An Ecological Approach toward the Prevention and Care of Victims of Domestic Minor Sex Trafficking

Abstract

Sex trafficking is a widespread form of human trafficking that exists globally. The forced sexual exploitation of young females for profit at the hands of traffickers is a human rights violation. Sex trafficking is a form of modern-day slavery where youths are sold as a commodity. It is difficult to determine the wide range of negative health outcomes associated with domestic minor sex trafficking due to the hidden nature of the crime and its lack of statistical data to determine prevalence. Viewing domestic minor sex trafficking through an ecological lens, assists in the understanding of the multiple complex interactions between victims, their relationships, and environments that influence their health. Forensic nurses are poised as experts in the healthcare of vulnerable populations and possess the knowledge to understand that social determinants of vulnerability depend on the distinct setting or environment where victims of sex trafficking reside and how different factors affect their victimology, resilience, and wellbeing.

According to the International Labour Office (ILO), approximately 21 million people are victims of human trafficking globally; 14.2 million are exploited for forced labor as compared to 4.5 million who are exploited for sex; more than 55% of victims are women and girls (ILO, 2017). Sex trafficking is the fastest growing form of human trafficking worldwide involving forced sexual exploitation of victims for profit. It is a profitable criminal industry with global earnings between US$ 7-10 billion annually (McClain & Garrity, 2011). Victims of sex trafficking are predominantly women and girls, and to a lesser extent, men, boys, and transgender individuals (Chung & English, 2015; Grace et al, 2012). Sex trafficking is a form of gender-biased crime and a violation of human rights. Jimenez, Jackson, and Deye (2015) noted that the level of social acceptance of the sexualization of children, the lack of response to crimes committed against them, and the existence of groups advocating for child-adult sexual relationships, contributes to the violation of female human rights resulting in damaged physical and mental health of victims.

In the United States, sex trafficking of children and adolescents is known as domestic minor sex trafficking (DMST) – a form of modern-day slavery – where victims are repeatedly traded as sexual commodities. DMST is one of the most hidden crimes of child maltreatment (Greenbaum, 2014; Reid & Jones, 2011). According to the U.S. Department of Justice, 82% of suspected cases between the years 2008 to 2010, were sexual in nature, while 40% of those cases were minors 17 years of age or younger (Banks & Kyckelhahn, 2015). Of this group, racial and ethnic diversity was noted (i.e. 22% White, 21% Hispanic/Latino, 35% Black/African American). The majority were U.S. citizens or permanent U.S. residents and less than 20% were undocumented or qualified aliens (Banks & Kyckelhahn, 2015). The average age of entry to sex trafficking in the United States is 12 to 14 years for girls and younger for boys (Reid, 2010). In 2016, 76% of reported cases of human trafficking in the US involved sex trafficking, 70% of whom were female and 27% minors (National Human Trafficking Hotline [NHTH], 2017).

In this article, we utilize an ecological model as a guiding framework, as we explore the multilevel interactions of the social determinants of vulnerability and identify strategies for prevention and care of victims and survivors of sex trafficking.

Ecological Model

There is no single factor that can explain the spread of human trafficking in the United States, rather, the complex nature of the crime has its roots in the interaction of many factors within the environment. In 2002, the World Health Organization (WHO) developed a report on violence and health that incorporated an ecological model to understand the nature and influences of violence (Krug, Mercy, Dahlberg, & Zwi, 2002). The ecological environment consists of four different levels of systems arranged as a nested structure (i.e. individual, relationship, community, and societal). At the individual level, the child’s own biology and personal history factors increase the likelihood of becoming a victim of crime (Krug et al., 2002). For example, presence of physical or mental disability can alter the interpersonal relationships among family members with the child. The second level, relationship, looks at the individual’s close relationships such as family, friends, teachers, intimate partners, and peers, and explores how these relationships increase the risk of being a victim (Krug et al., 2002). The third level, the community, considers social relationships embedded in neighborhoods and schools, and explores the characteristics of these settings that increase the risk for violence and victimization (Krug et al., 2002). The last level, societal, looks at the broader social and cultural contexts that affect social identities and relationships among individuals, families and communities such as socioeconomic opportunities, racial and ethnic differences and public policies (Krug et al., 2002). Poverty poses severe restrictions to the family’s ability to support the child’s physical, emotional and cognitive development. In essence, the theory allows for the ecological model to be refined in distinguishing four environmental systems that provide a framework of understanding of how an individual interacts and examines the relationships between individuals’ life contexts within communities and the wider society.

