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. Author manuscript; available in PMC: 2022 May 11.
Published in final edited form as: Int J Inj Contr Saf Promot. 2021 Dec 19;29(1):86–92. doi: 10.1080/17457300.2021.2004430

The relationship between commercial sexual exploitation of children (CSEC) and childhood sexual abuse (CSA) among boys and girls in Haiti

Jay G Silverman a, Sabrina C Boyce a, Ruvani W Fonseka a, Daniel Triplett a, Laura F Chiang b, Sharon S Caslin b, Anita Raj a
PMCID: PMC9090956  NIHMSID: NIHMS1789831  PMID: 34923923

Abstract

To test the hypothesis that childhood sexual abuse (CSA) is a risk factor for commercial sexual exploitation of children (CSEC), we analysed data from the Haiti Violence against Children Survey (VACS), a population-based sample of adolescents and young adults ages 13–24 (1459 males and 1457 females). Twenty-one percent of males and 25% of females reported CSA; 6% of males and 4% of females reported CSEC. The adjusted odds ratios (AORs) for CSEC based on exposure to CSA were 5.6 (95% confidence interval/CI: 3.1–10.2) for males and 5.9 (CI: 2.6–13.0) for females. For each year earlier that males first experienced CSA, the odds of CSEC increased 60% (AOR 1.6, CI 1.2–2.0). in this first nationally-representative study of lifetime CSEC, both boys and girls victimised by CSA in haiti were more likely to have also experienced CSEC than other youth, with children who experienced CSA at younger ages at the greatest risk.

Keywords: Adolescents, Haiti, child sexual abuse (CSA), commercial sexual exploitation of children (CSEC), internally displaced personse (IDP) camps

Commercial Sexual Exploitation of Children (CSEC) is defined by the International Labour Organization (ILO) as the sexual exploitation by an adult of a child or adolescent under 18 years old, accompanied by a payment in money or in kind to the child or adolescent or to one or more third parties (International Programme on the Elimination of Child Labour (IPEC), 2007). It has been linked to multiple poor health outcomes and increased risk of violence (Goldenberg et al., 2012; Parcesepe et al., 2016; Silverman et al., 2015). Despite its relevance as a public health and human rights concern, there remains a lack of population-based prevalence estimates of CSEC. It is imperative for researchers to understand the risk factors for CSEC in order to prevent more children from experiencing CSEC and its related health outcomes.

In order to reduce the likelihood of CSEC, it is important to understand what factors are most likely to increase children’s vulnerability to sexual exploitation. Studies from Mexico suggest child abuse and economic instability are risk factors for CSEC (Boyce et al., 2018; Rocha-Jimenez et al., 2018; Servin et al., 2015). In a study conducted in seven countries in Europe, experiencing physical or sexual violence, primarily by a father or step-father, seems to increase the risk of children being sexually exploited (Zimmerman et al., 2008). In the United States and Canada, sexual violence and adolescent pregnancy have been identified as risk factors for CSEC (Ahrens et al., 2012; Smith et al., 2009). Multiple studies in various international settings have also identified displacement and living in internally displaced persons camps as risk factors for CSA and CSEC, separately, but rarely have they been considered together (Catani et al., 2010; Centers for Disease Control & Prevention, 2014; McAlpine et al., 2016).

Most studies of CSEC have focused on non-population based samples, with mainly female participants. There is still a critical need to identify at the population level the most relevant modifiable risk factors for CSEC. These factors can inform evidence-based prevention efforts to reduce the prevalence of CSEC in the future. In particular, there is a strong need for data from multiple geographic and socioeconomic contexts, and from both females and males. Boys have been left out of much of the research on CSEC, especially those involving probabilistic sampling, and there is a large gap in researchers’ knowledge of the risk factors that make them more likely to experience CSEC (Cockbain et al., 2011; Dennis, 2008; Moynihan et al., 2018). What little data we do have on boys’ experiences of CSEC suggest that there are differences between their experiences and those of girls. In the United States, boys have been found to experience CSEC earlier than girls (Estes & Weiner, 2001). Boys who experience CSEC are also often intentionally left out of research and assigned agency that excludes them from being perceived as a ‘victim’ (Dennis, 2008).

