Mental Health Impact of Adolescent Sex Trafficking in the US

Mental Health Disparities of American, Female Sex Trafficking Victims Ages 12-18
Health Disparities
Imani S. Berry
Rollins School of Public Health
Emory University

Adolescent Sex Trafficking Victims 2
Abstract
Approximately 325,000 female adolescents ages 12-18 are currently at risk for being victims of
sex trafficking in the United States.1,2 The traumatic experiences before and during sex
trafficking often lead adolescent victims to have poorer health outcomes than their non-trafficked
counterparts, displaying higher levels of post-traumatic stress disorder (PTSD), anxiety, and
depression.3 Risk factors for trafficking span across individual, interpersonal, and societal levels,
ranging from housing instability to the perpetuation of gender-based violence in American
society at large.2 When examining trafficking prevention from a sociocultural perspective,
researchers recommend using a human-rights based approach, versus an anti-trafficking
approach.1 Effective mental health treatments for this population incorporate a myriad of
behavioral, sociological, and psychological methods, including patient education, individual and
group therapy. More research efforts are needed in the areas of sex trafficking prevention, victim
identification, and post-trafficking assessment and treatment.1,4
Introduction
According to national reports, there are currently over 325,000 adolescents between the
ages of 12-18 that are at-risk for domestic minor sex trafficking (DMST) in the United States.1,2
Victims of domestic minor sex trafficking display significantly higher rates of Post-Traumatic
Stress Disorder (PTSD) (77%), depression (55%), and anxiety (48%) compared to adolescents
who are not victims of sex trafficking.3,5 Fifty-seven percent of victims display comorbidity of
all three disorders.2,3 The effects of these mental health disorders can be debilitating and include
symptoms ranging from recurrent flashbacks to suicidal thoughts or actions.6 While researchers
have developed effective interventions to prevent sex trafficking and treat its mental health

consequences, the prevalence of adolescent victims continues to rise.7 Given that adolescents
make up the large majority of victims in the United States, there is a growing need to examine
the health impact of adolescent sex trafficking across individual, interpersonal, community, and
societal levels.5
Definitions
As sex trafficking becomes a growing threat to public health, it is important to first
understand the myriad of terms used by researchers to describe this phenomenon. Broadly, sex
trafficking is defined as the recruitment, transportation, transfer, harboring, or receipt of persons
for the purposes of sexual exploitation.1,2 Severe sex trafficking, the phenomenon explored
throughout this review, refers to the forced engagement in, and completion of, sex acts resulting
from physical or emotional coercion.6 Traffickers carry out this coercion, or sexual exploitation,
by establishing a hierarchical relationship with the victim, in which the victim is powerless to the
control of her trafficker.2 Within this context, there is much debate about whether sex trafficking
and sexual exploitation differ from prostitution. Prostitution is often portrayed as a voluntary
decision to solicit or perform sexual favors; however, this ideal has not been supported by
empirical data.2 In fact, approximately 95% of prostituted females report a desire to leave the
lifestyle, but lack the necessary resources to do so, a sentiment also shared by sex trafficking
victims.8 This shared sense of entrapment between females labeled “prostitutes” and females
who are labeled “victims” gives rise to the concept that all females involved in the sex trade
should be considered victims, both in the United States criminal justice system and society at
large. This ideal will be further explored in this review.

Prevalence of Sex Trafficking in American Adolescents
Within the profit-driven industry of sex trafficking, the commercial sexual exploitation of
children (CSEC) has become a growing concern in the United States. 1,2 Adolescents between the
ages of 12-18 have the fastest growing prevalence of all sex trafficking victims.2 Researchers
posit that there are approximately 325,000 female adolescents currently at risk for being
trafficked, of which an average of 2,000 new cases are reported to law enforcement within a 2-
year period.2 Researchers estimate there are nearly 50,000 adolescent victims per year.5 The
average age of initiation occurs between the ages of 12-14; however, most victims lack access to
health care respondents until age 15 which perpetuates the challenge of trafficking prevention.9
The covert nature of sex trafficking, combined with the lack of a ‘best practices’ data collection
tool to track victims, makes it difficult to report accurate prevalence rates.9 Additional factors
limiting prevalence data include the misidentification of victims by healthcare workers,
conflicting state and federal laws regarding criminalization, victim perceptions, and the absence
of public awareness regarding the nature of sex trafficking.5 While there has been an influx of
interest in researching this population, most prevalence studies will inherently lack accurate
prevalence statistics.10 Given these limitations, each statistic reported in this review should be
considered an underrepresentation of national prevalence of this population.
A major factor contributing to underreported prevalence rates of victims is that traffickers are
able to utilize a myriad of mediums to exploit their victims.7,11,12 The most common locations for
commercial exploitation include bars and clubs, residential brothels, street operations, and escort
services.7 Club operations include cantina bars, exotic dancing clubs, massage parlors, hostess
clubs, and karaoke clubs.7 Residential brothel settings include homes, apartments, hotels, and
mobile trailers.7 Street operations include solicitation occurring on-street or at truck stops.7

