Annotated Bibliography For Child Abuse Project Hi My assignment is based on research articles that I will use in my dissertation. My dissertation is based
Annotated Bibliography For Child Abuse Project Hi My assignment is based on research articles that I will use in my dissertation. My dissertation is based on the lack of research regarding commercial sexual exploitation of LGBT youth. For this assignment I need annotated bibliographies the attached articles. I’ve also attached the sample annotated bibliography from my school, please note the bibliography must be a minimum of 3 paragraphs each. In 45 pages, cite and annotate 10 articles from peer-reviewed journals that you would include in your literature review. In your annotation, be sure to include an explanation of how the articles relate to your Dissertation topic. Chameleons Eye / Shutterstock ©
A multidisciplinary response to commercial sexual exploitation of children
34 The Nurse Practitioner Vol. 41, No. 11
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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A multidisciplinary response to commercial sexual exploitation of children
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A multidisciplinary response to
commercial sexual
exploitation of children
Abstract: Commercial sexual exploitation of children (CSEC) is associated with
child abuse, neglect, poverty, homelessness, and societal causes. Sex trafficking is the
participation in commercial sex acts in which force, fraud, or coercion occur. This article
discusses the scope of CSEC and sex trafficking, and the necessary identification skills
and medical evaluations needed to help these patients.
By Pamela T. Avila, MSN, FNP-BC, PNP-BC
ommercial sexual exploitation of children (CSEC)
is a form of child abuse in which minors are involved in sexual activity in exchange for something
of value to the child.1 CSEC can include pornography, strip
dancing, escort services, Internet-based exploitation, and
gang or family-based prostitution.1
Sex trafficking is defined as the recruitment, harboring,
transportation, provision, or obtaining of a person for the
purpose of a commercial sex act.2 Children may be trafficked domestically or internationally, and trafficking does
not require that victims be transported from one location
to another.1
C
? Case example
A 14-year-old teen is a frequent runaway from her foster home
with truancy problems and a history of abusing multiple drugs.
Her parents have been incarcerated at various points for drugand alcohol-related charges during her childhood. The teen
has been in foster care for 4 years and alternately lived with
relatives in Arizona, who sent her back home to Portland,
Oregon, because they could not handle her.
The teen was recently picked up on the street by an older
man who gave her food and brought her back to his apartment.
He had sex with her several times over the next 2 months. After
being found by her caseworker, the teen disclosed that she had
been hit in the face by the older man, who swore at her and gave
her methamphetamine and alcohol. When asked for details by
her caseworker, the teen makes only vague remarks about her
street life and possibly having had sex with other older men.
She mentions that she thinks she may be pregnant, having
had no period for 3 months, and seems ambivalent about the
possibility of pregnancy.
? Scope of the problem
Every year, 1 million children are trafficked internationally. Sex trafficking is common in countries where women
and children are marginalized and where police corruption
is rampant.3 In Southeast Asia, Eastern Europe, and Latin
America, children are often sold into sex labor to support
families. Families may be disrupted because of armed conflict
and forced migration.3 Often lacking legal travel and immigration documents, children may be enticed by traffickers
Keywords: child abuse, commercial sexual exploitation of children, CSEC, sex trafficking
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The Nurse Practitioner November 2016 35
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
A multidisciplinary response to commercial sexual exploitation of children
who promise employment, schooling, passports, residency,
documentation, or marriage. Sex trafficking is highly profitable and is the fastest-growing industry for organized crime,
bringing in $5 billion worldwide.3 Unlike drugs, humans may
be sold repeatedly.
Most victims are trafficked within their own countries.
In the United States, sex trafficking of children is an unrecognized epidemic, and estimates are difficult to quantify
for a variety of reasons. Thousands of youth run away from
home each year; up to a third of them may be lured into
transactional sexual encounters within 48 hours of leaving
home.4 The nonprofit organization ECPAT-USA estimates
that about 5,000 to 6,000 children are involved in domestic
sex trafficking annually in the United States.5 However, the
U.S. Department of Justice estimates that about 200,000
children are involved in sex trafficking each year; the reality
is that the data are not collected reliably due to the hidden
nature of the crime.1
Many misperceptions exist among professionals as to the
scope of the problem. Although CSEC exists throughout the
United States, professionals in smaller and rural communities are often unaware that there may be a problem with
sex trafficking of minors in their area. Consequently, less
recognition and reporting, less professional training, and
fewer victim services are available in smaller communities
than in large metropolitan regions.6
An example of this paradigm shifts impact occurred in
Sweden in the 1990s. While the sale of sex was legalized in
1995, the purchase was not, making buyers the criminals.
