Understanding and Responding to the Needs of Commercially Sexually Exploited Youth

Commercial sexual exploitation of children (CSEC) is a critical human rights and public health issue that child psychiatrists and other mental health providers can play an important role in addressing. 

Although commercially sexually exploited youth often go unidentified by health providers, these youth may have frequent contact with health care, juvenile delinquency, and foster care systems, and therefore, likely interact with mental health providers who work in these settings. 

Although the data on commercially sexually exploited youth are limited, studies show that these youth are at high risk for medical and psychiatric problems and have challenging psychosocial histories, including having experienced childhood abuse, homelessness, and foster care placement.^1–4 The exact numbers of commercially sexually exploited youth are unknown given the clandestine nature of the exploitation and underreporting. Experts suggest that the number of sexually exploited children in the United States may be growing.¹ 

Understanding the risk factors for commercial sexual exploitation, the health and mental health implications, and treatment options can help improve detection and care for this underserved population.

Psychiatric interview: potential associated signs, mental health symptoms, and red flags for detecting commercially sexually exploited youth

Appearance and behavior

• Youth is accompanied by an individual that appears controlling or does not want the youth to be interviewed alone
• Youth displays a withdrawn, frightened, or guarded affect
• Youth gives vague or changing demographic information
• Youth appears intoxicated or impaired by substance use
• Youth has evidence of branding or tattoos (including facial tattoos, gang-related tattoos)
• Youth has evidence of physical injury (scars, burns, lacerations, fractures, traumatic brain injury)
• Youth appears to be in poor physical health (evidence of skin infections, poor dentition, malnourishment)
• Youth is carrying large amounts of money or expensive items that appear beyond the youth’s means

Social history

• Youth has a history of homelessness (includes running away, being abandoned, or forced to leave home)
• Youth has an older boyfriend and/or history of multiple sexual partners
• Youth has a history of juvenile justice system involvement
• Youth has a history of involvement with child welfare services (including living in a group home/foster care home)
• Youth does not attend school or is frequently truant

Medical history

• Youth has a history of pregnancy, abortion, ectopic pregnancies
• Youth has a history of multiple sexually transmitted diseases, pelvic inflammatory disease
• Youth has frequent emergency room visits (including for physical injuries, reproductive concerns, or sexually transmitted diseases)

Mental health symptoms

• Youth has symptoms of depression
• Youth is suicidal
• Youth has symptoms of posttraumatic stress disorder, traumatic stress, and/or anxiety symptoms
• Youth has symptoms of a substance use disorder
• Youth has problems with anger
• Youth has self-harming behaviors
• Having these signs does not mean that a child is being commercially sexually exploited, and lack of these signs does not rule out that a child is being commercially sexually exploited.

Adapted from Greenbaum VJ. Commercial sexual exploitation and sex trafficking of children in the United States. Curr Probl Pediatr Adolesc Health Care 2014;44(9):245–69; with permission. Data fromRefs.^2,4,18,27,39

Below:  Ecological Framework for Contextualizing and Conceptualizing Commercial Sexual Exploitation of Children

Full article at:   http://goo.gl/P7PRRH

By:  Roya Ijadi-Maghsoodi, MD,a,b,* Mekeila Cook, PhD,c Elizabeth S. Barnert, MD, MPH, MS,d Shushanik Gaboian, MSW,eand Eraka Bath, MDf

^aVA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Building 500, Room 1601, Office of Healthcare, Transformation and Innovation, Mail Code 10–C, Los Angeles, CA 90073, USA

^bDepartment of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA

^cIntegrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 11075 Santa Monica Boulevard, Suite 100, Los Angeles, CA 90025, USA

^dDepartment of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA

^eDepartment of Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA

^fChild Forensic Services, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, 300 Medical Plaza, Room 1243, Los Angeles, CA 90095, USA

^*Corresponding author. Email: ude.alcu.tendem@idooshgamidajir

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From Exploitation to Industry: Definitions, Risks, and Consequences of Domestic Sexual Exploitation and Sex Work among Women and Girls