Ecological Systems and Risks for DMST

Viewing human trafficking through the lens of an ecological model can shed light on the various influences over a course of life and across historical time such as changes in family structures, socioeconomic status of the environment and employment from a young age toward understanding the multiple complex interactions between victims of sex trafficking and their social environments (McIntyre, 2014). The multi-system model enhances the understanding of victims’ exposure to sex trafficking risk factors, violence, vulnerability, impact of trauma and assault, and resources for their reintegration to society and recovery (Busch-Armendariz, Nsonwu, & Heffron, 2014).

A study on survivors of trafficking and their support providers validated the model’s relevance in coordinating services, understanding trust building methods, developing survivor-centered approaches for reintegration and promoting resilience of victims and survivors (Busch-Armendariz et al., 2014). Victims and their environments were in continuous interaction with each other; these interactions can be understood or ignored because of the complex victimization endured by victims. Each ecological system that victims interacted with offered a strategic position to understand their multiple, complex, immediate and long term needs critical to developing victim-centered policies and services by legal, social and medical providers, and public officials (Busch-Armendariz et al., 2014).

Individual Level Factors

At the individual level, the risks of victimization increase during adolescence, as children transition to young adulthood which is associated with an inner developmental struggle with issues of independence, identity, sexuality, and relationships (Varma, Gillespie, McCracken, & Greenbaum, 2015). Typically, adolescents exercise their independence by challenging authority and occasionally breaking the rules. Parents have decreased direct physical control as adolescents are much more independent and can go to places without adult supervision. Lack of parental supervision compounds an adolescent’s cognitive developmental struggles with identity, self-esteem issues, and inadequate life experiences (Varma et al., 2015; Reid, 2014). Thus, children are at a higher risk just by being children; children and adolescents lack the physical and mental strength to fight traffickers, lack credibility among adults in society, and are readily accessible in communities (Cole & Sprang, 2015; Countryman-Roswurm & Bolin, 2014).

Widespread access to the internet and advertising for sexual services has increased over the years, leading to the growth of DMST among adolescents (Cole & Sprang, 2015; Greenbaum, 2014; McClain & Garrity, 2011). Advertisement of children in the adult section of Backpage, a classified advertising website, has led to an increase in sex trafficking and the commercial sexual exploitation of women and children (Musto, 2013). Additionally, the use of Facebook, chat rooms, Myspace, and other web-based communications among adolescents have increased their vulnerability. Adolescents’ proclivity to internet use makes them easy targets for traffickers who recognize their weaknesses and use emotional strategies to meet their needs for attention and love (Greenbaum, 2014).

Fedina, Williamson, and Perdue (2016) reported that at-risk adolescents in the US were most likely to have experienced higher rates of runaway behaviors, childhood sexual abuse (including rape) prior to being victims of trafficking. Many runaways and homeless adolescents are at risk for “survival sex” as a means to obtain money for food, shelter, and drugs (Varma, et al., 2015). Chohaney’s study (2016) in Ohio found that survival sex increased the odds of minors being victimized. Furthermore, the lack of available support and resources for victims, while attempting to escape, significantly increased the odds of re-victimization. The emotional trauma resulting from performing forced sexual acts has profound, long-lasting adverse effects on the developing brain of the adolescent victim, resulting in heightened levels of fear, dissociative disorders, memory impairments, diminished sense of self, and difficulty in understanding emotions (Reid and Jones (2011).