The Violence Against Children and Youth Surveys (VACS), led by national governments, with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC), as part of the Together for Girls (TfG) partnership, provide one way to fill some of the gaps in our understanding of CSEC globally. VACS includes nationally representative population samples of children and youth aged 13–24 that has been implemented in over 20 different countries (Centers for Disease Control & Prevention, n.d.; Chiang et al., 2016). It is a cross-sectional survey that measures the magnitude, nature, and consequences of violence in childhood, including CSEC and CSA. The VACS questionnaire uses comparable validated measures which have been developed for use in surveys focused on population-level health data, children, and violence (Brener et al., 1995; Garcia-Moreno et al., 2006; Runyan et al., 1998; Rutstein & Rojas, 2006). The initial VACS in Swaziland only included females in the sample, but every subsequent country included both females and males, whereas many violence studies do not collect data from boys and men (World Health Organization et al., 2013; Zimmerman et al., 2008), or do not consider sex disaggregation in risk factors for or characteristics of CSEC (Cockbain et al., 2011).

VACS represents the first nationally representative data globally to assess CSEC among youth, and Haiti is an important country in which to study CSEC. Haiti has a history of economic instability, which has been identified as one risk factor for CSEC (Rocha-Jimenez et al., 2018; Servin et al., 2015). In 2005, 1 in 3 Haitian households with children included those who met the UNICEF definition of orphaned or vulnerable (Gupta & Agrawal, 2010). Haitian children experienced trauma and displacement as a result of the 2010 earthquake; over 10,000 people, primarily females, in the capital of Port-Au-Prince were sexually assaulted, in the majority of cases by either unknown assailants or intimate partners, in the weeks following (Kolbe et al., 2010); and over one quarter of Haitian youth aged 13 to 24 years old were displaced or moved due to the earthquake (Centers for Disease Control & Prevention, 2014). Living in camps and forced displacement are both risk factors for trauma and CSA (Betancourt et al., 2012; Centers for Disease Control & Prevention, 2014). International organizations, such as the United Nations, the Inter-Agency Standing Committee on Protection from Sexual Exploitation and Assault, and the Gender Based Violence Area of Responsibility (GBV AoR) are leading multi-lateral efforts to address sexual exploitation and abuse in humanitarian settings, like Haiti, and are critical to violence prevention efforts (Gender-Based Violence AoR Global Protection Cluster, n.d.; Inter-Agency Standing Committee, n.d.; United Nations Office for the Coordination of Humanitarian Affairs, n.d.). Previous analyses of VACS data from Haiti have found that rates of physical violence against children are high, with about two-thirds of males and females age 13–24 reporting such abuse (Flynn-O’Brien et al., 2016). Among these youth, the abuse seemed to appear in multiple settings – at home, at school, and in public, with 54% reporting that the father perpetrated the violence, 47% the mother, 28% a male public authority member, 27% a male teacher, 11% a female authority figure, and 10% a female teacher. Finally, youth in Haiti have reported a relatively high rate of CSEC, with close to 7 percent of boys and 4 percent of girls reporting having exchanged sex for goods or money (Centers for Disease Control & Prevention, 2014).

Researchers need to better understand the relationship between childhood sexual violence and CSEC, among both boys and girls and across a wide variety of geographic locations. This study aims to understand the relationship in Haiti, using the Haiti VACS cohort, a nationally-representative sample of adolescents and young adults age 13–24, including almost equal numbers of males (n = 1459) and females (n = 1457). The Haiti VACS was administered in 2012, timed to capture longitudinal effects of the 2010 earthquake and the resulting displacement and insecurity of a large number of Haitians, including children. Previous reports on these data have described the prevalence of CSA, physical violence, and lifetime CSEC among those 18–24 years of age. No studies to date have assessed the lifetime prevalence of CSEC among the complete national sample inclusive of both children and adults, the ages at which these experiences occurred, or associations of lifetime CSEC with CSA. In addition to the hypothesised association between child sexual violence and CSEC, we assessed how age at first CSA affects risk for CSEC, specifically among those whose experiences of CSA preceded their experience of CSEC. Throughout our analyses, we consider the ways that post-disaster displacement and living in internally displaced persons camps might have contribute to CSA and CSEC.

