COVID-19 and Youth Who Have Experienced Commercial Sexual Exploitation: A Role for Child Mental Health Professionals During and in the Aftermath of a Pandemic

Abstract

The COVID-19 pandemic has exacerbated some of the most pressing social problems and structural inequities, with a disproportionate impact on some of the most vulnerable youth. The goal of this article is to raise awareness among child mental health professionals of the ways in which the pandemic has likely exacerbated the commercial sexual exploitation of children in the United States. A second goal is to promote child mental health professionals’ ability to identify and care for these resilient yet underresourced youth.

The COVID-19 pandemic has exacerbated some of the most pressing social problems and structural inequities, with a disproportionate impact on some of the most vulnerable youth. The goal of this article is to raise awareness among child mental health professionals of the ways in which the pandemic has likely exacerbated the commercial sexual exploitation of children in the United States. A second goal is to promote child mental health professionals’ ability to identify and care for these resilient yet underresourced youth.

The commercial sexual exploitation of children (CSEC) encompasses sex trafficking and a broad range of sexual crimes committed against children, including commercial sex acts, prostitution, child pornography, and “survival sex” to earn food, shelter, or basic necessities.¹ to highlight the resilience and agency of youth who have experienced CSEC, we will use the term “CSEC survivor” in this paper. Although young CSEC survivors rarely self-identify or independently seek mental health treatment, they are at greater risk for mental health symptoms and commonly come to the attention of child mental health professionals in hospitals, juvenile justice settings, and foster care systems.²

Background

Around the world, the impact of stay-at-home orders, suspensions in services, and other changes related to the pandemic on economic conditions, housing, employment, and other social determinants of health may have amplified risk factors for CSEC.^{3 , 4} A robust ecological framework is needed to understand the risk factors for CSEC, which exist on individual, family, and community levels.⁵ The pandemic has led to a rise in job losses, homelessness, and food insecurity, which have compounded pre-existing structural inequities in underresourced communities of color and immigrant communities. Closures of schools, clubs, and other activities left many youth isolated from their support networks. Because of challenges, some youth experienced new-onset problems with anxiety, depression, externalizing behaviors, suicidality, and trauma-related symptoms, and a worsening of existing mental health conditions. Loss of a loved one, economic strain, and poverty may lead to family stress, and possibly child abuse, maltreatment, and domestic violence.⁶

Increased poverty and need due to the pandemic may render already vulnerable youth even more likely to fall prey to traffickers, who commonly provide money, gifts, and the promise of a “better” life.³ In addition, the loneliness and heightened mental health struggles that some youth have experienced during the pandemic may have rendered them even more susceptible to a trafficker’s grooming tactics, such as compliments and promises of love. At the same time, isolation may have left some youth at greater risk for victimization. Youth began living more of their lives online through virtual school, gaming apps, and social media, and often were unsupervised. Consequently, increased reports of online sex trafficking suggest that traffickers and predators found easier, more convenient access to them. In 2020, reports to the National Center for Missing and Exploited Children’s CyberTipline increased by 28% to more than 21.7 million.⁷ After the implementation of stay-at-home orders, reports of online situations of sex trafficking increased by more than 45%.⁸ However, it is important to note that this information on correlations between CSEC and factors associated with the pandemic comes from advocacy organizations, as there are no peer-reviewed data or other definitive evidence available on this topic.

These increased online reports of CSEC were accompanied by a decreased opportunity to identify and support CSEC survivors.³ Prior to the pandemic, CSEC survivors were often identified while seeking care for sexually transmitted infections, injuries, or other acute concerns in emergency departments and hospitals.³ During the pandemic, clinic closures, increased wait times for appointments, “pauses” in routine medical care, and worries about contracting the virus in health care settings led to a decrease in CSEC survivors presenting to health care practitioners.^{3 , 4} Moreover, reductions in legal, education, and employment supports compromised the ability of CSEC survivors to receive the comprehensive, collaborative services that they need.^{3 , 4} Telehealth services may not be optimal to fill this void.³ CSEC survivors might lack the requisite devices, Internet connection, or technological literacy needed to successfully participate in tele-services. Moreover, individuals still in trafficking situations often lack private space, or may fear their trafficker “listening in” on their televisits^{. 4}

Practice Recommendations

Child mental health professionals working in emergency, residential, juvenile justice, welfare, and community settings are uniquely positioned to help identify CSEC survivors and to intervene.² Child mental health professionals should recognize “red flags,” such as highly sexualized behavior or dress, running away, substance use, an abnormal number of sexually transmitted infections or sexual partners for a young age, and certain online behaviors, such as “sexting” or viewing pornography.^{2 , 5}