In the last 15 years, terms such as prostitution, sex trafficking, sexual exploitation, modern-day slavery, and sex work have elicited much confusion and debate as to their definitions. Consequently several challenges have emerged for both law enforcement in the prosecution of criminals and practitioners in service provision. This article reviews the state of the literature with regard to domestic, sexual exploitation among women and girls in the United States and seeks to (1) provide definitions and describe the complexity of all terms relating to domestic sexual exploitation of women and girls in the United States, (2) explore available national prevalence data according to the definitions provided, and (3) review the evidence of mental health, social, and structural risk factors at the micro-, mezzo-, and macrolevels…

In conjunction with sexual abuse and assault, other forms of nonsexual trauma, such as physical and emotional abuse, are also important risk factors to consider. One study of 278 sex workers in Miami found that 51% of their sample had experienced physical abuse and 65% had experienced emotional abuse, in addition to 53% who had experienced sexual abuse (Surratt, Kurtz, Weaver, & Inciardi, 2005). Childhood emotional abuse is also significantly associated with commercial sexual exploitation and may contribute to a younger age of entry into prostitution (Roe-Sepowitz, 2012).

Subsequent to victims’ trauma and abuse previously experienced before exploitation, research also supports that victims of sexual exploitation endure several forms of victimization during or in addition to ongoing sexual exploitation. One study examining health outcomes among domestic, sexually trafficked victims found that most victims had experienced physical violence (88.9%), sexual violence (83.3%), and psychological violence (100%) during sexual exploitation (Muftic & Finn, 2013). Additionally, a sexually exploited girl or woman will have a greater likelihood of exposure to violence and abuse from a pimp and/or someone purchasing sex from them. The additional control and coercion of sexual exploitation by a pimp also promulgates additional exposure to threatened or actualized assault or other forms of trauma. Of the 71 women controlled by a pimp in a Chicago study, 21% were threatened to be raped and more than half reported to have been sexually assaulted (Raphael, Reichert, & Powers, 2010).

PTSD and Depression

Exposure to various forms of violence is empirically linked to levels of PTSD and depression. Two multicountry studies examined issues of depression and PTSD among sex trafficking victims and found significant associations between these mental health issues and trafficking. Hossain and her research team (2010) found that more than half of the 204 trafficking victims interviewed across 12 countries met criteria for depression, and 77% had symptoms of PTSD. Although this well-known study was not conducted in the United States, it is frequently referenced in domestic literature and must be addressed accordingly. The second study found a 68% (n = 562) rate of PTSD across all sexually trafficked participants from nine countries and 69% (n = 87) among U.S. victims (Farley et al., 2004).

On a smaller scale, several domestic studies have found similar associations and prevalence rates of PTSD among sexually exploited women. Several studies of 100 participants or fewer showed that female victims of sexual exploitation experience rates of PTSD ranging from 27% (Wells & Mitchell, 2007) to 50% (Twill et al., 2010). Similarly, these types of studies showed depression rates of up to 60% (Roe-Sepowitz, 2012). Given the extreme trauma that victims of sexual exploitation face and the empirical link between trauma and PTSD as well as depression, high rates of mental health consequences unfortunately are expected in this population.

…Many domestic victims of sexual exploitation are vulnerable youth who are already involved in the foster care system (Fong & Berger Cardoso, 2010). Involvement in the foster care system may stem from child abuse and neglect (Miller et al., 2011) or from the loss of a parent through death, divorce, or abandonment (Clawson et al., 2009). Youth who are considered to live in “out of home” placements—including youth shelters, group homes, and foster care—are at greater risk of becoming victims of sexual exploitation (Rafferty, 2013). Qualitatively, many sexually exploited women and girls report themes of isolation and lack of connection and resources, often stemming from the child welfare system, foster care placements, and abandonment (Farley, 2004; Rabinovitch, 2008; Ugarte, Zarate, & Farley, 2003)…

Full article at:   http://goo.gl/1Y4GFg

By:  Lara Gerassi

Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA

Address correspondence to Lara Gerassi, Brown School of Social Work, Washington University in St. Louis, St. Louis, MO 63130, USA. Email: ude.ltsuw@issaregl.

Published online 2015 Apr 9. doi:  10.1080/10911359.2014.991055

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History of Foster Care among Homeless Adults with Mental Illness in Vancouver, British Columbia: A Precursor to Trajectories of Risk

BACKGROUND:

It is well documented that a disproportionate number of homeless adults have childhood histories of foster care placement(s). This study examines the relationship between foster care placement as a predictor of adult substance use disorders (including frequency, severity and type), mental illness, vocational functioning, service use and duration of homelessness among a sample of homeless adults with mental illness. We hypothesize that a history of foster care predicts earlier, more severe and more frequent substance use, multiple mental disorder diagnoses, discontinuous work history, and longer durations of homelessness.