Materials and methods

Data source – Haiti VACS

The 2012 Haiti Violence Against Children Survey (VACS) was conducted to provide national population-based estimates of violence against children for the first time in Haiti (Centers for Disease Control & Prevention, 2014). It was a cross-sectional household survey of males and females age 13 to 24 years old designed to produce national level estimates. Haiti VACS used a stratified multi-cluster survey design that incorporated internally displaced persons (IDPs) living in settlements from the 2010 earthquake as well as non-camp enumeration areas called Section d’Enumération (SDE). The VACS sampling frame was stratified first into IDP camp/settlement areas and non-camp enumeration areas. Then primary sampling units of camps and SDEs were selected for inclusion in the study using probability of selection proportional to size (PPS) from their respective group. One hundred eighty-eight enumeration areas (EAs) were selected, 177 SDEs and 11 camps or camp segments in larger camps. The EAs were randomly assigned to female or male surveys, using systematic sampling with a random start. The male and female surveys were conducted in different EAs to protect confidentiality and reduce the chance that a dyadic sexual assault perpetrator and survivor pairs would both be interviewed in the same community. Based off of differential gender response rates and different proportions of households with eligible females or males, 84 female EAs (5 camps and 79 SDEs) and 104 male EAs (6 camps and 98 SDEs) were selected. Within each EA, a cluster of 35 households were systematically selected with a random start. In each household, one respondent was randomly selected from all eligible respondents age 13–24 using the Kish method (Kish, 1949). In each eligible household, trained enumerators would first conduct a short demographic interview with the head of the household and then a comprehensive interview with one 13–24 year old female or male respondent. The questionnaire lasted on average 60 minutes and was administered in Haitian Kreyol. Field work for the survey was conducted from April 2012 to June 2012. 1,457 females and 1,459 males completed the survey, with an overall response rate of 85.6% for females and 82.0% for males. A detailed description of the Haiti VACS methods and primary results can be found in the 2014 VACS country report (Centers for Disease Control & Prevention, 2014).

Ethical approval

The U.S. Center for Disease Control and Prevention (CDC) Institutional Review Board (IRB), the IRB at Interuniversity Institute for Research and Development (INURED), and the Haiti Ministry of Public Health and Population’s National Ethics Committee independently reviewed and approved the Haiti Violence Against Children Survey (VACS).

Measures

The primary outcome for the present analysis was a first exchange of sex for money, food, gifts, or favours prior to age 18 (yes or no), referred to as commercial sexual exploitation of children (CSEC). This was assessed by the youngest age reported in response to these two questionnaire items: ‘How old were you when you first exchanged money for sex?’ and ‘How old were you when you first exchanged food, gifts, or any favours for sex?’ The predictor of interest was age at first experience of childhood sexual abuse (CSA), which was created by taking the youngest age reported in response to any of the following items: ‘How old were you the first time anyone touched you in a sexual way without your permission but did not try to force you to have sex?’, ‘How old were you the first time anyone tried to make you have sex without your permission, but did not succeed?’, ‘How old were you the first time anyone pressured you, in a nonphysical way, to have sex when you did not want to, and sex happened?’, and ‘How old were you the first time anyone physically forced you to have sex without your permission?’ CSA experience was dichotomised as any affirmative response to the above questions or ‘none’ for initial analyses but age at first CSA was coded continuous in descending order for final analyses. Demographic characteristics assessed included age (categorised as 13 or 14, 15 to 17, 18 to 20, or over 20), completion of primary school (yes or no), not having lived with one’s mother since before age 13 (yes or no), not having lived with one’s father since before age 13 (yes or no), financial instability under age 18, meaning one’s household had insufficient money for food, clothes, school fees, or medical care, (yes or no) moving three or more times under age 18, (yes or no) and having ever resided in an internally displaced persons (IDP) camp or resettled area where people were living in tents (yes or no).

