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Commercial Sexual Exploitation of Youth in the United States: A Qualitative Systematic Review

TRAUMA, VIOLENCE, & ABUSE 1-14 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838017742168 journals.sagepub.com/home/tva

Michelle DeCoux Hampton1 and Michelle Lieggi2

Abstract Background: Homeless, runaway, and transgender youth are at high risk for commercial sexual exploitation in the United States. Research examining this phenomenon is growing but requires synthesis to facilitate its use by professionals who serve this population. The purpose of this review was to aggregate the qualitative evidence regarding commercially sexually exploited youth (CSEY) in the United States. Methods: The search included published and unpublished qualitative studies with current or former CSEY who reside in the United States. Results: There were 19 studies included in the review with a total of 795 participants. Eight themes were identified and grouped into three broader categories: experiences that preceded sex work entry, experiences that facilitated sex work continuation, and experiences that facilitated sex work exit. Conclusions: Understanding the barriers and facilitators of commercial sexual exploitation can inform the development of interventions that address the needs of CSEY and youth at risk for exploitation. The results of this review highlight the social and economic influences as well as the role of positive and negative reinforcements involved in sex work entry, its continuation, and exit. Needs for services, research, and advocacy are also discussed. Keywords human trafficking, sex trafficking, commercial sexual exploitation, adolescent, teen

The use of fraud, coercion, or force to compel slave labor or sexual services is known as human trafficking (State of California, 2012). Commercial sexual exploitation of youth, a type of human trafficking, involves sexual abuse of a child or adolescent for financial gain. It can include child pornography, physical abuse, or sex work (Mukasey, Daley, & Hagy, 2007). This phenomenon has received global attention in recent years. Several international reports identified risks for involvement, youth experiences, and challenges for recovery after commercial sexual exploitation (Carling, 2008; Dottridge, 2008; End Child Prostitution, Child Pornography and Trafficking of Children for Sexual Purposes, 2002, 2006; United Nations International Children’s Emergency Fund Pacific (UNICEF), 2006). Although there are similarities in the experience of CSEY internationally because legal, social, and cultural climates between nations can differ significantly, it is necessary to examine the characteristics and needs of each population according to its geographic location to develop appropriate prevention and response strategies. This review focuses on the unique needs of CSEY in the United States. Commercial sexual exploitation of youth prevalence in the United States is difficult to estimate. Estes and Weiner’s (2002) report on CSEY in the United States, Canada, and Mexico estimated that about 244,000 youth were at risk for commercial sexual exploitation in the course of a year. Youth who were at

the greatest risk were homeless, runaways, transgender, gang involved, abandoned, forced from home, residing close to Mexican or Canadian border cities, or in the United States as unaccompanied minors. Other estimates of prevalence are based upon reporting statistics. The Human Trafficking Reporting System provides U.S. state and local human trafficking (CSEY included) information and found that between 2008 and 2010, 82% of human trafficking incidents involved sex trafficking and identified that approximately 1,000 of those cases involved commercial sexual exploitation of youth (Banks & Kyckelhahn, 2011). The contrast between the number of youth identified as being at risk for exploitation and the number of reported cases is considerable and could be the result of underreporting. Traffickers purposely avoid law enforcement by frequently moving youth across borders and by using online advertising for

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School of Nursing, Samuel Merritt University, Oakland, CA, USA Institute for Nursing Excellence, University of California San Francisco Medical Center, San Francisco, CA, USA

Corresponding Author: Michelle DeCoux Hampton, School of Nursing, Samuel Merritt University, 3100 Summit Street, Oakland, CA 94609, USA. Email: [email protected]

2 marketing (Federal Bureau of Investigation [FBI], 2009). Youth often carry false identification and are made to appear older to avoid notice. Furthermore, the National Trafficking Resource Center and Polaris BeFree Hotlines that collect self-reported data regarding sex trafficking survivors identified that reports of abuse, if made, were not consistently nor effectively addressed or were dismissed altogether (Polaris, 2015). Collectively, these factors reduce the ability to accurately assess the true prevalence of commerical sexual exploitation of youth.

Characteristics of CSEY Because prevalence estimates are imprecise, studies that report the race, gender, and age of CSEY also produce conflicting results. Walker’s (2013) California Child Welfare Council report identified a large proportion of African American (66%) females (99%) with 73% between the ages of 16 and 18. Varma, Gillespie, McCracken, and Greenbaum’s (2015) study of CSEY recruited from three emergency departments in the southern United States, reported that 56% of the sample were African American, 100% were female, and the mean age was 16 years. In contrast, in a youth sample from the National Child Traumatic Stress Network Core Data Set, Cole, Sprang, Lee, and Cohen (2014) found that 40% of CSEY were White, 12% were male, and 72% were between the ages of 14 and 17.

Influences Preceding Commercial Sexual Exploitation Entry Basson, Rosenblatt, and Haley (2012) reported that 55% of CSEY (N ¼ 113) in a California community were abandoned by guardians indicating that a lack of basic needs might play a role in sex work entry. They also identified that many youth had parents who were involved in substance use, sex work, and/or other criminal activities. In addition, a large percentage (75%) experienced child abuse or neglect. Although reports of child abuse in CSEY are common, its influence in sex work entry is not likely to be the sole contributing factor. To distinguish the characteristics of child abuse survivors compared to CSEY, Cole, Sprang, Lee, & Cohen (2014) compared the groups on demographic, abuse, and behavioral characteristics. Despite both groups experiencing domestic violence, emotional abuse, sexual abuse, and neglect, the investigators reported that CSEY exhibited more behavioral problems such as cutting school, inappropriate sexual behavior, substance use, running away, and involvement in crime. The work of Finkelhor, Ormrod, and Turner (2007) might explain this result. In their study of 2,030 youth who were exposed to various types of trauma, youth who experienced polyvictimization (defined as experiencing greater than four types of trauma in a 1-year period) were more likely to screen positive for trauma and psychological symptoms than youth with fewer types and a lower frequency of traumatic experiences.

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Challenges to Commercial Sexual Exploitation Exit Exiting a life in commercial sexual exploitation is complicated by many factors. CSEY in Carr’s (2009) study (N ¼ 31) reported that they remained in relationships with traffickers due to fears of physical abuse, the trafficker’s request, and lacking funds for food, housing, and drugs. Traffickers also manipulated CSEY by playing the role of a boyfriend/friend, mandating debt repayment, or commanding loyalty after forcing the survivor to commit a crime (Reid, 2014). Lacking confidence regarding school and independent living skills can further perpetuate the perceived need to continue sex work (Fields & Abrams, 2010).