METHODS:

This study was conducted using baseline data from two randomized controlled trials in Vancouver, British Columbia for participants who responded to a series of questions pertaining to out-of-home care at 12 months follow-up (n = 442). Primary outcomes included current mental disorders; substance use including type, frequency and severity; physical health; duration of homelessness; vocational functioning; and service use.

RESULTS:

In multivariable regression models, a history of foster care placement independently predicted incomplete high school, duration of homelessness, discontinuous work history, less severe types of mental illness, multiple mental disorders, early initiation of drug and/or alcohol use, and daily drug use.

CONCLUSIONS:

This is the first Canadian study to investigate the relationship between a history of foster care and current substance use among homeless adults with mental illness, controlling for several other potential confounding factors. It is important to screen homeless youth who exit foster care for substance use, and to provide integrated treatment for concurrent disorders to homeless youth and adults who have both psychiatric and substance use problems.

Table 2

Foster care experiences among Vancouver At Home participants

	N (%)
Lived away from parents before age 18 (n = 445)	264 (59)
Reasons for living away (n = 264)4
Lived with relatives or friends	36 (14)
Foster home	98 (37)
Group home	23 (9)
Jail or detention	18 (7)
Ran away or kicked out	75 (28)
Moved out	28 (11)
Other	36 (14)
Placed in foster care (n = 442)	135 (30)
Reasons (n = 135)5
Parental illness or accident	19 (14)
Parental incarceration	5 (4)
Parental abuse or neglect	54 (40)
Behavioural problems	34 (25)
Don’t know	19 (14)
Other	14 (10)
Number of foster care placements (n = 125)
Median (IQR)	1 (1–4)
Age at time of most recent placement (n = 131)
Median (IQR)	10 (3–13)
Duration (months) of most recent placement (n = 122)
Median (IQR)	18 (8–48)
Biological children (currently or in the past) in foster care (n = 447)	41 (9)
Biological children (currently or in the past) adopted or living with someone else (n = 446)	105 (23)

4Proportions were derived using 264 as the denominator. Participants could endorse more than one reason.

5Proportions were derived using 135 as the denominator. Participants could endorse more than one reason.

Purchase full article at:   http://goo.gl/pzsqFs

By:   Patterson ML¹, Moniruzzaman A², Somers JM³.

¹Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British, Columbia, Canada. michelle_patterson@sfu.ca.

²Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British, Columbia, Canada. Akm_moniruzzaman@sfu.ca.

³Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British, Columbia, Canada. jsomers@sfu.ca.

BMC Psychiatry. 2015 Feb 26;15:32. doi: 10.1186/s12888-015-0411-3. 

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Methamphetamine Use among Homeless Former Foster Youth: The Mediating Role of Social Networks

OBJECTIVES:

Social network analysis can provide added causal insight into otherwise confusing epidemiologic findings in public health research. Although foster care and homelessness are risk factors for methamphetamine use, current research has failed to explicate why homeless youth with foster care experience engage in methamphetamine use at higher rates than other homeless young adults. This study examined the mediating effect of network engagement and time spent homeless on the relationship between foster care experience and recent methamphetamine use among homeless youth in Los Angeles.

METHODS:

Egocentric network data from a cross-sectional community-based sample (n = 652) of homeless youth aged 13-25 were collected from drop-in centers in Los Angeles. Questions addressed foster care experience, time spent homeless, methamphetamine use, and perceived drug use in social networks. Path analysis was performed in SAS to examine mediation.

RESULTS:

Controlling for all other variables, results of path analysis regarding recent methamphetamine use indicated a direct effect between foster care experience and recent methamphetamine use (B = .269, t = 2.73, p < .01). However, this direct effect became statistically nonsignificant when time spent homeless and network methamphetamine use were added to the model, and indirect paths from time spent homeless and network methamphetamine use became statistically significant.

CONCLUSIONS:

Foster care experience influenced recent methamphetamine use indirectly through time spent homeless and methamphetamine use by network members. Efforts to reduce methamphetamine use should focus on securing stable housing and addressing network interactions among homeless former foster youth.