Statistical analysis

Descriptive statistics and Rao-Scott chi-square tests were generated for all variables to assess for differences in socio-demographics by outcome and predictor variables. Rao-Scott chi-square tests were also performed comparing CSA and CSEC prevalence across males and females. Univariate and multivariable logistic regression models were used to evaluate associations of CSEC entry with CSA. Backwards stepwise model selection was utilised, beginning with all socio-demographic variables being forced into the model and removing them one-by-one using a threshold of α = 0.2. We did not find evidence of collinearity among variables in the adjusted models. Cross tabulations were also calculated among those who experienced CSEC and also experienced sexual violence under age 18 to assess the temporality of childhood sexual violence with respect to CSEC, categorised as prior to, in the same year as, or after CSEC. Results for males were compared to those for females with a chi-square test. Finally, exploratory unadjusted logistic regression models were used to evaluate associations of CSEC with age at first CSA (coded continuous in descending order), among the subset of respondents who experienced CSA prior to or in the same year as first experience of CSEC or (age 18 or older) entry into sex trade. Analyses accounted for clustering, stratification, and sample weights due to the complex sample design. All tests were two-tailed, statistical significance was evaluated at p < 0.05, and analyses were conducted using SAS software, Version 9.4 (Cary, NC, USA).

Results

The largest age group for males was 18 to 20, while the largest age group for females was over 20 (Table 1). More than one in three respondents of both sexes reported that their household had insufficient money for food, clothes, school fees, or medical care before they turned 18. One in five respondents had lived in an IDP camp. Over one in five males had experienced CSA, as well as almost one in four females. Among males, the only characteristic that was significantly associated with CSA was current age. Among females, the three characteristics which were significantly associated with CSA were current age, having moved three or more times before age 18, and having lived in a camp. Females who experienced CSA were significantly more likely to have moved 3 or more times before the age of 18 and have lived in a camp than females who did not experience CSA. CSEC experience was relatively common for youth in Haiti and was reported by 6.1% of males and 4.3% of females. Statistically significant differences existed by age category for males who experienced CSEC versus those who did not. Additionally, significantly fewer females who experienced CSEC had completed primary school, compared to those who did not experience CSEC. No other characteristics differed significantly across males or females who had experienced CSEC and those who had not.

Table 1.

Prevalence and Profile of Childhood Sexual abuse (CSA) and Commercial Sexual exploitation of Children (CSEC) among young Haitian males (13–24, n = 1459) and females (13–24, n = 1457).