Purpose The influences affecting commercial sexual exploitation entry are complex, and the needs are great for this vulnerable population. At the same time, intervention research is limited. As a result, the best approaches for prevention and intervention are difficult to determine. In order to build the evidence that service providers need to effectively work with CSEY, it is necessary to better understand the characteristics of the population affected by commercial sexual exploitation in the United States and to understand the experiences that influence youth vulnerability to sex work. Since exploring the nature of experiences and their meaning is the objective of qualitative research (Denzin & Lincoln, 2000), this review focuses exclusively on qualitative inquiry. There is a growing body of qualitative literature that examines CSEY experiences, but no systematic reviews that synthesize the literature focusing on the survivor’s unique perspective. The purpose of this review was to aggregate the qualitative evidence to describe the characteristics of CSEY in the United States and to explore the factors that influence sex work entry, its continuation, and exit.

Method The review was conducted by a PhD-prepared researcher with expertise in psychiatric–mental health nursing and a clinical research librarian at the University of California, San Francisco who performed the search. The search for published and unpublished studies was conducted in nine databases using key words: human trafficking, prostitution, commercial sexual exploitation, adolescent, teen, and youth. Qualitative studies that addressed the firsthand experience of current or former CSEY that were conducted in the United States since 2000 (the year the FBI, 2014, established the Crimes Against Children Program) were included in the review. Abuse types included but were not limited to sex work and child pornography. Studies pertaining to survivors of human trafficking or child sexual abuse without the experience of commercial sexual exploitation were excluded. The search was completed in December 2015. Titles and abstracts were reviewed, and studies that did not meet the

Hampton and Lieggi

PubMed n=180

CINAHL n=274

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PsycINFO n=440

1

ProQuest n=209

Web of Science n=380

ERIC n=34

PsycEXTRA n=72

Total References n=1,744

Duplicates n=454

References Screened n=1,290

References excluded n=1,241

Full-text Review n=49

Mednar n=47

Google Scholar n=108

Ref lists n=3

Full-text studies excluded n=30

Studies included in review n=19

Figure 1. Study selection flowchart.

inclusion criteria were excluded. Full-text reports were retrieved and examined to confirm that inclusion criteria were met. The remaining studies were critically appraised and evaluated to determine whether the stated methods were congruent with the identified qualitative methodology. Reference lists of all retrieved studies were searched for additional studies (see Figure 1). Data were extracted for each included study pertaining to sample characteristics, setting, methods, findings, and phenomenon of interest/purpose. Microsoft Word was used to record and organize data throughout the review. The purpose of each study differed and thus the focus and presentation of findings. As a result, themes were extracted based upon both (1) the investigators’ findings and (2) the participants’ quotes. The participants’ quotes provided rich data beyond the themes reported by the investigators. Themes derived from participant quotes were also validated for congruency with participant experiences in other studies. Finally, quotes were identified to illustrate each theme. Broad categories were identified and the themes allocated to categories. In the Results section, the themes are presented with an overview describing the range of experiences reported by the participants and with citations of the studies in which each theme appeared. Selected quotations are included to illustrate poignant themes.

were excluded if they were (1) not conducted in the United States (*43%), (2) not a qualitative study (*26%), (3) not CSEY (*24%), (4) commercially sexually exploited but not a youth sample (*4%), or (5) lacked participant quotes to validate the data (n ¼ 1). Three additional studies were identified from the reference lists of retrieved studies. A total of 19 studies were included in the review (see Table 1 for details of included studies).

Results

Methods of Inquiry

The search resulted in the identification of 1,290 references (excluding duplicates; see flowchart in Figure 1). Studies

Nine of the 19 studies reported qualitative methods with no specific approach identified (Ashley, 2008; Cimino, 2013;

Participant Characteristics There were 795 participants. Investigators recruited youth throughout the United States via snowball sampling, online survivor networks, social media, and service organizations. Participants were recruited in Arizona, California, Connecticut, Florida, Illinois, Massachusetts, Minnesota, New York, Washington, Washington, DC, and unspecified regions in the Midwest, West, Northeast, South, and Southwest. In total, there were 462 female, 276 male, and 57 transgender participants. There were 269 Black (35%), 173 mixed race (23%), 122 White (16%), 113 Latino (15%), 76 unknown/Other (10%), and 11 Asian (1%) participants (counts excluded Williams & Frederick, 2009 and Dank et al., 2015, due to incomplete race data). Excluding unknown race, there were 566 non-White (74%) and 122 White participants (16%).

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Table 1. Description of Included Studies. Study

Methods

Participantsa

Phenomenon

Location/Setting

Conclusions

Ashley (2008)

Mixed methods

12 F, 5 T

CSEY in Illinois

Bruhns (2014)

Consensual qualitative research

11 F

CSEY lived experience, exit, and recovery

Illinois/CSEY service setting Oakland, CA/ CSEY service setting

Cavazos (2014)

Feminist

13 F, 3 T

Experiences of CSEY

Cecchet (2012)

Narrative interviews

6F

CSEY resilience

Cimino (2013)b

Mixed methods

2 M, 4 F (þ10 adult-entry participants)

Examination of intentions to exit prostitution

School prevention, family violence reduction, and screening needed Exiting is facilitated by social support, consistent relationships, and support in meeting basic needs Trauma-informed, substance use and medical care, education, housing, and family reintegration needed Pregnancy, stress, and forming caring relationships led to sex trade exit Exiting sex work is influenced by attitudes, agency, self-efficacy, skills, and environmental constraints

Cobbina and Oselin (2011)b,c

Qualitative

20 F (þ20 adult-entry participants)

Events preceding sex work entry and outcomes

Curtis, Terry, Dank, Dombrowski, and Khan (2008)

Qualitative

CSEY characteristics, experiences, and service needs

Dank et al. (2015)

Mixed methods

N ¼ 249: 53.5% M, 42% F, 4.5% T N ¼ 283: 47% M, 36% F, 16% T

Edinburgh, PapeBlabolil, Harpin, and Saewyc (2015) Holger-Ambrose, Langmade, Edinburgh, and Saewyc (2013) Hurst (2013)

