Post Created by: Anish Raj, MD
Case: A 15-year-old female, with a history of PTSD, presents to the ED for medical clearance after being AWOL (absent from care) from her group home for the past 3 weeks. What are critical components you should consider prior to making any disposition plans for this patient?
I.) Background (Smith, 2014)
- Commercial Sexual Exploitation of Children (CSEC): the sexual abuse of a minor (< 18 years old) with remuneration in money, goods, or services—or the promise of money, goods, or services—to the child or a third-party for the sexual use of that child.
- Note: CSEC is an umbrella term that encompasses child sex trafficking, escorting, survival sex, child pornography, stripping, etc.
- Domestic Minor Sex Trafficking (DMST): the inducement of a commercial sex act of anyone under the age of eighteen by a controlling party (i.e. trafficker/exploiter/pimp) that takes place within U.S. borders and involves a child who is a U.S. citizen.
- Note: Per the Trafficking Victims Protection Act (TVPA), in cases of child sex trafficking, the inducement of a commercial sex act of a minor (< 18 years old) is enough to meet criteria for trafficking. Force, fraud, or coercion do NOT have to be demonstrated.
II.) Epidemiology (IOM, 2013)
- No consensus on estimates of incidence and prevalence
- Most widely cited national estimate: 244,000-325,000 children are at risk for CSEC
- Average age of initial involvement: 15 years old (Gibbs et al., 2015)
- Rhode Island preliminary data: ~70 suspected cases over the past 3 years
III.) Risk Factors
- *History of sexual abuse*: up to 70-90% of CSEC victims (Bagley & Young, 1987)
- History of running away and/or truancy: 70% of street youth estimated to be involved in CSEC at some point (Estes & Weiner, 2001)
- Child welfare (e.g. DCYF) involvement: 50-80% of CSEC victims (Walker, 2013)
- Juvenile justice system (e.g. RITS) involvement
- Adult (> 18 years old) “boyfriend”/“girlfriend”
- Multiple sexual partners at present
- Positive STI testing
- Substance use
IV.) Physical Exam
- Observation: are clothing and accessories congruent with age/time/season?
- Tattoos: name branding? explicit? gang insignia?
- Note: In Rhode Island, individuals must be > 18 years old to receive a tattoo or piercing in a licensed parlor.
- Signs of physical abuse (including but not limited to head trauma, oral trauma, genital trauma, and cutaneous injuries)
V.) Screening Examples (no brief, validated screening tool currently exists)
- Have you or any of your friends ever exchanged sex for money, a place to stay, food, or drugs?
- Has anyone ever asked you to have sex with someone else or made you have sex when you didn’t want to?
- Has anyone ever taken sexual pictures of you or posted such pictures on the internet? (Greenbaum et al., 2015)
VI.) What To Do If You Suspect CSEC
- Understand that it is very common for patients to NOT disclose
- Notify Aubin Center (i.e. page on-call physician) of suspected CSEC
- Determine need for forensic evidence collection if acute assault has taken place
- Consult Psychiatry for evaluation
- Confirm with law enforcement that missing persons report was filed if patient had been missing
- If no report was filed, communicate this information to DCYF due to concern for possible neglect by caregiver
- File report expressing concern for suspected CSEC to DCYF Hotline
- Complete PRE without hold and fax to DCYF
- Order screening labs: urine pregnancy, urine gonorrhea, urine chlamydia, urine trichomonas, urine toxicology screen, RPR, hepatitis C, hepatitis B, and HIV
- Consider administration of empiric STI antibiotic treatment (e.g. ceftriaxone, azithromycin, and metronidazole)
- Consider administration of Plan B
- Consider administration of HIV post-exposure prophylaxis (PEP) on a case-by-case basis in coordination with Aubin Center +/- Infectious Disease team
- Determine safe disposition plan
- Ensure patient has an outpatient appointment at Aubin Center if being discharged
- Consult social work and Aubin Center if patient is admitted
Faculty Reviewer: Christine Barron, MD
- Smith, Holly Austin. Walking Prey: How America’s Youth Are Vulnerable to Sex Slavery. New York: St. Martin’s, 2014. Print.
- Institute of Medicine and National Research Council. Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press; 2013. Print.
- Gibbs, D., Walters, J., Lutnick, A., Miller, S., & Kluckman, M. (2015). Evaluation of Services for Domestic Minor Victims of Human Tracking. Manuscript submitted for publication. Retrieved August 12, 2016, from https://www.ncjrs.gov/pdffiles1/nij/grants/248578.pdf.
- Bagley, C., & Young, L. (1987). Juvenile Prostitution and Child Sexual Abuse: A Controlled Study. Canadian Journal of Community Mental Health, 6(1), 5-26. doi:10.7870/cjcmh-1987-0001.
- Estes, R., & Weiner, N. (2001). The Commercial Sexual Exploitation of Children in the U.S., Canada and Mexico. Retrieved August 12, 2016 from http://www.gems-girls.org/Estes%20Wiener%202001.pdf.
- Walker, K. (2013). Ending the Commercial Sexual Exploitation of Children: A Call for Multi-System Collaboration in California (USA, California Child Welfare Council). Retrieved August 12, 2016, from http://www.chhs.ca.gov/Child Welfare/Ending CSEC-ACallforMulti-SystemCollaborationinCA-February2013.pdf.
- Greenbaum, J., & Crawford-Jakubiak, J. E. (2015). Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims. Pediatrics, 135(3), 566-574. doi:10.1542/peds.2014-4138.