Escort services commonly advertise victims on internet websites, telephone chat lines, and
private boat cruises.7 To assist in capturing more accurate prevalence statistics, it is
recommended that CSEC advocates maintain a presence in these commonly utilized locations.
While researchers cannot determine exact prevalence and incidence rates for adolescent
sex trafficking, they contend that perceptions of the severity CSEC vary across different
geographical locations. Researchers Cole and Sprang conducted a telephone survey of 289
healthcare professionals who work with at-risk youth and live in an undisclosed southern, rural
state in the United States.13 The purpose of this study was to examine respondents’ awareness,
knowledge, and perception of the severity of CSEC within their respective metropolitan,
micropolitan, or rural communities.13 Results indicated that professionals working in
metropolitan communities were more likely to view CSEC as a serious problem in the state
compared to other professionals. Metropolitan respondents also had received more training on
human trafficking and were more familiar with federal and state laws surrounding human
trafficking.13 Approximately 55% of metropolitan respondents had previously worked with a
suspected or definite victim compared to only 30% of respondents from micropolitan
communities.13 Based on these findings, researchers call for more awareness- building efforts,
training in non-metropolitan communities, and an identification of best practices for mental
health treatment.13 These research recommendations will be further examined in this review.
Trafficker Characteristics and Initiation of Victims
A trafficker, or pimp, is someone who procures clients, or buyers, for the victim and is
the primary recipient of all monetary or social rewards from her services.5 Traffickers can be
difficult to identify because their characteristics span across all social, ethnic, and racial groups.14
Research shows that 50% of traffickers are family or friends of the victim and are often engaged

in local gangs and other forms of organized crime.5 Based on results from a self-report study
reports from former sex traffickers, traffickers commonly possess no more than three victims at a
time.5 Although traffickers are most commonly male, they often utilize females to manage their
trafficking operation who are responsible for governing the ways in which the victims interact
with one-another. Next to the pimp or trafficker, the “bottom” who is also a victim herself, is at
the top of the hierarchy and serves as a manager of operations.14 In most cases, the “bottom” has
been with the trafficker the longest and the trafficker believes she is capable of managing the
other victims.14 Typically, the “bottom” is responsible for collecting the money that other victims
earn, disciplining them using methods taught by the trafficker, and luring other minors into the
lifestyle.14
Traffickers recruit victims from homeless shelters, runaway hangouts, schools, malls,
group homes, shelters, playground, and social media accounts like Facebook.5 Traffickers also
engage in trading victims as a method of procurement.5 Traffickers have been known to target
the most vulnerable and needy adolescents who can be easily manipulated into submission.5
Traffickers engage the victims by showing them affection and buying them gifts, such as food
and jewelry, in exchange for sex. 5
Once victims are lured, the seasoning process begins in which the victims develop a bond
with their captors.5 This process has also been referenced as the “trauma bond”, a process by
which the trafficker instills fear in the victim as well as gratitude for his keeping her alive.5
During this process, victims often develop a pattern that has been related to “Stockholm
Syndrome” in which they are loyal to, and defensive of, their perpetrators.5 As part of this
“brainwashing” process, traffickers strip victims of their previous identities, giving them new
identification cards, social security cards, driver’s licenses, and birth certificates.5 Throughout

the course of the operation, victims are subjected to starvation, spatial confinement, rape,
physical abuse, threats of violence to themselves and the victims’ families, and forced drug use.15
These practices force the victims to be psychologically, emotionally, and physically dependent
upon their trafficker, which promulgates their obedience to his demands.5
Buyer Characteristics
Most research on the buyers, or customers, of victims is primarily reflective of
international purchasers for sex and pornography in the United States.5 In general, most buyers
are white males who prefer sex with virgin victims because of their decreased risk to possess a
sexually transmitted infection.5 Buyers are identified across three categories: situational,
preferential, and opportunistic.5 Situational buyers purchase sex and sex acts with adolescents
based on their availability. Preferential buyers, commonly pedophiles, only seek services within
the market of young children. Contrary to the others, opportunistic buyers have the widest span
of purchasing power, and have no interest in purchasing victims of a specific age or based on a
victim’s willingness to perform. Major organizations, such as Marriott, Time Warner, and AT&T
invest in the pornography trade, which earns them millions of dollars per year.5 Because
adolescents are the target of the industry of sexual exploitation, researchers contend that these
organizations are perpetuating the problem.
Psychological Impact of Sex Trafficking
Post-trafficking victims often experience numerous stressors that contribute to
developing or worsening mental health disorders. Common stressors include experiencing the
stigmas that are associated with sex work, the stressful return to their dysfunctional families, and
the reminder of poverty and unemployment that initially caused them to leave.3 These factors