Mixed methods, retrospective

55 F, 7 M

Qualitative

12 F and 1 T

Exploration of homeless CSEY service needs

Mixed methods, retrospective

40 F

Relationship of childhood emotional abuse and CSE entry

Meister (2014)

Photovoice

5F

Monheit (2010)a

Phenomenology 7 F (þ8 adult-entry participants)

Exploring current health and safety of former CSEY Lived experience of sex work

Oselin (2014)a,b

Ethnography/ grounded theory

14 F (þ26 adult-entry participants)

Lesbian, Gay, Bisexual, Transgender, Queer/uestioning (LGBTQ) involved in survival sex CSE meaning and experiences

Sex work exit/sex worker-serving organizations

Midwest and West/national online recruitment Seattle/ trafficking service setting Phoenix/sex worker service setting, flyers, and Internet Minneapolis, Los Angeles, Chicago, Hartford/ nonprofit New York City/ street youth service agencies New York City/ street youth service agencies Midwest/child advocacy center Minneapolis and St. Paul/youth shelters and street corners Midwest, West, Northeast, and South/ Internet survivor networks Miami-Dade County/CSEY service agency 2 Large northeast and southwest cities/sex work service agency Minneapolis, Los Angeles, Chicago, Hartford/ nonprofit

Sex workers’ needs vary depending on age of entry: adolescent versus adult

CSEY survivors were largely born in the United States and did not have pimps. Housing was the most significant service need Youth worked both under trafficker’s control and independently. Most expressed a desire to stop sex work Access to trauma-informed care is recommended for treatment Basic needs and health and safety education recommended for youth prior to CSE exposure Prevention efforts are recommended and identifying children at risk based upon history of childhood abuse could be a way to identify youth at high risk Youth distrusted law enforcement. Engagement between police and CSEY is needed Entered sex work for money, housing, drugs, and to feel loved. Lack of self-agency made complicated exit Sex work service organizations can support and improve quality of life for those who are/are not ready for exit (continued)

Hampton and Lieggi

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Table 1. (continued) Study

Methods

Participantsa

Phenomenon

Location/Setting

Conclusions

Rees (2010)

Constructivist, grounded theory Feminist case study

18 T

Lived experience of transgender CSEY

3F

Lived experience, high school dropouts involved in sex work

New York City/ youth service agency Chicago/sex work service agency

Rothman, Bazzi, and Bair-Merritt (2015)

Constructivist grounded theory

4F

Exploration of abusive dating relationships prior to CSE

Stevens (2012)

Autoethnography

1F

Personal experience

Williams and Frederick (2009)

Qualitative

24 F, 3 M, 1 T

Factors leading in and out of CSE

Mentorship, employment support, and advocacy for transitionrelated health-care delivery Common experiences included limited or no supervision, pregnancy, substance use, sexual abuse, truancy, high crime, and untenable home life CSEY leaving violent relationships is similar to intimate partner violence. Opportunities to exit are brief and complicated by emotional attachment. Shame contributes to mental illness for survivors. Need validation to heal Complex trauma can elicit behavior that makes it difficult for teens to request or accept the help

Robinson (2004)

Location undisclosed/ violence advocacy agency New York City/ self-reflection Boston, Washington, DC/youth shelters, and service agencies

a M ¼ male, F ¼ female, T ¼ transgender. bThese studies included both adult- and adolescent-entry participants. Only the data pertaining to adolescent-entry participants were considered for this review. cThere were 13 mutual participants between these studies and 7 additional in Cobbina and Oselin’s (2011) studies. Mutual participants were counted only once in overall counts.

Categories and Themes

Table 2. Categories and Themes. Categories 1. Experiences that preceded sex work entry 2. Experiences that facilitated sex work continuation

3. Experiences that facilitated sex work exit

Themes A. B. C. D. E. F.

Inhospitable environment Unmet needs Influence of others Risks Rewards Balancing risks and rewards/neutral experiences G. Turning points H. Opportunities for exit

Cobbina & Oselin, 2011; Curtis, Terry, Dank, Dombrowski, & Khan, 2008; Dank et al., 2015; Edinburgh, Pape-Blabolil, Harpin, & Saewyc, 2015; Holger-Ambrose, Langmade, Edinburgh, & Saewyc, 2013; Hurst, 2013; Williams & Frederick, 2009). Consensual qualitative research, feminist, narrative, photovoice, phenomenology, feminist case study, constructivist grounded theory, autoethnography, ethnography, and grounded theory were also used (see Table 1 for study details; Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Meister, 2014; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Rothman, Bazzi, & Bair-Merritt, 2015; Stevens, 2012). Individual and focus group interviews and observations were most often used to collect data.

Eight themes and three categories were identified (see Table 2). The three categories were (1) experiences that preceded sex work entry, (2) experiences that facilitated sex work continuation, and (3) experiences leading to and following exit from sex work. Category 1: Experiences preceding sex work entry. The themes in this category included inhospitable environment, unmet needs, and influence of others. Experiences that contributed to youth vulnerability to commercial sexual exploitation involved psychological and physiological needs, severe environmental stressors, and peer, caregiver, or trafficker influence. Theme A: Inhospitable environment. In the majority of studies, participants described experiencing multiple types of traumas including experiencing childhood abuse in every form: sexual, physical, verbal, emotional, and neglect. They reported experiencing multiple forms of abuse from a single or multiple perpetrators that included biological, step, or adoptive fathers; mother’s boyfriend; mothers; sisters; grandfathers; uncles; or neighbors (Ashley, 2008; Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). Youth also reported witnessing violent altercations with and without the use of weapons at home between parents,

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caregivers, or other adults (Cavazos, 2014; Cecchet, 2012; Hurst, 2013; Robinson, 2004; Williams & Frederick, 2009). The people that my mama gave me to, one [of] their sons molested me real bad. I would go through the house and he would catch me in the kitchen and do stuff to me . . . Grandpa, his daddy, he would always give me a little money to feel and touch on me and stuff like that, so that’s how I got off into that [prostitution]. I learned then that if I wanted something, I had to give up something. (Cobbina & Oselin, 2011, p. 319)