Gender and minority ethnicity are additional risk factors for DMST. Girls are more likely to be victims than boys (Chung & English, 2015). African American females between 16-18 years are at a higher risk (Hampton & Shade, 2015). African American girls are most likely to be charged with prostitution instead of being treated as victims based on a study of international and domestic risk factors for sex trafficking (Clawson, Dutch, Solomon, & Grace, 2009). The perception that minority young females are not victims, and downgrading the role of race and racism in sexual exploitation, perpetuates sex trafficking among youth and women of color (Butler, 2015).

Relationship Level Factors

A review of the literature on the vulnerability of minors to sex trafficking by Choi (2015) revealed many risk factors at the relationship level,, such as a dysfunctional or unsafe family environment and lack of social support. Lack of familial support among adolescents increases their feelings of being alone without resources (Clawson et al., 2009). Girls with past histories of dysfunctional and troubled families, and/or abuse, concede to the demands by a sex trafficker in hopes of fulfilling their strong emotional needs for belonging and acceptance within a family unit (Reid, Huard & Haskell, 2015).

Coercive peer influences and having family members involved in sex work are significantly associated with DMST (Jimenez et al., 2015). Hargreaves-Cormany and Patterson (2016) found that young female victims were lured into sex trafficking by other juveniles close to their age who they thought were genuine friends. Familial trafficking, or having a family member involved in trafficking, perpetuates the cycle of child physical and sexual abuse, and neglect. Youth often run away to survive in order to escape an abusive environment. Ironically the freedom from this escape increases their risk of being lured by a trafficker for commercial sexual exploitation (Reid et al., 2015). Many of the familial risk factors such as parental substance misuse and domestic or intimate partner violence heightens the risk for family involvement in the child welfare system. Children and adolescents are at a higher risk due to insecure family attachments and lack of a safe home environment (Hargreaves-Cormany & Patterson, 2016).

Community Level Factors

At the community level, poor communities, often made up of single parent families are most disadvantaged because of the lack of police involvement and minimal community capacity to respond to organized criminal networks, and pre-existing adult prostitution markets (Reid & Jones, 2011). Populations experiencing extreme poverty are vulnerable due to their environmental circumstances and familial desperation. They are targeted by traffickers to work in the sex trade in order to pay off debts while experiencing violence and abuse and threats of being reported to the police or immigration authorities (Logan, Walker, & Hunt, 2009).

Broader community influences include the presence of transient adult males within a community and gang membership (Mitchell, Finkelhor, & Wolak, 2010). It is not uncommon for youth to be coerced into sex trafficking as part of an initiation process or to ensure monetary wealth for gang members (Mitchell et al., 2010). Communities with transient adult males such as members of the military, truckers, conventioneers, and tourists were found to be more likely impacted by sex trafficking rings (Miller-Perrin & Wurtele, 2017).

It is not unusual, that school-aged youths are at a high risk of trafficking on school grounds, school events, and even carried out by classmates. Greenbaum (2014) addressed peer trafficking recruitment among adolescents in the school system by a peer youth known as the “popular girl/boy” and/or mature looking. Consequently, some youths attend school while being trafficked, and may exhibit challenging behaviors and diminished academic performance (Grace et al., 2012, Greenbaum 2014).

Societal Level Factors

At the societal level, the social and class roles of women in the global economy result in a power imbalance and contribute to female vulnerability. Globally, women comprise 66% of the workforce but earn much less than men and are forced to work in poorer working conditions. The global poverty rates are higher in women than men, making them a desirable target for human traffickers (Cecchet & Thoburn, 2014). Williamson and Prior (2009) identified poverty as a major risk factor among Midwest adolescent female victims; runaway adolescent victims were lured by traffickers and forced to perform sex for survival because of their inability to meet their basic needs for food, shelter, and transportation. By contrast, (Flowers, 2001) found that girls who were coerced into prostitution in the US came from all socioeconomic and ethnic backgrounds and were not limited to those from impoverished families.