Via:   http://goo.gl/jhIkXv

By:   Yoshioka-Maxwell A1, Rice E1, Rhoades H1, Winetrobe H1.

• 1School of Social Work, University of Southern California, University Park Campus, Los Angeles, CA. 

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Intergenerational Transmission of Maltreatment: A Multilevel Examination

Despite the commonly held belief that there is a high degree of intergenerational continuity in maltreatment, studies to date suggest a mixed pattern of findings. One reason for the variance in findings may be related to the measurement approach used, which includes a range of self-report and official indicators of maltreatment and both cross-sectional and longitudinal designs. 

This study attempted to shed light on the phenomenon of intergenerational continuity of maltreatment by examining multiple indicators of perpetration of maltreatment in young adults and multiple risk factors across different levels within an individual’s social ecology. The sample included 166 women who had been placed in out-of-home care as adolescents (>85% had a substantiated maltreatment incident) and followed into young adulthood, and included three waves of adolescent data and six waves of young adult data collected across 10 years. 

The participants were originally recruited during adolescence as part of a randomized controlled trial examining the efficacy of the Treatment Foster Care Oregon intervention. Analyses revealed weak to modest associations between the three indicators of perpetration of maltreatment in young adulthood, i.e., official child welfare records, self-reported child welfare system involvement, and self-reported maltreatment (r = .03–.51). Further, different patterns of prediction emerged as a function of the measurement approach. Adolescent delinquency was a significant predictor of subsequent self-reported child welfare contact, and young adult partner risk was a significant predictor of perpetration of maltreatment as indexed by both official child welfare records and self-reported child welfare contact. In addition, women who were originally assigned to the intervention condition reported perpetrating less maltreatment during young adulthood. 

Implications for measurement and interventions related to reducing the risk for intergenerational transmission of risk are discussed.

Full article at: http://goo.gl/JXehc5

By: Leslie D. Leve, Atika Khurana, and Emily B. Reich

University of Oregon

Correspondence concerning this article should be addressed to Leslie Leve, Prevention Science Institute, 6217 University of Oregon, Eugene, OR 97403-6217; direct inquiries regarding clinical aspects of Treatment Foster Care Oregon and its implementation to Patricia Chamberlain, Oregon Social Learning Center, 10 Shelton McMurphey Boulevard, Eugene, OR 97401. Email: ude.nogerou@evel or ; Email: gro.clso@cittap.

 

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Delinquency, Depression, and Psychosis among Adolescents in Foster Care: What Holds Three Heads Together?

Child psychopathology research has traditionally distinguished between internalizing and externalizing disorders, with the former treated with interventions that focus on alleviating negative internal states, and the latter with interventions that reward prosocial behavior and attempt to extinguish negative behavior. Not all disorders fall neatly into these categories, of course. Psychosis could be seen as an externalizing disorder (e.g., patients who become violent when hearing threatening voices) or an internalizing disorder (e.g., believing one is being punished). Multidimensional Treatment Foster Care (MTFC), a comprehensive care system for delinquent girls, appears to have beneficial effects on delinquency, depression, and subthreshold psychotic symptoms over 2 years. Although treatments that have nonspecific benefits might undermine the view that specific disorders have unique causal mechanisms, they are welcome in public health settings, where pure clinical presentations are rare.¹

In the well-done study by Poulton et al.² in this issue of the Journal, 166 girls (13–17 years of age) who had been arrested at least once in the prior 12 months and placed in out-of-home foster care were randomly assigned to MTFC or a group care as usual treatment. Unlike prior “ultra high-risk” studies, the sample was not selected for psychosis symptoms but had historical risk factors (i.e., childhood abuse and neglect) and current diagnoses (i.e., conduct disorder) that are related to psychosis onset. Although the primary purpose of MTFC was to decrease delinquency, the investigators observed secondarily that girls showed decreases in subthreshold psychotic symptoms.

MTFC was implemented in 22 group homes in which foster parents were trained and supervised to implement a reinforcement model. The adolescents attended public school and received concurrent individual therapy. After an average 6-month stay, adolescents returned to parents (or other caregivers) who were trained in effective parenting skills (e.g., consistency, non-harsh discipline) in a family-therapy format. Thus, the program aimed to change the context in which delinquent behaviors developed, first by providing a new home environment and then by modifying the old one. Participants in the group care condition lived in 1 of 35 intensive care settings, where they received at least weekly services and off- or on-grounds schooling.