When abuse occurred, reporting was not considered a viable option to escape the inhospitable environment it created. Youth with foster care experience described that reporting abuse resulted in either no action or an exacerbation of problems such as fear of family separation or undesirable placement changes (Ashley, 2008; Curtis et al., 2008; Dank et al., 2015; Williams & Frederick, 2009). In addition to physical and sexual abuse, youth described the effects of neglect or the lack of supervision and engagement. Even when basic needs were met, the lack of an attentive adult was described as a contributing factor to commercial sexual exploitation involvement (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Monheit, 2010; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). The school environment was also inhospitable to many participants. While youth identified certain helpful teachers and enjoyed school at times, they also described a lack of teacher supervision, in general, bullying, fighting with peers, involvement in crime while in school, disinterest, difficulty with academics, and cutting school to drink, use drugs, or loiter. As a result, many were expelled or failed to graduate from high school (Ashley, 2008; Bruhns, 2014; Curtis et al., 2008; Hurst, 2013; Meister, 2014; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012). One of the most commonly cited events that occurred in close proximity to recruitment into commercial sex work was leaving home. Often, youth were forced to leave home due to intolerable abuse, a caregiver’s demand, or choosing to leave to avoid rules and expectations. With no source of income and a lack of education needed to secure gainful employment, youth were unable to secure basic necessities and thus became vulnerable to sex work recruitment (Ashley, 2008; Cavazos, 2014; Cecchet, 2012; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Holger-Ambrose et al., 2013; Monheit, 2010; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). Theme B: Unmet needs. As described above, living in an inhospitable environment created the circumstances that resulted in significant unmet need. Participants identified that obtaining basic needs for food, clothing, and shelter were a daily struggle (Cavazos, 2014; Cimino, 2013; Dank et al., 2015; Hurst, 2013; Rees, 2010; Williams & Frederick, 2009). Pregnancy and the responsibility to care for others presented an additional burden for CSEY.

Although some youth reported having abortions or miscarriages after pregnancy, many CSEY had children who were in their care, with family members, or in the foster care system (Cavazos, 2014; Cecchet, 2012; Curtis et al., 2008; Monheit, 2010; Oselin, 2014; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). Many also felt a responsibility to care for their siblings, parents, and friends (Ashley, 2008; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Monheit, 2010; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009), thus increasing the amount of financial support needed to survive and limited options besides sex work to earn a livable wage or to obtain basic necessities. Transgender youth were also forced to make difficult choices about employment. Male to female transgender youth, in particular, were faced with discrimination in employment when early in the transition or when masculine features were prominent. They felt pressured to maintain an appearance consistent with male gender norms in order to secure and maintain a job but were reluctant to abandon (even temporarily) the pursuit of living in accordance with their true gender identity. This was a choice many transgender CSEY were not willing to make (Ashley, 2008; Bruhns, 2014; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Rees, 2010; Robinson, 2004). When left without options for survival and the absence of a support network, the pimp (the term pimp is used in the results rather than trafficker to use language consistent with the participants) became a provider and fulfilled unmet needs. When relationships later became exploitive, a sense of indebtedness, emotional connection, and loyalty were powerful incentives to remain involved in sex work (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Dank et al., 2015; Hurst, 2013; Oselin, 2014; Robinson, 2004; Rothman et al., 2015; Williams & Frederick, 2009). . . . If you think about a bad relationship that you were in, at first it wasn’t bad. There was so much love there, but maybe after about 6 months . . . it just turns bad, but you want so much for what it was in the beginning to return that you’ll stay in that relationship and you’ll do anything in hopes that it will return back to that. But the problem for girls in the life and with pimps is that that was never real, so it will never, ever go back to that because it never existed . . . . (Rothman et al., 2015, p. 21)

In addition to basic needs for housing and food, sex work met other compelling needs. It was a means to supply drug addiction. As addiction severity increased, thus did the need for sex work to support the habit (Cavazos, 2014; Cimino, 2013; Dank et al., 2015; Monheit, 2010; Robinson, 2004; Williams & Frederick, 2009). For some participants, involvement in sex work provided a sense of control and empowerment after feeling powerlessness as a result of childhood abuse. They exercised a sense of identity, redemption, and/or agency in sex work (Bruhns, 2014; Cimino, 2013; Cobbina & Oselin, 2011; Oselin, 2014; Rothman et al., 2015). Finally, involvement in commercial sexual exploitation was described by many participants as

Hampton and Lieggi a means to satisfy needs for acceptance, validation, and love. It made participants feel desired and important (Ashley, 2008; Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Rothman et al., 2015; Stevens, 2012; Williams & Frederick, 2009). Theme C: Influence of others. Normalization of sex work and crime was a third facilitator involved in sex work entry. Because drug use, sales, and sex work were overtly visible in the neighborhoods in which youth were raised and their parents, siblings, and friends were involved, sex work was viewed as socially acceptable. Many also reported idolizing sex workers in their lives and aspired to be like them (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Rees, 2010; Robinson, 2004; Rothman et al., 2015; Williams & Frederick, 2009). . . . I was raised up with the game period, the pimping. My daddy was a pimp . . . My uncles ‘nem was pimps and I knew when I used to see the women and the houses we were in I was like, I was the one that lingered on with the adults. (Robinson, 2004, p. 119)

Overt exposure to sex work also involved ongoing exposure to a social network of sex workers and pimps who could potentially influence the youth over an extended period of time, laying the foundation for later involvement. In retrospect, several participants reported that a grooming process preceded sex work entry. They identified parents, foster parents, siblings, and boyfriends (including pimps posing as boyfriends) as traffickers who initially provided assistance and care to later require sex work as repayment (Bruhns, 2014; Cavazos, 2014; Cimino, 2013; Hurst, 2013; Monheit, 2010; Oselin, 2014; Robinson, 2004; Williams & Frederick, 2009). Recruitment also occurred overtly without the guise of a personal relationship. Pimps recruited youth from shelters or service settings. CSEY also described first encounters in which they were approached by customers directly on the street or through casual persuasion by peers or other sex workers. In some cases, participants were also required to recruit other youth for the pimp (Ashley, 2008; Cavazos, 2014; Cecchet, 2012; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Holger-Ambrose et al., 2013; Hurst, 2013; Monheit, 2010; Rees, 2010; Robinson, 2004; Rothman et al., 2015; Stevens, 2012; Williams & Frederick, 2009). Category 2: Experiences throughout sex work involvement. Themes in this category aligned with Skinner’s (1953) theory of operant conditioning. There were three themes identified in this section: risks, rewards, and balancing risks and rewards/neutral experiences. The risks identified were consistent with punishment or aversive events that are believed to reduce the likelihood of repeating a behavior. The rewards were consistent with both positive (receiving something of value) and negative

