Safe-Guarding Youth from Online Sexual Exploitation in the Digital Era: A Role for Primary Care

Abstract

Online child sexual exploitation refers to the use of technology to sexually exploit or harm a person under age 18. In 2020, over 21.7 million reports of online child sexual enticement were filed with law enforcement, highlighting the alarming prevalence of this form of exploitation. This phenomenon has become increasingly prevalent in recent years due increased household internet access to the internet, the increased use of smartphones among children and teens, and the rapid expansion of new technological platforms such as live-streaming and gaming. Despite its risk and prevalence, this form of sexual abuse against children is largely underrepresented in the medical literature, with no formal screening or reporting guidelines for primary care physicians. This paper aims to define online child sexual exploitation, explore its health impacts, identify associated risk factors, and emphasize the pivotal role of primary care physicians in screening and counseling youth. By shedding light on this issue, we strive to address the critical need for safe-guarding the well-being of children and adolescents in an increasingly digital age.

“Preventive health visits provide an ideal opportunity for screening and educating youth and their families on a variety of health topics, including online safety.”

Introduction

According to the National Center for Missing and Exploited Children, online child sexual exploitation (OCSE) is defined as the use of technology as means to sexually manipulate or harm a minor (person <18 years).^1,2 The impact of technological advancements and the increased risk of harm to youth online is profound. Globally, millions of videos and images depicting children being sexually abused and exploited are uploaded everyday. ³ In the United States, the National Center for Missing and Exploited Children (NCMEC) CyberTipline, the nation’s centralized reporting agency for sexual exploitation of children, shows the number of reported online enticements toward minors has increased steadily year-by-year since 2008, and increased 97.5% in 2020 relative to 2019. ⁴ In 2016, there were 8 million cases of online sexual enticement, which increased to 18 million in 2018. By 2020, this number surged to 21.7 million—the highest number of reports received in a single year. Additionally, around 17 000 reports of child sex trafficking were made in 2020, highlighting how traffickers are increasingly utilizing social media and gaming platforms to target child victims. ⁵

Online Child Sexual Exploitation and Primary Care

The rising prevalence of OCSE emphasizes how crucial it is to educate children and their caregivers about safe use of the internet. As health educators and informed points of contact, physicians are well-suited to discuss online risks and prevention strategies with pediatric patients and their families. Counseling on internet safety exemplifies the anticipatory guidance that is a pillar of primary care practice and is provided on other preventative medicine topics like seat belt and helmet use, safe sex practices, or the dangers of secondhand smoke. Family medicine physicians and pediatricians could be crucial agents in the prevention of adverse childhood experiences, such as sexual violence in the online environment, minimizing both the short-term and long-term mental and physical health consequences of these events.^6,7 However, training guidelines for physicians who deliver primary care to children and adolescents have failed to incorporate the various forms of online sexual exploitation in their curricula. This gap in training limits the collective understanding of this type of sexual abuse and leaves primary care physicians ill-equipped with the knowledge and tools to increase awareness of, prevent, and ultimately mitigate sexual exploitation of pediatric and adolescent patients online.

Previous research on sexual exploitation of minors online has largely focused on mitigation strategies for law enforcement,^8-11 guidance for the judiciary system, ¹¹ development of trauma-informed care guidelines for mental health providers, ¹² and education and prevention strategies for the public education system. ^{13 – 16} Early research from the Crimes Against Children Research Center at the University of New Hampshire emphasized that pediatric health professionals should become knowledgeable of this form of harm to children online and comfortable with providing advice to caregivers. ¹⁷ Guidelines informing primary care clinicians on ways to combat this issue is derived from studies that predate the launch of the smartphone, social media platforms, ¹⁸ and the rise in popularity of applications such as TikTok or Snapchat in 2016. ¹⁹ This gap in the literature base has left clinicians without standardized evidenced-based medical guidelines that assess for this form of sexual abuse in their pediatric population and provide advisement in the context of new technology.

This paper serves as an educational primer, describing OCSE and its risks among pediatric and adolescent patients, with the goal of increasing awareness of OCSE prevention among primary care clinicians. Specifically, we define the types of OCSE, discuss risk factors for OCSE, and discuss the role primary care providers can have in screening for OCSE risk and delivering advice on internet safety to patients and their caregivers.

Youth and the Internet

Electronic technology and online activities have become an important part of youth culture, with more children and teens accessing the internet than ever before.^1,20 Globally, children and adolescents account for one third of internet users, ²¹ with number of children with internet access and the amount of time spent in the virtual space. ²² In the United States, 8–12-year-olds consume just under 5 hours of screen media entertainment per day, with 13–18 year olds averaging just under 7.5 hours. ²³ By age eleven, over 50% of youths have their own smartphone, a proportion that increases to ∼70% of adolescents by age 12. ²³ With near ubiquitous uptake of smartphones among teens, 45% of youths report being online “almost constantly.” ²⁴ Live video chatting in particular, wherein unmoderated videos happen live and can be recorded, saved and reposted, rose from 7% to 18% of all screen media in teenagers from 2015 to 2018. ²³ The rise in youth online presence and utilization was magnified by the COVID-19 pandemic. While internet use allowed for virtual education, entertainment, and peer-to-peer socialization it also presented unique risks never encountered by previous generations.^25,26 New social platforms become available every day; however, there is a critical lag-time between the roll-out of new platforms and safety measures. ²⁷ Despite caregiver concern, this discrepancy provides an opportunity for online predators to gain access to and harm youths online.