CSA, No. (wtd. %) CSEC, No. (wtd. %)
Characteristic Total, No. (wtd. %) Yes No Yes No
Males (n = 1459)
Total – 318 (21.1)# 1141 (78.9) 90 (6.1)# 1369 (93.9)
Current age
13–14 356 (19.7) 61 (14.8)* 295 (21.0) 14 (10.0)* 342 (20.3)
15–17 402 (24.2) 107 (29.2) 295 (22.9) 28 (27.6) 374 (24.0)
18–20 376 (31.5) 101 (39.3) 275 (29.4) 31 (45.0) 345 (30.6)
>20 325 (24.7) 49 (16.7) 276 (26.8) 17 (17.5) 308 (25.2)
Completed primary school 784 (61.2) 170 (59.1) 614 (61.8) 49 (62.7) 735 (61.2)
Last lived with mother under 13 1227 (86.3) 271 (87.0) 956 (86.1) 70 (79.4) 1157 (86.7)
Last lived with father under 13 1083 (80.6) 250 (81.4) 833 (80.4) 67 (80.2) 1016 (80.6)
Financial instability under 18a 559 (38.6) 116 (34.3) 443 (39.8) 35 (42.9) 524 (38.4)
Moved ≥3 times under 18 183 (13.5) 48 (15.1) 135 (13.1) 15 (19.2) 168 (13.1)
Resided in an IDP camp 284 (18.9) 72 (21.7) 212 (18.1) 23 (26.4) 261 (18.4)
Females (n = 1457)
Total – 375 (24.9) 1082 (75.1) 83 (4.3) 1374 (95.7)
Current age
13–14 249 (16.3) 29 (7.6)* 220 (19.1) 5 (6.9) 244 (16.7)
15–17 387 (27.0) 140 (40.1) 247 (22.6) 30 (37.3) 357 (26.5)
18–20 389 (28.3) 121 (32.0) 268 (27.1) 29 (32.7) 360 (28.1)
>20 432 (28.5) 85 (20.3) 347 (31.2) 19 (23.1) 413 (28.7)
Completed primary school 770 (58.9) 192 (56.3) 578 (59.7) 37 (43.4)* 733 (59.5)
Last lived with mother under age 13 1139 (80.9) 284 (79.3) 855 (81.4) 62 (81.1) 1077 (80.9)
Last lived with father under age 13 1019 (79.1) 256 (74.1) 763 (80.7) 54 (73.3) 965 (79.3)
Financial instability under 18a 616 (43.4) 151 (41.7) 465 (44.0) 33 (43.2) 583 (43.4)
Moved ≥3 times under 18 172 (11.9) 61 (15.9)* 111 (10.6) 14 (19.2) 158 (11.6)
Resided in an IDP camp 301 (20.5) 89 (25.3)* 212 (19.0) 25 (28.2) 276 (20.2)
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Abbreviations: No.: number; wtd.: weighted

All analyses account for clustering, stratification, and sample weights due to the complex sample design; frequencies are unweighted and percents are weighted.

a

While respondent was under 18, his or her household had insufficient money for food, clothes, school fees, or medical care.

*

p<.05, indicating statistically significant differences at alpha = 0.05 among groups within each variable.

**

p < 0.01.

#

p < 0.1 across males and females, indicating non-significant differences at alpha = 0.1 across genders.

Unadjusted analyses found that both males and females who experienced CSA were significantly more likely to experience CSEC relative to those who did not experience CSA (males: 17.0% vs 3.2%; odds ratio [OR]: 6.2 [95% CI: 3.4–11.3, p < 0.01]; females: 12.0% vs 1.8%; OR: 7.6 [95% CI: 4.0–14.2, p < 0.01], respectively) (Table 2). After model selection, the final multivariable model for males was adjusted for age and whether the respondent had last lived with his mother under age 13; the model for females adjusted for age and education. Living in a camp, despite being a variable of interest, was not retained in the final models. After adjusting for covariates, the associations between CSEC and CSA found in the unadjusted analyses remained present. Specifically, the adjusted odds of CSEC experience were 5.6 (95% CI: 3.1–10.2, p < 0.01) times higher for males experiencing CSA and 5.9 (95% CI: 2.6–13.0, p < 0.01) times higher for females experiencing the same, compared with respondents not experiencing CSA.

Table 2.

Unadjusted and Adjusted Associations of Commercial Sexual Exploitation of Children (CSEC) with Childhood Sexual Abuse (CSA) among Young Haitian Males (13–24, n = 1459) and Females (13–24, n = 1457).

Males (n = 1459) Females (n = 1457)
CSA CSEC No. (wtd. %) OR (95% CI) AOR (95% CI)a CSEC, No. (wtd. %) OR (95% CI) AOR (95% CI)b
Yes 55 (17.0)** 6.2 (3.4–11.3)** 5.6 (3.1–10.2)** 57 (12.0)** 7.6 (4.0–14.2) ** 5.9 (2.6–13.0) **
No 35 (3.2) 1 [Reference] 1 [Reference] 26 (1.8) 1 [Reference] 1 [Reference]
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Abbreviations: CSEC: commercial sexual exploitation of children; CSA: childhood sexual abuse; No.: number; AOR: adjusted odds ratio; CI: confidence interval.