7 (avoiding something unpleasant) reinforcement that is believed to increase the likelihood of repeating a behavior. Participants detailed the pros and cons of sex work including factors that enabled its continuation or prevented an exit. Theme A: Risks. Participants in most studies reported violent and nonviolent crimes committed against them. There were multiple rapes, assaults, and nonviolent acts such as failure to pay for services or robbery. Perpetrators were customers, police, pimps, and other sex workers (Ashley, 2008; Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). In addition, they complained of conflicts with other sex workers and pimps over territory and fights in shelters with other youth (Curtis et al., 2008; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). CSEY in the included studies also coped with multiple health and safety risks such as sexually transmitted infections, injuries resulting from violence, and severe and often debilitating psychological sequelae associated with trauma (Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Monheit, 2010; Rees, 2010). Participants reported problems with overwhelming emotional and physical fatigue (Cecchet, 2012; Cobbina & Oselin, 2011; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004), concentration and focus, intimacy and interpersonal relationships, depression, suicidality, and psychosis that required therapy, medications, and self-care strategies (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Hurst, 2013; Meister, 2014; Monheit, 2010; Oselin, 2014; Rees, 2010; Stevens, 2012). . . . I know there are things as far as like STD’s and HIV and I don’t care. What I mean is, I really don’t care if a person want to go out there and have sex. I used to feel bad ‘cos there was a lot of kids got out there at an early age but . . . I actually have to go out there and make money, you know, so how can I care about the risks . . . (Rees, 2010, p. 104)

Involvement in commercial sexual exploitation also involved emotional risks and losses. Participants described fear due to actual and anticipated threats. They feared potentially violent clients, death, the dark, arrest, and being exposed as a sex worker (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). Youth discussed the losses associated with sex work that were both abstract and concrete. The loss of innocence, identity, jobs, and custody of children were described as particularly painful experiences (Cecchet, 2012; Curtis et al., 2008; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012). Although sex work was seen as a lesser evil compared to selling drugs, several participants verbalized that they felt

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disgust about their involvement in sex work and voiced concerns about their lifestyle being exposed to others (Ashley, 2008; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Monheit, 2010; Rees, 2010). Many experienced self-loathing and guilt and perceived discrimination and stigma from family members, the community, and police (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cobbina & Oselin, 2011; Curtis et al., 2008; Hurst, 2013; Monheit, 2010; Rees, 2010; Stevens, 2012; Williams & Frederick, 2009). Stigma regarding race emerged as an additional layer of stigma for youth (Cavazos, 2014; Cecchet, 2012; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Robinson, 2004). Black participants commented that perceptions of beauty, acceptance, and self-worth were influenced by skin tone (dark vs. light) and hair texture. Racial bias was present in their personal lives and in sex work. . . . and I also think it needs to be very clear . . . that this is culturally disproportionate. I see a lot of PSAs [prostitute serving agencies] with White girls in them and quite frankly that’s not the most sexually exploited youth . . . you’re talking about an African-American child, a Latina child . . . and it almost feels like as soon as the White community knew this was happening to their children it became a national epidemic . . . it didn’t mean shit before that . . . and . . . that is an unfortunate reality . . . . (Cavazos, 2014, p. 90)

Finally, although there were positive interactions with law enforcement reported (such as being rescued by an officer or being shown kindness), negative experiences were detailed by the participants in 15 of the 19 studies. Negative and abusive interactions included failure to assist when asked, harassment, entrapment, rape, quid pro quo sex acts, or forced informing to avoid arrest. Youth, unable to know whether law enforcement officials presented a threat to them, learned to mistrust the police who had the power to at least interfere with their ability to make money or at worst to arrest or abuse them (Ashley, 2008; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Meister, 2014; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). Theme B: Rewards. There were numerous rewards associated with sex work described by participants and that provided both negative and positive reinforcement for continued sex work. With housing and food as persistent needs (Ashley, 2008; Cavazos, 2014; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Holger-Ambrose et al., 2013; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009), youth were able to avoid hunger, homelessness, and substance withdrawal (negative reinforcement) when pimps provided access to these resources. They were also able to avoid some threats of violence by complying with the pimp’s sex work demands. Youth described the coercive tactics pimps used to continuously shape their behavior. They controlled money, withheld identification, and offered intermittent gestures of kindness (Bruhns, 2014; Cecchet, 2012; Cimino, 2013; Curtis et al.,

2008; Dank et al., 2015; Edinburgh et al., 2015; Hurst, 2013; Monheit, 2010; Robinson, 2004; Stevens, 2012; Williams & Frederick, 2009). Such is the power of effective slave training. When done properly—with just the right mix of isolation, degradation, violence, pain, terror, and occasional kindness—it can really be used to control someone body and soul. (Stevens, 2012, p. 90)

There were several external and internal rewards that provided strong positive reinforcement for continued sex work involvement. External rewards involved money, material possessions, the appearance of a glamorous lifestyle, and drugs. Many youth desired nonessential material goods. Youth enjoyed expensive clothing, cars, and/or electronics and viewed them as a way to achieve status. Sex work was a means to obtain them (Ashley, 2008; Cecchet, 2012; Cimino, 2013; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). In addition, the ability to earn money quickly was seen as a highly positive aspect of sex work. Youth reported that earning large sums of money in a short period of time was exciting, even if they were not able to keep it (Ashley, 2008; Bruhns, 2014; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Holger-Ambrose et al., 2013; Monheit, 2010; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). The ability to shop, travel, and attend parties with people who they perceived as wealthy was described as glamorous and an attractive aspect of the lifestyle (Ashley, 2008; Bruhns, 2014; Cimino, 2013; Curtis et al., 2008; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rothman et al., 2015). If youth expressed a desire to withdraw from sex work, regular customers offered to increase payment for them to return and addiction necessitated a regular income or source to obtain drugs (Cimino, 2013; Dank et al., 2015). Drugs, even if initially used recreationally, eventually progressed to use as a method of coping, to function, escape, or as a self-destructive behavior (Ashley, 2008; Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004). The internal rewards that provided positive reinforcement included a sense of validation and self-worth associated with sex work (Bruhns, 2014; Cimino, 2013; Hurst, 2013; Oselin, 2014; Robinson, 2004). Some participants viewed sex work as a marketable skill. They described feeling pride in their ability to provide a service to others (Bruhns, 2014; Curtis et al., 2008; Dank et al., 2015; Williams & Frederick, 2009). Furthermore, the sense of community that fellow sex workers experienced provided a surrogate family for youth who were estranged from relatives and caregivers. They shared resources, supported one another emotionally, helped with obtaining customers, and provided a safety net (Ashley, 2008; Curtis et al., 2008; Dank et al., 2015; Monheit, 2010; Rees, 2010). . . . I knew who my people were, where I belonged, who I belonged to . . . The good parts was the sense of belonging. I knew I belonged to that group of ghetto hustlers. (Monheit, 2010, p. 212)