Over 24 months, adolescents in MTFC had a steeper decline in psychotic symptom severity and roughly half the number of psychotic symptoms compared with adolescents in group care. Psychotic symptoms were measured from the Brief Symptom Inventory (5 items) and the Diagnostic Interview Schedule for Children–IV Psychotic Symptoms scale. The Brief Symptom Inventory included the items “feeling lonely even when you are with people” and “never feeling close to another person.” Psychosis and depression are both characterized by emotional withdrawal, and in this sense, it is not surprising that a treatment that decreased depression also would decrease subthreshold psychosis...

Full article at: http://goo.gl/1EfII3

By: Dr. David J. Miklowitz, 

Dr. David J. Miklowitz, University of California–Los Angeles School of Medicine;

Correspondence to David J Miklowitz, PhD, Division of Child and Adolescent Psychiatry, UCLA Semel Institute Room 58-217, David Geffen School of Medicine, 760 Westwood Plaza, Los Angeles, CA 90024-1759; Email: ude.alcu.tendem@ztiwolkimd

  

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Trends In Child Sexual Abuse Cases Referred for Forensic Examination in Southern Denmark from 2000 to 2011 - Did The 'Tønder-Case' Have an Impact?

In 2005 a serious case of child sexual abuse from the region of Southern Denmark was revealed to the Danish public. The case became known as the 'Tønder-case'. It was the first in a series of 4-5 serious cases of child maltreatment in Denmark, cases which spurred heavy public debate. 

In this study all the cases of child sexual abuse referred for forensic examination in a 12 year period, a total of 368 cases, were systematically evaluated. In order to identify any trends that could be correlated to an impact of the 'Tønder-case', cases from 2000 to 2002 and cases from 2009 to 2011 underwent an in-depth analysis. In the 12 year period there was a significant increase in numbers of cases. In the subgroups, comprised of 113 cases meeting the inclusion criteria, we found a significant increase in the frequency of cases involving incest and systematic abuse, as well as an uncorrelated increase in the frequency of cases where children were placed in foster care prior to the examination. 

These results were countered by a significant decrease in the number cases police reported child sexual abuse in the same period. The possible impact that cases like the 'Tønder-case' and the following press coverage may have on disclosure and the handling of this type of case by authorities is discussed, as well as further perspectives of extensive press coverage.

Purchase full article at: http://goo.gl/uV3USP

By: Skovmand S1, Astrup BS2.

• 1Institute of Forensic Medicine, University of Southern Denmark, J.B. Winsløwsvej 17, 5000 Odense C, Denmark.
• 2Institute of Forensic Medicine, University of Southern Denmark, J.B. Winsløwsvej 17, 5000 Odense C, Denmark. Electronic address: birgitte@schmidtastrup.dk.

  

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History of Foster Care among Homeless Adults with Mental Illness in Vancouver, British Columbia: A Precursor to Trajectories of Risk

It is well documented that a disproportionate number of homeless adults have childhood histories of foster care placement(s). This study examines the relationship between foster care placement as a predictor of adult substance use disorders (including frequency, severity and type), mental illness, vocational functioning, service use and duration of homelessness among a sample of homeless adults with mental illness. We hypothesize that a history of foster care predicts earlier, more severe and more frequent substance use, multiple mental disorder diagnoses, discontinuous work history, and longer durations of homelessness.

In multivariable regression models, a history of foster care placement independently predicted incomplete high school, duration of homelessness, discontinuous work history, less severe types of mental illness, multiple mental disorders, early initiation of drug and/or alcohol use, and daily drug use.

This is the first Canadian study to investigate the relationship between a history of foster care and current substance use among homeless adults with mental illness, controlling for several other potential confounding factors. It is important to screen homeless youth who exit foster care for substance use, and to provide integrated treatment for concurrent disorders to homeless youth and adults who have both psychiatric and substance use problems.

Read more at:  http://ht.ly/S9PI2 

By: Michelle L Patterson, Akm Moniruzzaman, and Julian M Somers

Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British, Columbia Canada