwide standards for youth trafficking so that no youth across the United States would be criminally charged for being exploited or trafficked.

Furthermore, the intersectional marginalization (Crenshaw, 1990) experienced by girls of color needs to be considered when developing interventions and this work should be joined by challenging the systems that perpetuate and facilitate this marginalization. For example, the public systems (e.g., child welfare, juvenile justice, mental health) that seek to address the needs of youth and families impacted by CSE have historically also been sources of trauma for communities of color. Yet, testing the effectiveness of psychosocial interventions have largely been with White European Americans and little progress has been made in terms of program engagement, outcomes, and mechanisms of change for cultural tailoring to include youth of color (Pina et al., 2019). Moving forward, development and evaluation of programs targeting the needs of youth experiencing CSE are important, but more importantly the standards, approaches, and methods of research and/or practice should be critically assessed within the context of racism and sexism (Bowleg, 2021).

The current review found that the scientific rigor of the research designs in the current literature is low. Future research and evaluation of programs should also strive to carry out the most rigorous research design as possible. Yet, we also recognize that this is particularly difficult given that traditional experimental designs or randomized control trials may not be feasible with this population. There are significant ethical concerns of utilizing a control group that is not receiving treatment or using a waitlist control group because of the potential for harm among youth being trafficked. At best, quasi-experimental designs are most feasible, though also difficult. Identifying a comparison group, for example, is challenging given the hidden nature of CSE. Researchers should consider including more nontraditional approaches when evaluating programs such as qualitative designs, participatory action research approaches, or linked administrative data. Participatory action research is especially recommended as most individuals in the anti-trafficking movement signal the need to include those with lived experience in prevention and intervention efforts (e.g., Hampton & Lieggi, 2020). Indeed, programs that include survivors, such as My Life My Choice which is included in the current review (Rothman et al., 2020), are a testament to the power of lived experience in advancing practice, policy, and research (Table 2).

Table 2.

Study Implications.

Focus	Implications
Policy	Improving access to evidence-based interventions is crucial for those identified as experiencing commercial sexual exploitation (CSE).
	Identification efforts and policies should be coupled with linkages to services and evidence-based programs.
	Policymakers should ensure that the definition of human trafficking, as defined in the Trafficking Victims Protection Act, is operationalized at the state-level across the country so that no child can be criminally charged for being exploited or trafficked.
Practice	There is a need for tangible evidence-based programs tailored to youth experiencing, or at risk of, CSE.
	Research-practice partnerships can further support the development, implementation, and evaluations of programs for CSE.
	The intersectional marginalization of youth of color should be taken into consideration when developing and evaluating programs for CSE.
Research	More research is needed to describe and evaluate relevant programs that address the complex needs of youth experiencing CSE.
	Evidence for program effectiveness is needed to ensure intended benefits are maximized. More studies and practice models should intentionally focus on the specific needs of cisgender male and transgender CSE youth.
	When traditional research designs are not feasible, researchers should consider using nontraditional approaches (e.g., participatory action research methods) to effectively develop and evaluate programs.

Limitations

This review focused solely on studies that were in English and ones that were conducted in the United States. This narrows the generalizability of the evaluations identified and there are likely programs excluded. Our review included some studies that evaluated programs specific to youth and adults and other studies that evaluated programs specific to adults because of our inclusion criteria (up to age 21). This may confound the evaluation findings in terms of actual implications for children and youth experiencing CSE. Selecting the age range for this review was a challenge, as service sectors in different geographic areas define different ages as adults. By including up to age 21, we hoped to find evidence across these geographic areas. Even though every attempt was made to conduct a comprehensive search, such as program mining, some publications (especially gray literature not published online, not accessible via website) may have been missed.

Conclusion

There has been significant progress in policy and legislation to identify victims of CSE while efforts to develop and evaluate programs for youth experiencing CSE have significantly lagged. Despite the limitations, this scoping review provides comprehensive evidence of evaluated programs and services for youth impacted by CSE. Overall, evidence found across the studies is promising, but more research is needed to establish stronger evidence of effectiveness in addressing the needs of youth victims of CSE. Improving the evidence-base for youth experiencing CSE should include nontraditional approaches to program evaluation given the ethical concerns of traditional designs (e.g., randomized control trials) while taking into account the intersectional marginalization of girls of color who are disproportionately impacted by CSE.

Supplemental Material

sj-docx-1-tva-10.1177_15248380221126185 – Supplemental material for Evaluation of Services for the Commercial Sexual Exploitation of Children and Youth: A Scoping Review

Supplemental material, sj-docx-1-tva-10.1177_15248380221126185 for Evaluation of Services for the Commercial Sexual Exploitation of Children and Youth: A Scoping Review by Bo-Kyung Elizabeth Kim, Carly B. Dierkhising, Jessenia De Leon, Jacquelyne Sandoval, Alyssa Brissett and Dawn Bounds in Trauma, Violence, & Abuse

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: This resource was prepared by the author(s) using Federal funds provided by the U.S. Department of Justice, National Institute of Justice through grant number NIJ 2019-V3-GX-0006. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U.S. Department of Justice.

ORCID iDs

Bo-Kyung Elizabeth Kim

Carly Dierkhising

Dawn Bounds

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Bo-Kyung Elizabeth Kim, PhD, MSW, is an Assistant Professor at the University of Southern California Suzanne Dworak-Peck School of Social Work. She received a PhD in Social Welfare at the University of Washington and completed her postdoctoral fellowship at the University of Califorina, Berkeley. Her research focuses on informing service systems and evidence-based practice strategies as alternatives to youth incarceration to reduce mental, emotional, and behavioral health inequity experienced by youth of color.

Carly B. Dierkhising, PhD, is an Associate Professor at California State University, Los Angeles in the School of Criminal Justice and Criminalistics. She holds a Doctorate in Developmental Psychology and a Masters in Clinical Psychology. Dr. Dierkhising is committed to developing actionable research and translating research to practice and policy in order to improve the lives of trauma-exposed and system-involved youth.

Jessenia De Leon, MSW, is a doctoral candidate at the University of Southern California in the USC Suzanne Dworak-Peck School of Social Work. She holds a Masters in Social Work focused on children, youth, and families. Jessenia’s research is centered on strengthening organizational capacity and fostering sustainability for nonprofit organizations that address the mental health needs of vulnerable youth.

Jacquelyne R. Sandoval, MSW, is a Policy Director for Emergency Management for the Los Angeles Mayor’s Office of Public Safety. She is also a Research Coordinator at California State University, Los Angeles (CSULA). Prior to pursuing her higher education, she served in the United States Marine Corps. She graduated with her B.S. in Criminal Justice from CSULA and holds a Master of Social Work degree from the University of Southern California.

Alyssa E. Brissett, MLIS, MA, is the Head of Reference Services at NYU Libraries, and previously held the position of Head, Education, Social Work and Gerontology Library Services at the University of Southern California. She holds a Master of Library and Information Science from Wayne State University and a Master of Arts in Childhood Education from New York University. Her research interests include social justice and antiracism in libraries, organizational change, and equitable library hiring practices.

Dawn Bounds, PhD, PMHNP-BC is an assistant professor in the Sue and Bill Gross School of Nursing and creator and director of the Centering Youth & Families for Empowerment andResilience (CYFER) Lab at the University of California, Irvine. As a psychiatric-mental health nurse practitioner, her program of research is focused on digital mental health promotion and the prevention of risk behaviors in adversity-impacted youth.

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