All analyses account for clustering, stratification, and sample weights due to the complex sample design; frequencies are unweighted and percents are weighted.

**

p < 0.01.

a

Adjusted for current age and whether the respondent had last lived with his mother under age 13.

b

Adjusted for current age and education.

Among respondents who experienced CSEC, 58.8% of males and 69.2% of females had experienced CSA (Table 3). Of those having experienced CSA, 43.8% of males experienced it prior to CSEC entry, 20.2% in the same year as entry, and 36.0% after entry. For females, these proportions were 59.4%, 8.1%, and 32.5%, correspondingly. Youth who experienced CSA before or in the same year as first experiencing CSEC or transactional sex (if over 18) were examined in more detail to evaluate whether a temporal trend existed correlating the specific age at which one first experienced CSA and whether he or she subsequently experienced CSEC or instead experienced transactional sex at age 18 or older (Table 4). Results revealed that for each additional year earlier males had their first experience of CSA, the odds of CSEC were 1.6 (95% CI: 1.2–2.0, p < 0.01) times higher. To illustrate this, 13.9% of males who first experienced CSA at age 14 experienced CSEC compared with 8.3% of those who first experienced CSA at age 17. Among females, for each additional year earlier they first experienced CSA, the odds of CSEC experience were 1.2 (95% CI: 1.0–1.4, p = 0.07) times higher, which showed a non-significant trend. Accordingly, the proportion of females who experienced CSEC did not differ greatly between those who first experienced CSA at 14 versus 17 (4.9% vs 3.5%). Only unadjusted analyses were performed for this step due to small sample sizes.

Table 3.

Temporality of Childhood Sexual Abuse (CSA) with Respect to First Commercial Sexual Exploitation of Children (CSEC) Experience Among Young Haitian Males (13–24, n = 55) and Females (13–24, n = 57) who experienced CSEC and CSA.

Males (n = 55) Females (n = 57)
CSA, No. (wtd. %) CSA, No. (wtd. %) p valuea
Prior to first CSEC experience 24 (43.8) 35 (59.4)
In same year as first CSEC experience 12 (20.2) 6 (8.1) 0.27
After first CSEC experience 19 (36.0) 16 (32.5)
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Abbreviations: No.: number; wtd.: weighted.

All analyses account for clustering, stratification, and sample weights due to the complex sample design; frequencies are unweighted and percents are weighted.

a

Overall p value for differences by sex.

Table 4.

Associations of CSEC with age at first childhood sexual violence among young Haitians (age 13–24) who experienced childhood sexual violence prior to or in the same year as first CSEC experience.

Males (n = 41) Females (n = 52)
OR (95% CI) OR (95% CI)
Age at first sexual violencea 1.6 (1.2–2.0)** 1.2 (1.0–1.4)b
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Abbreviation: OR, odds ratio; CI, confidence interval. All analyses account for clustering, stratification, and sample weights due to the complex sample design.

**

p < 0.01.

a

Coded continuous in descending order.

b

p=.07.

Discussion

In this first nationally representative study of lifetime CSA and CSEC in Haiti, approximately 1 in 20 children among the general population may be considered victims of CSEC. In this study, we found that CSEC and CSA are common and interrelated among children in Haiti. The more than 1 in 5 children victimised of CSA were far more likely than other children to have also experienced CSEC, with children who experienced CSA at younger ages at the greatest risk. These findings support existing evidence on the interconnectedness of multiple forms of violence and exploitation, including studies where child abuse, particularly CSA, has been linked to CSEC (Ahrens et al., 2012; Guedes et al., 2016; Rocha-Jimenez et al., 2018; Servin et al., 2015; Smith et al., 2009; Zimmerman et al., 2008).