Hampton and Lieggi Alternately, transgender youth viewed sex work as a means to express their gender identity. It was a way to achieve a feminine appearance (male to female transgender) and to “date.” Transgender youth often opted for black market hormones and procedures due to the lengthy process associated with gender transition care in a traditional health-care setting. Many described detrimental outcomes when using unidentified or unregulated substances or undergoing procedures by unlicensed practitioners (Ashley, 2008; Cavazos, 2014; Curtis et al., 2008; Rees, 2010). For transgender and cisgender youth, there were many opportunities for engagement within the health system. Although not all interactions were described as helpful, youth reported familiarity with and use of a wide variety of services. They were treated by providers including case managers, emergency medical technicians, physicians, therapists/psychologists, and residential counselors. They accessed services in the community, clinics, psychiatric and drug rehabilitation facilities, residential care, and acute emergency services. The quality of interaction ranged from highly supportive to nonresponsive and similar to their wariness of law enforcement officials, they also discussed a tendency to initially reject assistance due to lack of trust (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Williams & Frederick, 2009). These data indicate that there potentially many opportunities to identify and intervene with CSEY if they can be identified. Theme C: Balancing risks and rewards/neutral experiences. Sustained involvement in sex work required balancing the extremes of risk and reward to attempt to establish equilibrium. Youth learned to avoid and mitigate risks to the degree possible. Enhancing safety in sex work required learning a set of rules to avoid conflicts regarding territory, behavioral expectations set by the pimp, money exchange, and the sex worker hierarchy (Cavazos, 2014; Curtis et al., 2008; Dank et al., 2015; Hurst, 2013; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). Novices were mentored by more senior sex workers. Sex work activities were often organized by pimps around major events or on call, by referral, online advertising, and street solicitation (Cavazos, 2014; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Holger-Ambrose et al., 2013; Rees, 2010). Many CSEY participants perceived online communication as safer than street solicitation because they were able to screen potential clients before meeting in person (Cavazos, 2014; Dank et al., 2015; Holger-Ambrose et al., 2013; Rees, 2010). They learned common customer characteristics, types of services, and the process of financial transactions (Cecchet, 2012; Cimino, 2013; Curtis et al., 2008; Dank et al., 2015; Edinburgh et al., 2015; Oselin, 2014; Rees, 2010; Robinson, 2004; Williams & Frederick, 2009). In four studies, participants reported working without a pimp. Transgender youth, those involved in survival sex, and those approached directly by customers navigated sex work independently but also reported working with a pimp previously (Ashley, 2008; Bruhns, 2014; Monheit, 2010; Rees, 2010).

9 There were personal strengths described by some youth that helped to balance risks and rewards. Faith in a higher power was described as a source of comfort for some (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Meister, 2014; Robinson, 2004). Others described effective coping strategies, resilience, and tenacity that either helped them to survive or were developed as a result of sex work (Cavazos, 2014; Meister, 2014; Monheit, 2010). And you know, it’s not been easy with the [criminal] record that I have, but I think you prove yourself . . . And you reinvent yourself . . . you know, you knock on a front door and they don’t let you in. You knock on the side, they don’t let you in. I’m coming through the window, you know? I’m really tenacious, yeah. And I think those are some of the transferrable skills that come from the life that I led . . . . (Monheit, 2010, p. 216)

Category 3: Experiences leading to and following sex work exit. A limited number of studies focused on factors that influenced the exit process. There were two themes identified in this category: turning points and opportunity. Participants described how psychological sequelae, personal growth, life events, and support made an exit from sex work possible. Theme A: Turning points. Participants described intense psychological symptoms associated with sex work that escalated to a point that sex work could no longer be sustained. Rage, flashbacks, fear of the dark, emotional fatigue, guardedness, and relationship problems were described (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Hurst, 2013; Monheit, 2010; Robinson, 2004; Stevens, 2012). . . . it was becoming too much. I was tired of condoms, the smells, the people touching me . . . I watched a situation with a bikini barista—I saw this man handing a lady an unusually large tip, and I’m thinking, ‘oh I know [what they’re] doing,’ and then all of a sudden a flashback of stuff that happened when you’re in the life. I think I’ve shut down so many things emotionally . . . just because of the trauma. (Cecchet, 2012, pp. 70–71)

In addition to psychological symptoms, several participants reported distinct turning points that prompted the decision to exit sex work. For some, the shift occurred as an epiphany or spiritual experience. A shift was described from a moment-tomoment survival mind-set to one that focused on goals for education and career (Bruhns, 2014; Cecchet, 2012; Oselin, 2014; Rees, 2010; Robinson, 2004; Stevens, 2012). For others, involuntary commitments (incarceration or hospitalization) provided a means of escape. Pregnancy or children, fear, or no longer finding sex work tolerable inspired others to make the exit (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Cobbina & Oselin, 2011; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004). Theme B. Opportunity and support. There were a broad range of services needed to facilitate a sustained exit from sex work. Participants who were successful were able to obtain assistance