Feminist scholars have described sex trafficking as a form of gender inequality and gender-based discrimination – a form of “sexual colonization” where women and girls are the devalued species (Reid, 2012). Sexualization of children by the media and lack of societal response to crimes committed against children increase the risk for DMST (Jimenez et al., 2015). In some sectors of the US population, a culture of acceptance of prostitution and pimping puts children and adolescents at a higher risk (Orme and Ross-Sheriff, 2015). Erotic dance industries and the media (including magazines, music videos, entertainment and fashion industries) promote tolerance of sexism towards women. Media portrayals of girls being “sexy” as a form of “cuteness” normalizes sexualization of girls in society (Miller-Perrin & Wurtele, 2017). Verbal and physical violence against young females commonly seen in mature-labeled video games, but sold for profit to youngsters, potentiates gender discrimination.

The inability to properly identify DMST victims in health care settings, medical clinics, schools, juvenile justice systems, child welfare services, and detention centers promotes adolescent vulnerability to continued exploitation (Chaffee & English, 2015; Chung & English, 2015; Cole & Sprang, 2015; Salisbury, Dabney, & Russell 2015). Lack of awareness of the problem by public health workers has been attributed to lack of time to assess potential victims due to added workload imposed on their workday and clinical duties. In addition, there is an absence of practices, education, and screening tools for managing the care of victims (Chung & English, 2015).

Konstantopoulos et al., (2013) found that participants from eight urban cities described their local health system responses as inadequate and characterized by long waiting times, restricted hours of operation, and lack of culturally sensitive services. These resulted in inadequate health care and inability to identify the physical and mental health needs of victims. Although healthcare professionals in urban communities were more exposed and aware of DMST victims, there is lack of collaboration among agencies preventing victims from receiving the needed services (Cole & Sprang, 2015). Unfortunately, rural health professionals often associate sex trafficking as a problem only for urban communities. Other factors related to health professionals’ lack of knowledge and inadequate care for victims are varied. These include lack of DMST education in professional schools, scarcity of trafficking training programs for practicing health workers, and lack of linear referral mechanisms to social services (Cole & Sprang, 2015).

Discrimination is another factor that affects adolescent victims of sex trafficking. Some victims refrain from seeking care due to fear of biased treatment by health care providers, law enforcement, and social services, especially among those with substance misuse problems and co-occurrence of emotional and behavioral problems (Clawson et al., (2009). The stigma and shame associated with sexual trafficking prevents victims from accessing health services because of the anticipated negative responses from health care providers (Hopper & Hidalgo, 2006). Emergency room healthcare providers often describe victims of DMST as “frequent fliers” for sexually transmitted infections (STIs) treatment or “troubled teens” (Reid, 2010). Bias in healthcare organizations towards poor women, girls and specific communities heightens the perceived inequality in healthcare delivery by victims (Reid, 2010).

Governmental policies greatly impact the care and accessibility of services for DMST victims and survivors. At the federal level, the Trafficking Victims Protection Act (TVPA) (2000), is arguably the most important anti-trafficking law ever passed. Specifically, “any person under age 18 who performs a commercial sex act is considered a victim of human trafficking, regardless of whether force, fraud, or coercion was present” (TVPA, 2000). Therefore, force, fraud, and coercion does not need to be proven when children under 18 years of age performing a commercial sex act; as victims of human trafficking they must be protected. The TVPA and its subsequent reauthorizations clarified the definition of a human trafficking victim, over 18 years of age, as a person induced to perform labor or a commercial sex act through proven force, fraud, or coercion. In 2013, TVPA expanded the federal criminal code to include prohibition against foreign travel and engagement in illicit sexual conduct by a US citizen. It implemented provisions within the State Department to respond to disaster areas and/or crises and reinforced collaboration with state and local enforcement agencies to facilitate arraignment and prosecution of traffickers (U.S. Department of State, 2017).