Since 1995, the incidence of street sex trafficking has been
halved; however, critics of the law state that buyers may be
now bringing the market underground by electronic and
cellular means, thus potentially putting more women at risk
and increasing the stigma.7
In the United States, protection for victims varies by
state. Federal law offers legal protection so victims cannot
be punished for participating in illegal activities while they
were being trafficked. The federal Victims of Trafficking
and Violence Protection Act focuses on the prevention of
sex trafficking, protection of victims, and prosecution of
perpetrators.2 Victim services including healthcare, shelter,
and even monetary restitution are available.
? Risk factors and health consequences
Between 78% and 91% of the victims of CSEC have a history
of physical or sexual abuse.4 About 64% report a history
of parental substance abuse.4 Many CSEC victims come
from neighborhoods where poverty, high crime rates, and
violence exist. Eighty-one percent have a history of running
away.4 Many commercially sexually exploited adolescents
identify as lesbian, gay, bisexual, transgender, or questioning.4 Other risk factors include psychological problems,
such as poor self-esteem, depression,
substance abuse, or social isolation.8
Adolescents with disabilities have three
Victims of CSEC may exhibit signs of postto four times the risk of physical and
traumatic stress disorder, such as anxiety,
sexual abuse compared with those who
depression, hypervigilance, or paranoia.
are not disabled.9
Many of the risk factors associated
with CSEC are related to child abuse
and neglect and have serious health implications. AccordIt is essential that healthcare professionals examine the
ing to the Adverse Childhood Experiences (ACE) study
language used to describe victims of commercial sexual
conducted by Kaiser Permanente and the CDC, there is a
exploitation and the biases implied by the terminology. The
strong cumulative, synergistic relationship between certain
use of words such as child prostitute defines the child as a
negative childhood life events and adult diseases, such as
perpetrator rather than a victim of a crime. By using terms
ischemic heart disease, cancer, chronic lung disease, skeletal
such as CSEC, law enforcement and other professionals
fractures, and liver disease (see Adverse childhood experiences
change their response to victims. Transactional sex can be
affecting adult health).10,11
normalized by the desensitization of words such as pimp,
john, and ho. Preferable use of language such as trafAdverse childhood experiences studied included psyficker, buyer, and victim recognizes the roles of those
chological, physical, or sexual abuse; violence against the
involved in sex trafficking without minimizing the impact
childs mother; or living with household members who were
of the crime and deflecting responsibility from those who
substance abusers, mentally ill, suicidal, or previously incarneed to be held legally accountable. Anyone who is forced
cerated. Sexually abused children are 27 times more likely
into sex acts is a victim, whether or not coercion, fraud, or
to be arrested for prostitution as adults than children who
threats are used.2 The correct use of language by healthcare
were not abused.10 Other problems correlated with higher
providers helps break stereotypes and creates opportunities
ACE scores include teen pregnancy, HIV and other sexufor policy changes.
ally transmitted infections (STIs), homelessness, criminal
36 The Nurse Practitioner Vol. 41, No. 11
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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A multidisciplinary response to commercial sexual exploitation of children
behavior, substance abuse, and mental illness. Homeless
youth involved in transactional sex are 20% more likely to
attempt suicide.4
? Traffickers, buyers, and facilitators
Recruitment of children for sex trafficking may occur at
transit stations, malls, homeless shelters, juvenile justice
centers, schools, or online social networks. Recruitment
can occur as part of a family business, providing income by
trafficking minors sexually. Many former victims are also
hired to recruit peers. The average age at recruitment is 13.1
By the time victims are in their 20s, traffickers are usually
done with them.
Methods of recruitment by traffickers include what has
been called finesse pimping, in which victims are seduced
by gifts of clothes, cash, shelter, food, or drugs. Guerilla
pimping, by contrast, may include coercion, kidnapping,
aggression, threats against family, degradation, isolation,
enslavement, or torture.1
The buyers are mostly men of all ages. They may be
single or married; some have teenage daughters. They are
represented by all professions and socioeconomic statuses.12
Although many have no previous criminal record, buyers
often rationalize crime as a way to have sex without commitment, considering the sex a business transaction or service.