will be further examined in the Risk Factors for Trafficking section of this review. Research
shows that most victims struggle with debilitating symptoms that impair their integration into
new environments or their reintegration into old ones. In general, victims who possess social
support experience less severe symptoms compared to victims who do not have social support.3
While some victims receive formal psychiatric care for their symptoms, many lack access to
these services. Among those who do receive services, research shows that the most common
disorders reported post-trafficking are PTSD, depression, and anxiety.3
Mental Health Disorders: PTSD, Depression, and Anxiety
Post-traumatic Stress Disorder, abbreviated PTSD, typically occurs as a result of a
person’s experience with an aversive, traumatic event or threat to their physical wellbeing.6,16
Historically, researchers posited that only war veterans could experience symptoms of PTSD up
until the end of the Vietnam War; however, after assessing victims of natural disasters and other
aversive stimuli, researchers believe anyone can experience symptoms of PTSD.6 In 2010, the
U.S Department of Health and Human Services released a report detailing the perceived severity
of symptoms experienced by female trafficking victims with PTSD.17 Overall, most victims
reported severity in the areas of recurrent thoughts or memories, being easily startled or “jumpy”,
trouble sleeping, avoiding certain activities, and had emotional reactions upon being reminded of
trafficking events.17 PTSD involves a “fight or flight” response from victims, in which they
either display visible signs of anger or aggression or disengage completely.5 All results from this
report are displayed in Table 1.17

Table 1- PTSD related symptoms and perceived severity from female sex trafficking victims 17
Symptom % of victims
Recurrent thoughts/memories of terrifying events 75%
Feeling as though the event is happening again 52%
Recurrent nightmares 54%
Feeling detached/withdrawn 60%
Unable to Feel emotion 44%
Jumpy, easily startled 67%
Difficulty concentrating 52%
Trouble Sleeping 67%
Feeling on guard 64%
Feeling irritable, having outbursts ofanger 53%
Avoiding activities that remind them of the traumatic or hurtful event 61%
Inability to remember part or most of traumatic or hurtful event 36%
Less interested in daily activities 46%
Feeling as if you didn’t have a future 65%
Avoiding thoughts orfeelings associated with the traumatic events 58%
Sudden emotional or physical reaction when reminded of the most hurtful
or traumatic events (Zimmerman et al., 2006)
65%
PTSD commonly co-exists with clinical depression, although it is seen alone in some
cases. In the case of comorbidities between PTSD and clinical depression, victims experience
more distress, disability, and worse recovery outcomes.6 Most victims experience the symptoms
of feeling “depressed or very sad” (95%) or “hopeless about the future” (76%).17 Respondents
who participate in studies with 100 total participants or fewer show depression rates up to 60%.2

Regarding anxiety, most victims report nervousness or shakiness inside (91%), terror/panic
spells (61%), and fearfulness (85%).17
As research shows, adolescent victims of sex trafficking, particularly those who incur
injuries and sexual violence, report higher rates of mental health impairments compared to other
adolescents.3 In 2010, Hossain et al. conducted a study to examine the association between
traumatic events and mental health among women and girls who were victims of trafficking.
Although the respondents were not American, this study serves as a reference point for most of
the literature on female sex trafficking.2 During the study, researchers utilized subscales of the
Brief Symptom Inventory and Harvard Trauma questionnaire to assess 204 respondents in seven
post-trafficking service settings.3 As a form of data analysis, they ran multivariate logistic
regression models to examine depression, PTSD, and anxiety. The regression model was
adjusted to account for pre-trafficking abuse, in an effort to accurately reflect trafficking-induced
exposures. In their findings, “sexual violence experienced during trafficking” was associated
with higher levels of PTSD (adjusted odds ratio [AOR] = 5.6; 95% confidence interval [CI] =
1.3, 25.4).3 Victims who experienced longer trafficking durations had higher levels of depression
and anxiety (AOR = 2.2; 95% CI = 1.1, 4.5).3 Victims who had longer durations of time since
trafficking had lower levels of depression and anxiety, but not of PTSD.3 Over 80% of
respondents possessed at least one of the disorders, and displayed symptoms of PTSD,
depression, and anxiety reflected in the following percentages: PTSD (77%), depression (55%),
anxiety (48%).3 Similarly to other debilitating mental health disorders, adolescent survivors are
recommended to receive treatment for their PTSD, depression, and anxiety.18 Effective treatment
methods for victims struggling with these disorders will be further examined in this review.