At the state level, Safe Harbor Laws were promulgated to address the discrepancies in the treatment of children exploited for commercial sex at the state level by providing legal protection of victims from prosecution for offenses such as prostitution based on the understanding that a child may have been coerced or forced to commit an offense (Shields & Letourneau, 2015). Therefore, additional criminal charges incurred during captivity are dropped after victims and survivors complete a safe diversion program. Safe Harbor Laws also require that well-developed services be made available to victims and survivors, including medical and psychological treatment, emergency and long-term housing, education assistance, job training, language assistance and legal services (Polaris, 2015). Currently, thirty-four states have passed Safe Harbor Laws, but each state differs significantly on how they implement the law. These variations include whether victims’ records are expunged, or victims are given immunity from prosecution, types of victim assistance offered, transfers from the juvenile justice system to child protection agencies, and utilization of custodial arrest or temporary protective custody (Fedina et al., 2016). Statewide differences significantly impact the way victims are treated and cared for.

Ecological Approaches to DMST Prevention and Care of Victims

Child survivors and victims of sex trafficking are in need of support plans based on a comprehensive ecological system approach to provide the necessary support and services pre, during, and post-exploitation (Cecchet & Thoburn, 2014; McIntyre, 2014). The ecological model provides a multilayered level of approach to simultaneously address DMST across several different levels to promote an action plan for the healing and recovery of victims. Forensic nurses can play a significant role at various levels. Forensic nurses can promote trust and empowerment, build self-esteem, coping, and adaptation capabilities of victims and survivors (McIntyre, 2014). Nurses can collaborate with community-based teams and participate in interagency task forces and technical working groups as experts, educators, and trainers of multidisciplinary team members on the physical, mental, social and spiritual health of victims. It is through the collaboration among interdisciplinary team members, adopting a victim-centered approach, that treatment and understanding of the individual victim will be promoted. Nurses can also participate in research to enhance understanding of health outcomes and test effective nursing care approaches and strategies (Dovydaitis, 2010; Sabella, 2011). Forensic nurses possess expertise regarding the environments surrounding nursing practice, forensic science, and the law to address holistically the needs of human trafficking victims through an ecological approach, and are uniquely positioned to affect positive change across healthcare practices relating to persons ensnared in human trafficking environments (Sanchez & Stark, 2014).

Interventions at the Individual Level

Forensic nurses can lead in the care of sex trafficking minors at the individual level by developing an efficient plan of care to include trauma-informed care principles that acknowledges each victim’s unique trauma (Cecchet & Thoburn, 2014) inclusive of social, mental, and physical health services. This can be accomplished by providing a comprehensive individualized medical assessment and treatment (e.g. nutritional, dermal, dental, gynecological and infectious problems) (Cole & Sprang, 2015; Kalergis, 2009). In addition, mental health care plans are critical for victims’ recovery because many suffer from post-traumatic stress disorder, depression, anxiety, and are at high risk for suicidality (Greenbaum, Dodd, & McCracken, 2015). Programs should include an assessment of the victim’s developmental level and provide skill building such as self-esteem programs, education, and job skills (Clawson & Goldblatt Grace, 2007). According to Cecchet and Thoburn (2014), the severity of trauma experienced by survivors is influenced by the length of victimization. Newby and McGuinness (2012) report that victims of severe trauma described their experience as a form of numbness and detachment from others. Knowing their life events, such as entry to and length of victimization, can provide critical insights into the psychological effects of sex trafficking. This knowledge is critical to the development and promotion of an individualized approach to care including resilience and recovery strategies (Cole, Sprang, Lee, & Cohen, 2016). Also, implementing existing screening tools such as the “Trafficking Victim Identification Tool” for the assessment and identification of victims, depends on the forensic nurse’s ability to sensitively build trust and rapport with victims, recognizing their fears, and the trauma they likely have endured, before trying to acquire facts about trafficking crimes and/or their long-term needs (Simich, 2014). Prevention should be aimed at addressing individual risk factors and taking steps to modify service programs and promote awareness. Trauma informed care principles should be promoted in primary care clinics, emergency rooms and other health care organizations where forensic nurses practice.