Fathers have been known to hire CSEC victims to teach a son
to become a man. Adolescents have been hired to provide
sexual acts at stag parties, to entertain clients, or simply to
provide sexual experiences that a buyers partner will not
perform.8 Facilitators include those who are peripherally
involved, such as taxi drivers, hotel owners, Internet businesses, government officials, or gangs who perpetuate the
crime or look the other way.
? Identifying at-risk adolescents
Identifying adolescents involved in sex trafficking can be
difficult, as it is a clandestine industry. CSEC victims may
be intercepted through law enforcement or child protection services as cases of curfew violation, drug offenses, or
as runaways/truants. Most commonly, healthcare providers will encounter them when they present in a clinic as a
result of assault, sexual abuse, or to seek contraception or
STI treatment.
Little research exists, but by one estimate, 25% of CSEC
victims had seen a healthcare provider in the last 6 months
(mostly ED, outpatient, or family planning clinics).4 Although 80% to 98% of CSEC victims in the United States
are female, these numbers may be skewed.4 Males are often
more difficult to identify, may be less likely to have a trafficker, and are therefore more likely to be invisible to
data collection.
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Adverse childhood experiences affecting
adult health8
Sexual abuse
Physical abuse
Emotional abuse
Physical neglect
Emotional neglect
Addicted household member
Incarcerated household member
Chronically mentally ill household member
Violence to mother
Not raised by biological parents
Some behavioral clues that may lead NPs to suspect
adolescents are being trafficked include having excessive
amounts of cash, new clothes and accessories, hotel keys,
and false identification. They may seem unfamiliar with
their location if they have traveled from somewhere else.
Trafficked adolescents may be accompanied by an older,
controlling boyfriend or someone who falsely identifies as
a family member, and victims may be unable to make eye
contact with the person who presents with them.
Victims may exhibit signs of posttraumatic stress disorder, such as anxiety, depression, hypervigilance, defensiveness, or paranoia.13 CSEC victims may also cope by engaging
in substance abuse and adopt a materialistic or self-sufficient
persona, rationalizing that they are professionals.
A common psychological response to trauma is known
as repetition compulsion, which entails repeating similar
experiences in an attempt to master previous traumatic
abuse.13 CSEC victims often have Stockholm syndrome, a
condition in which kidnapped individuals are brainwashed
by their captors. They may turn passivity to activity by identifying with the aggressor, refusing the help of rescuers, and
appreciating the smallest act of kindness by the captor. This
is also known as trauma bonding and may occur in situations where survival is threatened, individuals are isolated,
and escape is next to impossible.13
Physical clues to be suspicious of include bruises, cuts,
bites, patterned injuries, ligature marks, blunt trauma,
branding/tattoos of a pimps name or barcodes, frequent
STIs, genital trauma, cutting (self-harm), traumatic alopecia,
intoxication/withdrawal, and I.V. drug abuse tracks.
? Challenges and interventions
One of the major challenges for NPs is dealing with the
emotional armor in which CSEC victims encase themselves.
Many trafficked adolescents distance themselves from those
who might help them by developing a tough exterior.13 The
NP has to develop certain skills in order to successfully engage with a child who is hesitant. How does the NP convince
The Nurse Practitioner November 2016 37
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
A multidisciplinary response to commercial sexual exploitation of children
asked what she needs most from the clinic staff. Although
she should be offered STI testing and prophylaxis, toxicology
screening, and contraception, she might state that she only
wants a pregnancy test.
Explaining that nurses must act as mandated reporters
of child abuse, the NP should strive to give the teen as much
control as possible over aspects of her care. The NP should
ask questions in a sensitive and nonjudgmental manner, giving the teen a sense of autonomy. The
teen may need a great deal of reassurance that she would not need to discuss
Child victims of sex trafficking need to be told
information or endure any procedure
that the NP or medical examiner is mandated
she did not feel comfortable with.
to report any suspicions of sexual abuse.