Types of Online Child Sexual Exploitation (OCSE)

OCSE includes a variety of sexual acts or interactions between an online predator and a child in a virtual setting. These may include grooming, catfishing, live video streaming, consuming child sexual abuse material (CSAM), and coercing or blackmailing children for sexual purposes (sextortion) (Table 1).

Table 1.

Online Sexual Exploitation of Children and Teens.

Type	Description	Examples
Grooming	6-stage process by which offender develops a relationship with a minor online to enable sexual exploitation to occur	1. Identify target, 2. Gather information, 3. Gain access, 4. Fill emotional/physical needs, 5. Lower inhibitions, 6. Gain/maintain control
Catfishing	Offender creates a fake online identity, posing as same-age peer. Peer pressure and normalization are used to coerce minor into sending or viewing indecent pictures and videos, possibly meeting in person	Loop recorders, scripts, and coercing 1 child to victimize another
Sextortion	Offender blackmails a minor with an indecent photo or video to acquire more sexual content, engage in sex, or obtain money	Develop a romantic relationship, threaten to create sexual videos or images using editing tools, pose as modeling agency
Live video streaming	Surreptitiously recorded live videos online that are not moderated, therefore, subject to explicit, illegal, or disturbing content	Children are enticed to undress, expose themselves on camera, engage in sexually explicit or self-harm activities
Child sex abuse material‡	Images and videos of a minor being exploited and/or abused. Re-victimization occurs each time an image is viewed or shared	Production, possession, distribution, and advertising
Child sex trafficking	A minor is bought or sold for sexual purposes. Traffickers are most often adults who first target children online	Children engage in sex for basic needs (food, shelter, safety, and money)

‡_e.g. “child pornography” in the legal system.

Grooming refers to the process by which an offender develops a relationship with the child to enable a sexual relationship to occur, and involves 6 well-defined stages. ²⁸ Catfishing involves an online offender creating a fake identity to enable the grooming process to occur. The minor is led to believe the predator is a same-age peer. ²⁹ Grooming and catfishing require considerable access and interpersonal skill on the part of the predator.

Sextortion involves the use of nonphysical forms of coercion to acquire more sexual content, engage in sexual acts, or obtain money from a minor. ³⁰ An estimated 5% of 12- to 17-year-olds in the United States have been victimized online by sextortion.

Live Video Streaming is a newer method of online sexual exploitation. Live Video Streaming involves real-time recording and broadcasting of child sexual abuse to viewers who are either passively watching or actively communicating with the child and the abuser. CSAM refers to all images or videos of a minor being sexually exploited or abused. Production and access to CSAM has increased, with this material found on social media, live-streaming, gaming, and email. ³¹

Risk Factors for Online Child Sexual Exploitation

All children are at risk of sexual exploitation on the internet. Existing data from NCMEC’s Victim Identification Program ³² and Interpol’s Global Tracking System ³³ note the majority of youths depicted in child sexual abuse material are prepubescent. Female gender increases risk of being sexually exploited online.^4,34-37 Girls account for 78% of youths targeted for sexual enticement online and the o majority in CSAM.^2,4

However, boys and very young children are at greatest risk of the most severe online sexual abuse according to data published by INTERPOL. This includes infants and toddlers as victims of extreme sexual assault. ³³ In these instances, male victims tend to be younger than females, and less likely to have reached puberty. Child victims are from every type of community and socio demographic background, ³³ but children without strong social support networks, being victims of bullying, or experiencing homeless are at even higher risk. ⁵ Runaway or homeless children are at an increased risk of sexual exploitation, both online and offline, ³¹ as are children who self-identify as lesbian, gay, bisexual, or transgender.^35,38

Internet use patterns among minors can also confer substantial risk. Interacting with unknown people online raises risk, ³⁴ as 98% of reported sexual enticement offenders in the NCMEC database are unknown to the child offline. ⁴ Unmonitored use of the internet in private spaces, especially live-streaming and social media applications, represents another important risk factor. ³⁶ As such, the American Academy of Pediatrics recommends prohibiting use of internet-connected devices in the child’s bedroom. ²⁵ Expert opinion by law enforcement confirms that increased time spent on the internet, ²⁴ and an increasing number of platforms and applications used by youth further increases the likelihood of being targeted and victimized.

The Prevention Role for Primary Care

According to the National Center for Health Statistics, 95.6% of children under age 18 had a doctor visit in 2019, ³⁹ creating an important opportunity for prevention work. Preventive health visits provide an ideal opportunity for screening and educating youth and their families on a variety of health topics, including online safety.