If child mental health professionals suspect that a youth has been experiencing CSE, they should first be mindful of their ethical professional responsibility to youth—“do no harm.” The privacy of youth should be respected, and, in general, information regarding their trafficking situation should not be disclosed without their consent. They should be aware of the mandated reporting duties in their jurisdiction, and review with youth the associated limits to confidentiality.⁵ Depending on local laws, protocols, practices, and culture around youth with CSE histories, a report to child protective services could lead to unintended consequences, including juvenile justice involvement or even Immigration and Customs Enforcement removal for undocumented youth. Many states currently have “Safe Harbor” laws that decriminalize sex trafficking and CSEC, divert these cases from juvenile justice to child protection, and provide additional protections and services to CSEC survivors.⁹

It is important to use a systemic, multidisciplinary approach and build relationships with other local professionals working with exploited children, including social and legal service providers and human trafficking task forces, as integrated collaborative care is key to effectively helping CSEC survivors and ensuring that their best interests are being served.^{2 , 5} As the pandemic may have compromised a youth’s support networks and social connections, it may be necessary to help youth re-establish networks or find other supports to reduce isolation. To address the social determinants of health, child mental health professionals should familiarize themselves with local community agencies that provide housing, food, immigration services, and other basic necessities. For assistance in addressing concerns for CSEC among patients, clinicians can consult the following resources:

• •National trafficking organizations, such as the National Human Trafficking Resource Center Hotline (1-888-3737), HEAL Trafficking (healtrafficking.org), Polaris Project (www.polarisproject.org), Shared Hope International (sharedhope.org), or National Center for Missing and Exploited Children (www.missingkids.org)
• •Resources from the American Academy of Pediatrics, such as the clinical report “Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims” (2015), or the policy statement “Global Human Trafficking and Child Victimization” (2017)
• •Practice Guideline by the American Professional Society on the Abuse of Children, “The Commercial Sexual Exploitation of Children: The Medical Provider’s Role in Identification, Assessment and Treatment” (2013)
• •SOAR Human Trafficking Trainings for Health Professionals from the National Human Trafficking Training and Technical Assistance Center (nhttac.acf.hhs.gov/soar/soar-for-individuals/soar-online)

When engaging with CSEC survivors, child mental health professionals should take a trauma-informed approach that prioritizes safety and seeks to foster a sense of agency, choice, and empowerment.^{2 , 5} They should be mindful of aspects of the interview that might lead to re-traumatization, and take care to avoid nonverbal communication that might convey shock, pity, or disgust. It is important to note that these youth are often engaged in “adult” activities and may be suspicious of services designated for children, decline services, or resent being categorized as “victims.” There are frameworks that stem from the lived experiences of CSEC survivors that detail how they wish to be treated by health professionals and to obtain care, such as the “fierce autonomy” model.¹⁰

Given the psychological coercion that is often at play in trafficking situations, many CSEC survivors have difficulty “breaking free” of their “invisible chains.”¹¹ In such cases, child mental health professionals should keep in mind that their goal is to enhance safety, not to “rescue” youth or “investigate” their cases. Child mental health professionals might consider taking a harm reduction approach, using shared decision making to promote autonomy, and engaging the youth in safety planning—especially online safety planning.¹⁰

Reports suggest that CSEC survivors have been disproportionately burdened by conditions related to the pandemic,⁴ compounding their pre-existing vulnerability due to economic, housing, and other structural stressors, and likely escalating their mental health needs as well. The pandemic has highlighted and accelerated risk factors for CSEC in our society, and these vulnerabilities are likely to persist into the future. The potential increased prevalence of CSEC,^{7 , 8} increased online recruitment, and increased barriers to identification of and services for CSEC survivors may linger as well. Given the nature of their training and skill set, child mental health professionals may be particularly well equipped to help youth to feel empowered to make safe and healthy choices. For example, they should encourage youth to access health care for birth control, sexually transmitted infections, injuries, and other reproductive and physical needs. They can and should consider routinely engaging youth in discussions of their online activities, body safety, and boundaries. They might also provide psychoeducation to youth on recognizing grooming tactics, recruitment strategies, and other hallmarks of sexual predation.⁵ Education on these skills and CSEC should be included in the training of child mental health professionals.

Importantly, child mental health professionals should seek to mitigate the increase in CSEC upstream on a structural and community level. They should consider advocating for economic and income stabilization, employment protections, continued eviction moratoriums, supports for LGBTQ youth, and resources to stabilize families and prevent child maltreatment, running away, and substance use. They might also inform policies to enhance the safety of the most structurally vulnerable youth. As we continue to navigate the pandemic and its aftermath, it is critical that child and adolescent psychiatrists help identify, support, care for, and advocate for CSEC survivors.