As adolescent sex trafficking in the United States continues to become a public health
concern, it is pertinent that health care providers are familiar with the systems that are mitigating
[its] perpetuation.2 The goal of this analysis is to broaden the understanding and awareness of
adolescent sex trafficking, and its debilitating effects on the mental health of victims. At a
glance, this review will continue to analyze adolescent sex trafficking, examining common
characteristics of victims, risk factors for DMST, CSEC prevention efforts, and mental health
treatment. This review will conclude with recommendations for future research and overarching
conclusions made by researchers in the field of adolescent sex trafficking.
DMSTRisk Factors using SEM Theory
Before researchers are able to fully comprehend the effects of adolescent sex trafficking,
[they] must first examine the risk factors that cause particular adolescents to be more susceptible
to sex trafficking. These risk factors will be examined in this review using the Social Ecological
Model across individual, interpersonal, and societal levels, which researchers have termed
“microlevel, mezzolevel, and macrolevel” systems.2,18 Microlevel systems are influenced by
individual characteristics, such as substance abuse, housing instability, suicide risk, gender, and
race.2 Mezzolevel (mesolevel) systems include dysfunctional family dynamics and intimate
partner violence.2 Macrolevel systems examine the economic costs of sex trafficking, social
norms perpetuating sexual exploitation, and the impact of a national demand for sexual
exploitation.2,19
In 2014, researchers Ceccet and Thoburn conducted a qualitative research study to
examine the factors that contributed to the survival of six victims of adolescent sex trafficking in
the United States.18 The goal of this study was to learn which factors allowed victims to leave the
sex trade and reintegrate back into their original communities.18 Researchers analyzed data using

the aforementioned Social Ecological Model and discovered patterns of “personal resilience”
among respondents across microlevel, mezzolevel, and macrolevel systems.18 With respect to
these systems, respondents reporting about microlevel factors had insecure attachments with
family, which contributed to their susceptibility to be recruited for sex trafficking.18 At the
mezzolevel, respondents reported that unsafe relationships caused the victims to experience
increased emotional insecurity, further quantifying their risk of trafficking.18 At the macrolevel,
most respondents reported that they were raised in environments that “desensitized them to
prostitution”, which continually perpetuates sex trafficking on a national level.18 As it relates to
the areas of “escape and resilience”, researchers saw differing characteristics across the three
systems. Respondents at the microsystem level reported that they left the sex trade as a result of
pregnancy or mental health symptoms.18 At the mezzolevel, participants reported that they
desired relationships that made them feel safe and increase their self-worth.18 At the macrolevel,
post-trafficking victims reported that they began processing their traumatic experiences by
utilizing resources in the mental health system after leaving the sex trafficking industry.18 The
reports from the victims in this study indicate the necessity for public health officials to possess a
thorough understanding of the contributing risk factors for DMST in the United States. Risk
factors for DMST will be further examined across the microlevel, mezzolevel, and macrolevel of
society in this review. Figure 1 illustrates CSEC risk factors using this ecological framework.4

Figure 1- Ecological Framework for Contextualizing and Conceptualizing CSEC 20
Microlevel Characteristics of DMST
During the process of exploring this population, researchers must examine the individual
factors that put certain youth at risk for being trafficked. This section will include an analysis of
the most commonly examined microlevel factors that promote or perpetuate sex trafficking in
adolescent females, including substance abuse, housing instability, suicide attempts, gender, and
race.
Substance Abuse
Traffickers often utilize illegal substances as a form of controlling and intimidating their
victims, thereby causing female victims of sex trafficking to be more susceptible to drug abuse
compared to other females.9 21 While some victims engage in substance use before entering the
lifestyle, many victims are forced to use drugs and eventually exchange sex acts for drugs at
some point during their trafficking.2 Research supports that younger victims experience higher
rates of drug use compared to older victims, indicating that the age of initiation into trafficking is
correlated to higher rates of drug use in this population.22 To this end, results from a Minneapolis