If the teen discloses that she is being
commercially sexually exploited, the
NP might ask her how ready she feels
to accept help. Using motivational interviewing techniques,
interview and exam by asking permission at appropriate
the NP might ask the teen to give her readiness a number
junctures. Making no false promises about what services can
from 1 to 10, with 1 being totally uninterested in leaving
be provided and being sure to review limits of confidentiality
and 10 being completely ready with a plan in mind. If the
will help to develop trust.
teen indicates she is a 4, the NP might say, Great … what
NPs need to see CSEC victims as compliant victims
makes you say 4 instead of 1 or 2? This would give the
who do not identify as such. Nevertheless, it is important
teen an opportunity to openly discuss her ambivalence, as
to recognize that CSEC victims are complex, and trust is
well as focus on the confidence she has about making this
instilled over time. Asking screening questions during an
important lifestyle change. In this patient-centered way, the
exam is a good way to ascertain whether the adolescent is
teen and the NP are more likely to establish trust.
involved in or at risk for trafficking (see CSEC screening
questions).
? Medical exam and treatment
One method of providing patient-centered care is apAny child or adolescent suspected of being trafficked should
plying the Stages of Change Model, which explores patients
have a complete physical exam with his or her permission.
ambivalence toward behavior change. The use of motivaAccording to local law enforcement jurisdictional and institional interviewing techniques, including reflective listening,
tutional protocols, if an adolescent discloses sexual assault
learning to deal with resistance, focusing on change talk,
within the past 84 hours, a forensic evidence exam (rape
and goal setting can encourage patients to make healthy
kit) should be performed.14 If the victim is an adolescent,
changes. This will then improve their self-efficacy and ability
to make beneficial lifestyle choices.
this can be performed by a sexual assault nurse examiner
In the case study of the 14-year-old teen, the NP might
(SANE) or any healthcare provider who has specialized
observe physical injuries and ask if someone is hurting her.
training in the collection, documentation, and preservation
Another question might be whether anyone was taking care
of sexual assault evidence.14
of her, or whether she had attempted to get any medical care
Prepubertal children may have forensic evidence colafter she was injured by the older man. She should also be
lected within 72 hours of assault and should be examined by
a pediatric SANE or referred to a local child abuse clinic.14
While the victim may be ambivalent about reporting details
CSEC screening questions
of the assault, he or she should be reassured that providing
details of the assault is not a requirement for receiving a
Have you ever run away?
Where do you stay/sleep?
complete exam and treatment.15 Child victims of sex traf How do you make money while on the run?
ficking need to be told that the NP or medical examiner is
Are you in charge of your own money?
mandated to report any suspicions of sexual abuse.
Is someone looking after you?
The purpose of a complete exam is to determine the
Have you ever exchanged sex for food, money, shelter,
or drugs?
degree of any physical injury and evaluate the patients
Have you been threatened or harmed?
mental and physical health status. Physical injury might in What does your tattoo mean?
clude fractures, concussions, strangulation, genital trauma,
CSEC victims of their exploitation when the victims do not
think they are being exploited? How do NPs work with a
girl who considers her trafficker a daddy and says she is
in love with him?
Trafficking victims should be told that they are deserving of care with a nonjudgmental approach; they should not
be seen as offenders. The NP should talk with the adolescent alone and be sure to give him or her control over the
38 The Nurse Practitioner Vol. 41, No. 11
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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A multidisciplinary response to commercial sexual exploitation of children
bruising, bites, and burns. Mental health assessment should
include determining whether the patient has any suicidal
ideation, depression, anxiety, substance abuse, and/or need
for detoxification.
Presumptive STI treatment for gonorrhea and chlamydia as well as testing for hepatitis B, C, syphilis, and HIV
should be addressed (see Initial diagnostic testing for victims
of CSEC). Female CSEC victims should be screened for
pregnancy and offered prophylaxis, prenatal care, or safe
pregnancy termination. Treatment of other acute conditions
should also be offered for any other acute condition, such as
hepatitis A, tuberculosis, methicillin-resistant Staphylococcus
aureus, endocarditis, asthma, malnutrition, dental infections,
and the like.15
Postexposure prophylaxis (PEP) to prevent HIV infection is controversial. While the risk of HIV transmission can
be high, the patient must be followed reliably. Determining
risk of HIV transm…
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