The prevalence of CSEC and CSA was found to differ slightly between females and males, with boys being at a non-significantly lower risk than girls for CSA (21% vs. 25%, p = 0.09), while they were at somewhat higher risk than girls for CSEC (6% vs. 4%, p = 0.07) across this nationally representative sample. In particular, there is a strong need for data from multiple geographic and socioeconomic contexts, and from both sexes to better understand the context of CSA and CSEC. The findings from this study suggest that boys experience CSEC at similar to or greater levels than girls in Haiti, with similar relationships between CSA and CSEC. This finding responds to a gap identified by a recent systematic review of international studies on the sexual exploitation of boys stating that there is limited data on the antecedents of CSEC (Moynihan et al., 2018). One difference between boys and girls in this research, in which experiencing CSA at a younger age impacted entry into CSEC for boys and not girls, is supported by research from the United States that found age differences between boys’ and girls’ entry into CSEC (Estes & Weiner, 2001). More research needs to be done on CSEC and CSA globally that includes boys, so their shared and unique risk factors can be understood more clearly.

Similar to findings from analyses of these data that examined sexual abuse occurring post-earthquake, including that occurring among those 18 years or older, we found that having ever resided in an internally displaced persons (IDP) camp was associated with greater risk for CSA among girls, but not among boys. Because the CSA may have occurred prior to living in a camp in the current analyses, this finding may indicate that this environment poses risk for CSA for girls, or it may indicate that those girl children who experienced CSA were more likely to have resided in an IDP camp, perhaps based on having inadequate economic or social resources to relocate to a more secure environment. Although we hypothesised, based on previous research (McAlpine et al., 2016), that having resided in an IDP camp would also relate to risk for CSEC, this factor did not relate to CSEC in univariate analyses, nor did it reach the required level of significance (p<.20) for inclusion in final models assessing associations between CSA and CSEC. Based on these finding, it appears that having resided in an IDP camp neither promotes or reduces risk for CSEC in this setting, nor does it account for additional variance in CSEC beyond that accounted for by CSA.

These results are not without limitation. The measures of CSA and CSEC are self-reported and may be subject to response bias. A larger subsample of respondents indicating these experiences could provide an even more precise estimate of effect (i.e. smaller confidence intervals), yet even with this relatively small sample of respondents reporting CSEC, effects were strong and would be unlikely to change in a practically meaningful way. This nationally representative sample of 2,916 participants offers a strong representation of the Haitian youth population and their experiences around CSA and CSEC. Moreover, the subsample used in the analysis allows for establishing a temporal sequence with CSA occurring before CSEC, a step toward understanding potential causality.

Because CSEC and CSA are related, CSEC prevention may benefit from being integrated into existing national efforts to address CSA. Specifically, CSEC prevention that targets children identified as having experienced CSA may be beneficial for not only reducing CSEC, but the negative health outcomes that are associated with this experience. Preventing the exponential physical and mental health repercussions that can result from experiencing multiple forms of violence and trauma during childhood is of utmost priority for helping Haiti to recover from the aftermath of the earthquake. The United Nations (UN) suggests that prevention of CSEC can occur through research and cooperation with non-governmental organizations and civil society to decrease the factors that increase vulnerability to CSEC (United Nations, 2015). Such work is possible through organizations like GBV AoR that are working in Haiti and other nations to prevent violence in natural disaster and conflict-related humanitarian emergency settings. Coordinated prevention, like that done by GBV AoR and others, paired with CSEC screening among CSA survivors is needed not only in Haiti but in countries around the world of every income level to understand the constellation of risk factors that can increase risk for CSEC among youth.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding for the implementation and coordination of the survey was provided by the President’s Emergency Plan for AIDS Relief (PEPFAR). Funders had no role in study design, collection, analysis, or interpretation of data, the writing of this manuscript, or the decision to submit the paper for publication.

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Footnotes

Disclosure statement

No potential conflict of interest was reported by the authors.

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