Interventions at the Relationship Level

At the relationship level, nurses should foster positive family and peer networks as part of the care of victims. In a study by Pierce (2012), survivors often identified the lack of a caring adult within their family as a strong indicator for being trafficked (Pierce, 2012). Supportive peer networks within school and neighborhoods, particularly in high crime areas, offer significant protection for children and adolescents. Forensic nurses can provide supportive educational programs for families, schools, and communities focusing on nourishing family relationships, healthy sources of social support, safety, and resources to assist with stability of housing conditions, as ways of helping to reduce risk factors (Cecchet & Thoburn, 2014). Prevention should be aimed at developing connections with service providers that provide help and support for troubled and dysfunctional families, and additionally, implementing educational programs to bring awareness of the need for strong family relationships for safer behaviors and protection against human trafficking.

Interventions at the Community Level

At the societal level, forensic nurses can bring awareness to school boards, municipal and county stakeholders, and neighborhoods about human trafficking and assist them in developing protocols to monitor their community and how to take steps to address problems such as local homelessness and violence. A study by Covenant House (2013) found that 48% of the youth engage in sexual activity in return for a place to stay out of the streets. Unfortunately, there is a severe shortage of crisis shelters. A study by Clawson and Goldblatt Grace (2007) on housing placement of female victims after rescue, found minimal numbers of residential treatment centers, child protective services-funded group homes, foster care placements, and juvenile corrections facilities. A U.S. survey found a total of 2,173 available shelter beds for human trafficking victims (Polaris Project, 2012). Therefore, they can develop a list of service providers such as churches, shelters, and non-profit organizations that are supporters of the anti-trafficking efforts and offer services within their own unique community. Prevention at the societal level needs to bring awareness of residential housing with comprehensive supportive services such as medical, mental health, substance abuse, counseling, and positive skill-building tailored to the specific needs of victims that can enhance their reintegration in the community and promote healing, recovery, and resilience. Residential facilities should provide victims with a place to call home (Clawson & Goldblatt, 2007).

Interventions at the Societal Level

At the societal level, nurses can participate in developing a comprehensive supportive infrastructure to address local and state policies using an interprofessional platform. They can develop educational programs about all levels affecting DMST victims with stakeholders, law enforcement, and social service providers. Nurses can initiate or participate in evaluating policies and initiatives already in place and unravel the complex interplay of multiple influences of family, community, and society on children and adolescents. Understanding these connections can lead to dynamic assessment practices and effective responses for victims and survivors. Effectiveness of laws and policies to protect children and victims/survivors should be considered such as the age change in the Safe Harbor Laws from 15 to 18 (Connor, 2016). Prevention should be aimed in addressing the larger cultural, social, and economic factors that contribute to DMST. For example, the variations of the Safe Harbor Laws across states still pose a problem in addressing the assessment procedures, treatment, and interventions of DMST victims that often lead to inconsistent and inadequate protection and supportive service for victims. Another area can be policy awareness. Forensic nurses can lead in prevention by writing petitions to their congress representative to support bills and acts that promote anti-trafficking efforts. In addition, the initiation of research collaboration with other disciplines can support a change and/or development of anti-trafficking policies at a national level.

Conclusion

The systems based ecological model, fosters an in-depth understanding of the physical, psychological, social, and spiritual consequences of victimization, healing and reintegration in the context of one’s life experience and relationships with the social environment. While progress has been made, more work is needed to ensure that victim services are rigorously and consistently implemented. Understanding the social determinants of vulnerability of DMST victims can provide the forensic nurse provider a framework for innovative approaches to address its root causes through a social ecological model. It is with this understanding that when assessing the social determinants of vulnerability, the practitioner and/or researcher must consider the distinctive environments and/or settings affected by sex trafficking. Forensic nurses can be the pioneers in the implementation of protocols, education, and policies grounded on trauma-based principles addressing each level of the social ecological model. The goal is to meet the needs of DMST victims across several different levels at the same time and support their resilience abilities. Future goals are to have forensic nurses expand their practice by being the leaders on the field of human trafficking prevention.