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with money, housing, and relocation. They were able to work on education goals and to obtain health care such as drug rehabilitation and mental health-care services (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Meister, 2014; Monheit, 2010; Oselin, 2014; Rees, 2010; Robinson, 2004; Rothman et al., 2015; Stevens, 2012). Attempts to escape commercial sex work were cyclical and marked by several attempts to leave followed by a return to sex work when stalked by the pimp or she or he was unable to meet survival needs. Youth also reported leaving one pimp to go to another (Cavazos, 2014; Dank et al., 2015; Robinson, 2004). Successful exits were often facilitated by fortunate circumstances when youth took advantage of opportunities that arose when the pimp traveled, was incarcerated, or youth were engaged with service agencies who supported them throughout the exiting process (Bruhns, 2014; Cavazos, 2014; Cecchet, 2012; Cimino, 2013; Curtis et al., 2008; Monheit, 2010; Rees, 2010; Robinson, 2004). Participants in three studies suggested that opportunities for education could be a way to prevent youth from entering sex work. They suggested educating at-risk youth about strategies that traffickers use for recruitment, providing mentorship, and for transgender youth providing services beyond safe sex education (Cavazos, 2014; Curtis et al., 2008; Rees, 2010). I think if . . . people went into the high schools and talked about and educated about prostitution at that time . . . I don’t think I would have did it. (Cavazos, 2014, p. 84)

Discussion Nineteen studies were included in this review that examined the experience of CSEY in the United States. The participants were primarily non-White (74%) females (58%). This is similar to other published studies (Bounds, Julion, & Delaney, 2015; Varma, Gillespie, McCracken, & Greenbaum, 2015). However, the representation of males (35%) is higher than what has been reported in many previous studies. The three categories and eight themes presented in the results describe the complex experiences associated with sex work entry, its continuation, and exit. The previously discussed theories of trauma (Finkelhor, Ormrod, & Turner, 2007) and behavior (Skinner, 1953) provide some context for understanding the underlying network of influences and psychosocial problems that entangle youth in sex work. Additionally, Bandura’s (1971) social learning theory, stating that behavior is learned by observation and imitation, could contribute to understanding the role that exposure to criminal activity might play in sex work entry. However, these theories were not developed to apply specifically to commercially sexually exploited populations. In 2008, Byrne and Trew developed a model to explain factors that promote an orientation toward crime or against it. This model might align more closely with the experience of CSEY and provide additional insight into the factors that influence its entry and exit. Byrne and Trew examined the experiences of 18 offenders (sex workers included) in Ireland and identified characteristics that led to the participants’ orientation

Table 3. Byrne and Trew’s (2008) Development of a Positive or Negative Crime Orientation. Characteristic

Definition

Negative informal social bonds

Poor ties with family, friends, or intimate partners. Problems with school, work, or community Family or social ties with persons involved in offending Risks of offending viewed as less costly than conformity

Bonds to offending friends Opposition to formal social institutions Personal problems Financial problems Low self-control

Category/ Theme 1A, 1C; 2A

1A, 1C; 2B, 2C 2B

Traumatic experiences, alcohol 1A, 1B; 2A, 2B or drug use, health problems Lacking money for basic needs: 1A,1B; 2B individual or family Thrill seeking or reactionary 2B decision-making

toward or desistance from crime. Because the characteristics were consistent with those of the participants in the reviewed studies, it is used as the context for interpreting the results. (Note that the term criminal offense is used because it was associated with Byrne and Trew’s work and should not be interpreted to mean that CSEY should be viewed as criminals.) According to the model, a positive orientation toward offending behavior was facilitated by negative informal social bonds, bonds to offending friends, opposition to formal social institutions, personal problems, financial problems, and low selfcontrol. Conversely, a negative orientation and desistance occurred when those characteristics and problems were addressed, that is, personal development and changes in social bonds, lifestyle, personal problems, and financial circumstances (see Tables 3 and 4 for definitions of each model characteristic).

Experiences That Preceded Sex Work Entry In this category, the three themes aligned with four of the six Byrne and Trew (2008) characteristics (see Table 3): negative informal social bonds, bonds to offending friends, personal problems, and financial problems. They also aligned with previous research. Reid’s (2014) study identified the methods pimps used to recruit CSEY. Romance, flattery, assistance with meeting survival needs, and normalizing sex work were effective strategies that resulted in the girl’s adherence and loyalty. Running away from home, childhood abuse, and truancy were also consistent with Basson et al. (2012); Cole et al. (2014); and Salisbury, Dabney, and Russell (2015) and collectively contributed to developing a positive orientation toward sex work.

Experiences That Facilitated Sex Work Continuation The three themes in Category 2 aligned with all six of Byrne and Trew’s (2008) characteristics (see Table 3), and previous literature supports several of the challenges experienced by the

Hampton and Lieggi

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Table 4. Byrne and Trew (2008): Desistance From Criminal Offending. Characteristic

Definition

Personal development

Changes in identity and maturation Repair of family and social ties Severing ties with offenders Resolution of drug or health problems Resolution of financial challenges

Changes in social bonds Changes in lifestyle Changes in personal problems Changes in finances

Category/ Theme 3A 3B 3B 3A 3B

participants. Gibbs, Hardison Walters, Lutnick, Miller, and Kluckman’s (2015) study of a case management program for CSEY survivors reported that needs for food, housing, and assistance with benefits were persistent. It is important to understand that youth who continue to have unmet needs, even while receiving services, will not have the ability to exit sex work. In Varma et al.’s (2015) study of CSEY who were treated at a pediatric emergency department, 31% reported violence associated with sex and 75% reported violence inflicted by police. Although troublesome to acknowledge, these reports of law enforcement abuses must be taken seriously. In Northern California, charges were filed against several officers for crimes involving an adolescent sex worker. The officers were terminated after the suicide note of an officer implicated himself and other officers within the several local departments (McKirdy & Sidner, 2016). Since law enforcement officials are among the professionals most likely to come in contact with CSEY, youth must be able to trust that they can safely report abuse and receive support services. For transgender youth, gender expression (under the theme of rewards) aligned with opposition to formal institutions. Burke, McCauley, Rackow, Orsini, and Simunovic’s study (2015) acknowledged the need for specialized services for transgender youth involved in sex work. Similar to cisgender CSEY, they also engage in sex work to meet basic needs, but it is also one of the limited opportunities to live a life more closely aligned with their gender identity. The development of the emotional connection to the pimp has been explored in the previous research (Reid, 2014), but there has been less attention given to the bond with friends and even customers in the sex work community. Although force and coercion were substantially involved in sex work, it is important to acknowledge that for some (and/or at some times), personal agency creates a barrier to sex work exit. The intermittent reinforcement of relatively positive experiences might explain why youth could be reluctant to report commercial sexual exploitation. Bandura’s (1971) social learning theory suggests that intermittent rewards effectively reinforce behavior.