Health Implications

Like other forms of sexual abuse, online sexual abuse can harm victims and their families emotionally and physically for a lifetime. Unlike other forms, however, the child can be re-victimized millions of times, every time an image is watched, sent or received. Thus, OCSE should be considered an important adverse childhood experience (ACE) with potential detrimental impact on lifespan wellness through maladaptive health behaviors and negative health outcomes similar to those reported for well-defined ACEs, including sexual abuse.

Educational Action for Clinicians

Despite limitations in the evidence base, primary care clinicians can use currently available knowledge in their practice to increase awareness of OCSE and promote safety online. Similar to harm reduction models proposed for counseling youths and families about social media use and mental health, ⁴⁰ clinicians should advise reducing the amount of time spent engaging with social media or live-streaming applications. Less time engaging with social media directly reduces the opportunity of being targeted online. Current guidelines published by the American Academy of Pediatrics for screen media use in this age group recommend families “establish consistent limits on the time spent using media and the types of media,” with an overall recommendation of less than 2 hours of entertainment screen media per day. ²⁵ Other tactics include limiting the number of applications used by the child, enforcing parental controls, and enhancing privacy settings. Families can be directed to instructional videos created by Common Sense Media to learn how such controls are put into place. ⁴¹ Clinicians should advise that use of all internet-connected devices be prohibited in private spaces of the home, such as the bedroom, in order to maximize caregiver oversight of the child’s activities online. ²⁵ (Table 2).

Table 2.

Guidance for Keeping Children Safe Online.

Advice for Caregivers	Introduce children to smart devices and media platforms slowly
	Limit the number of applications installed. Pick 1 or 2 and understand how they work
	Establish house rules: No device use in the bedroom or bathroom
	Limit time spent on entertainment screen media, preferably under 2 hours
	Use “friending” and “mirroring”
	Use build-in device restrictions and parental controls
	Use iPhone and Android caregiver controls
Advice for youth	Only “friend” people you know in person
	Never arrange to meet a virtual friend in real life without first discussing it with a trusted adult
	Limit information shared (full name, date of birth, phone number, address, or school should not be shared)
	Keep your information and passwords private
	Use privacy settings
	Trust your “gut instinct”
	Don’t give in to pressure
	Don’t share sensitive or sexually explicit images
	It is never too late to say “STOP” and ask for help
	There are many ways to report content that makes you feel uneasy‡

‡_Report anonymously at https://www.missingkids.org/gethelpnow/cybertipline or 1-800-THE-LOST or any local township, county, or state agency.

Screening for OCSE

Similar to other preventive health topics subject to routine screening at the pediatric and adolescent well-visit, such as problematic internet use in adolescents ⁴² or depression screening beginning at age 12, ⁴³ screening for OCSE should be added to the toolkit. Primary care providers should be encouraged to briefly screen for OCSE that may have occurred or is occurring at the time of the pediatric well-child encounter. One challenge facing primary care clinicians is the fact that a validated screening tool has yet to be published. Table 3 presents a sample 4-question screener developed by the authors in conjunction with expert opinion. Affirmative responses should be reported as mandated by state laws, and the provider should connect the exploited child to appropriate counseling services and follow-up care.^44-49

Table 3.

Sample Screening Questions for Online Child Sexual Abuse.

Have you ever been asked to send/share nude or indecent pictures/videos of yourself online?

Has anyone ever sent you a nude or indecent picture or video online?

Has anyone ever threatened you online?

Do you know how to anonymously report someone online? ‡

‡_See footnote in Table 2, methods for reporting by patients/caregivers. Mandated reporters must report positive responses (questions 1-3) according to state laws.

Conclusion and Next Steps

The recent rise of email, social media, online messaging, online gaming, and video streaming apps mirrors the increase in reported and confirmed cases of sexual exploitation of children and adolescents online. As internet access and use continues to increase in our pediatric patients we must remain wary of the opportunities for online child sexual exploitation. During the COVID-19 pandemic, the shift to a more virtual world increased child internet use, limited online safety monitoring, and reduced children’s access to trusted adults who are often key in identifying and reporting abuse. We must increase awareness and generate preventative solution to the threat of OSCE.

Primary care providers are important practitioners of preventive action, education, and advocacy across the lifespan, and can play a vital role in protecting children and teens from this relatively new threat. The first step to stopping OCSE is to understand what it is, who it impacts, and how to be safer online. Experts at fostering trusted patient–provider relationships, primary care clinicians are well-suited to screen for online sexual abuse and provide counseling to youths and their caregivers on ways to reduce risk during pediatric health encounters.

Appendix.

Abbreviations

OCSE

(Online Child Sexual Exploitation)

NCMEC

(National Center for Missing and Exploited Children

CSAM

(Child Sexual Abuse Material)

ACE

(Adverse Childhood Experience)

ORCID iDs

Allison R. Casola https://orcid.org/0000-0001-7836-3774

Olivia Rea https://orcid.org/0000-0003-2406-0844