Experiences That Facilitated Sex Work Exit For Category 3, both themes aligned with at least one of the five characteristics of Byrne and Trew’s (2008) desistance

model (see Table 4). Gibbs et al.’s (2015) study of four CSEY service agencies reported that 57–91% of youth required crisis or mental health service intervention, 29–73% received family reunification or counseling services, 17–78% benefits assistance, and 80% housing services. For participants in this review, relationships with professionals or personal support networks served as a means to disrupt negative social bonds when they coincided with sex work fatigue and an opportunity for escape. The results of this review should be interpreted in the context of its limitations. Approximately half of the studies included in the review lacked a specific qualitative methodology. Nonetheless, the methods of recruitment, interviewing, and data analysis were described as rigorous processes and met the stated purpose of the investigators. Second, the reviewers extracted findings and themes based upon the investigators’ analyses and data identified within participants’ quotes. It is possible that the themes identified in each study do not reflect the original investigators’ interpretations. However, the quotes were examined systematically and were found to be congruous with themes that appeared in participant quotes across studies. Finally, qualitative research is not intended for generalizability. However, the aggregate sample was large and represented a broad cross section of CSEY in the United States. The studies provided rich illustrations of each theme and credible evidence to support the data.

Implications for Practice To address the needs of CSEY, Bounds, Julion, and Delaney (2015) presented a practice-oriented set of recommendations based upon the Illinois Child Welfare System’s implementation of the United States’ first safe harbor law. The recommendations pertained to assessment, improved service delivery, building awareness, addressing gaps in the law that prevent effective service delivery, and specialized training for service providers. Studies by Burke et al. (2015) and Gibbs et al. (2015) evaluated intensive case management care models for CSEY service delivery. In Burke et al.’s. (2015) collaborative care model, services were delivered by an FBI victim specialist. Specialists facilitated service delivery including legal, health, and basic needs across systems of care. Although the case studies presented demonstrated successful outcomes, the level of training and ability to work across systems might be difficult to achieve without FBI resources and training. Gibbs et al.’s (2015) case management program provided holistic services for crisis management, health, food, clothing, education, housing, employment, family reunification, legal services, and substance use. The challenges for the program included a lack of available services or participants’ reluctance to use them due to fear or mistrust. Regarding screening, currently, there is no consensus regarding implementation of screening for CSEY and youth at risk for exploitation. Salisbury et al. (2015) implemented a pilot intervention to identify CSEY in a juvenile court system.

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Of 535 youth who participated in screening interviews, 47 were identified with risk factors common to CSEY, and 6 were confirmed as CSEY survivors and referred to services. This approach has the potential to identify survivors, but its use would require expansion beyond criminal justice to other service settings in which CSEY present such as schools, social service, and health organizations. Based on Finkelhor et al.’s (2007) findings that polyvictimization has been associated with more pronounced trauma and psychological symptoms, Musicaro et al.’s (2017) review of three high-risk groups for polyvictimization (including CSEY) recommends screening for its manifestations in all settings in which youth and young adults are served. The review highlights the complexity that individuals experiencing polyvictimization introduce to health, social service, and criminal justice systems. Trauma-informed approaches to care are also recommended to reduce the likelihood of revictimization and poorer health outcomes.

Implications for Practice, Policy, and Research

Implications for Research and Advocacy

The authors would like to thank the authors of the reviewed studies and their participants for contributing to the understanding of this complex phenomenon and Ms. Chloe Hampton for contributing to the organization of data and reporting of the results.

1. Need to build the infrastructure for services that allow for information sharing and collaboration between agencies that serve CSEY. 2. Implementation of screening for polyvictimization to identify CSEY in school, health, social service, criminal justice, and law enforcement settings. 3. Professionals in each discipline require specialty training appropriate for their roles. 4. Law enforcement personnel require policies and procedures that hold officers who abuse power accountable and create a safe setting for youth to seek assistance. 5. Potential opportunities to facilitate exit include emotional fatigue, internal shift in life goals, absence of trafficker, and engagement with a service agency.

Acknowledgments This review synthesized the qualitative literature regarding the experience of CSEY in the United States. This knowledge can be used as a foundation to develop effective response, advocacy, and intervention programs for CSEY and youth at risk for exploitation.

Conclusions Sex work involvement can be fraught with experiences that both repel (violence, jail, and fear) and reinforce the activity (attention, acceptance, and fast money). Understanding the barriers and facilitators of sex work can guide CSEY service development for all disciplines. See summary of the review’s critical findings and implications for practice, policy, and research. CSEY and youth at risk for exploitation encounter professionals in education, law enforcement, criminal justice, social service, and health care. Legislation and policies that allow for collaboration can ensure continuity of care. With providers trained in health, legal, and social service provision, intensive case management is a model of care that is promising.

Critical Review Findings 1. 2.

3. 4. 5. 6.

Layers of psychological, physical, and environmental traumas preceded commercial sexual exploitation (CSE). Deterrents to reporting abuses involved: nonaction, repercussions by traffickers, family separation, or a need to return to sex work because of unmet needs. Abusive interactions with police were described frequently and led to mistrust. Aspects of sex work viewed as positive create barriers to exiting sex work. Service coordination is needed. CSEY who are caring for others might require more. In addition to the needs of cisgender CSEY, transgender youth require safe psychological and medical care throughout the transition process and mentorship.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Michelle DeCoux Hampton is a professor and Doctor of Nursing Practice Program Director at Samuel Merritt University in Oakland, CA. She has clinical expertise in adult psychiatric–mental health nursing care in both inpatient and outpatient mental health programs in administrative and direct care roles. Her research experience has focused on phenomena associated with the experience of severe mental illness, racial disparities in mental health care, exploring the decision-making process regarding health service utilization among mental health consumers, psychiatric and medical comorbidity, and risk factors for HIV and Hepatits C Virus (HCV) transmission in adults with severe mental illness. More recently, she has participated in the evaluation of juvenile justice programs to reduce recidivism among youth offenders and the experience of commercial sexual exploitation by adolescents. Michelle Lieggi is a clinical research librarian at the University of California, San Francisco (UCSF) Medical Center Fishbon Library. She has provided research support for clinical staff at San Francisco General Hospital and UCSF Parnassus campuses. She provides literature searching and teaching to UCSF Medical Center staff in support of systematic reviews.