research study showed that adult victims who began trading sex for money as adults were more
likely to abuse substances before they became victims.23 Conversely, adults who began trading
sex for money as minors were more likely to use drugs after initiating trafficking.23 “Adult
starters” of trafficking were over three times more likely to use drugs before their first sex trade,
and were more likely to have children compared to “minor starters”.23 “Minor starters” were
more likely to trade sex before beginning drug use, and they showed worse health outcomes
among all measured domains.23 These findings show that DMST is directly correlated to
increased substance use, indicating a need for drug interventions for victims of DMST before
victims reach adulthood.23
As it relates to judiciary consequences, DMST victims are often forced to commit drug-
related offenses by their pimp or to maintain their drug habit.2 In a study of 100 female inmates,
researchers found that 75% experienced issues with substance abuse.24 The U.S criminal justice
system proves merciless to victims, viewing them as serial offenders who are unable to escape
their circumstances.2 As a result, victims quickly develop negative criminal records that follow
them throughout their lives, further limiting their professional and financial resources. This
spawns a negative cycle among victims that makes the sex trafficking lifestyle more appealing
than simply going without the resources needed to sustain their lives. As a result of this disparity
in accessible resources, federal and state governments are designing no-cost community
healthcare options for victims, which will be further explored in this review.
Housing Instability
Unstable housing among youth serves as a contributing risk factor to their likelihood of
being sex trafficked before adulthood.2 Based on reports from the National Center for Missing
and Exploited Children (NCMEC), over 98% of suspected or confirmed DMST victims were

classified as Endangered Runaways between 2004 and 2010.25 Compared to their resourced
counterparts, one-third of homeless youth experience disproportionate risk of trading sex for
food, money, shelter, or drugs.26-28 Most homeless youth are coerced, manipulated, or forced into
trading sex for these vital resources in order to survive because they lack alternative resources,
indicating that the choice to engage in sex acts is rarely voluntary.28
In a research study on homeless youth, Tyler et al (2004) examined the risk factors for
being sexually assaulted by a friend or stranger among 372 members of this population.29 Using
a systematic sampling method, community outreach workers interviewed each participant to
identify their risk of sexual victimization.29 Initially, researchers hypothesized that youth who
engage in more high-risk sexual behaviors would be at greater risk for sexual assault by friends
and strangers.29 Overall, results showed that 35% of respondents had been sexually victimized,
and females were greater than four times likely to engage in survival sex with a friend.29 Females
of younger age who ran away for the first time were more likely to experience sexual
victimization compared to older females.29 Respondents who engaged in deviant subsistence
strategies, survival sex, and grooming were more likely to experience victimization by a friend or
stranger.29
Youth currently residing in shelters, group homes, or foster care are at greater risk for
becoming victims of DMST.30 Because most DMST victims lack adequate parental or legal
guardianship, researchers consider the U.S foster care system both a risk factor and a
consequence of domestic minor sex trafficking.31 Foster children often experience a myriad of
situations that can compromise their mental health, including neglect, physical abuse, or sexual
abuse from their home of origin or their placement homes.32 Overall, most sexually exploited
foster children report feeling isolated, and lack strong connections and resources, which have

been attributed to their experiences within the foster care system.33 Among forty-seven
prostituted women, 64% indicated that they had been involved in the child welfare system and
78% had previously lived in foster care or group homes.34 During a literature review on the
effects of foster care, Oswald et al (2010) concluded that most foster youth have a history of
maltreatment in the following categories: neglect (18–78%), physical abuse (6–48%) and sexual
abuse (4–35%).32 Reasons for initial placement into foster care included emotional abuse (8–
77%), no available caretaker (21–30%), and parental substance abuse (14–30%).32 Research
shows that 70% of neglected foster youth have biological parents who abuse substances,
indicating a need to establish preventive substance abuse programs for biological parents as well
as DMST victims.32
Suicide Risk
Over the past few decades, researchers have closely examined the association between
“street youth”, or runaway youth, and their increased risk for attempting or committing suicide.
Evidence from qualitative analyses show that risk factors for suicide include the following
factors: being female, having a history of attempted suicide, feeling isolated, a history of
physical or emotional abuse, poor self-esteem, depression, having a friend who attempted
suicide, lack of food and shelter, HIV/AIDS, lack of control over one’s life, and a history of
substance abuse. 27,35 Inone particular study, Kidd et al interviewed 29 street youth to examine
their experiences with suicide, and found that 76% had previously attempted suicide as a result
of trading sex acts for resources.27 In a study examining the interplay between suicide and
substance use, Greene and Ringwalt (1996) found, through logistic regression analyses, that
youth who used sedatives, hallucinogens, and inhalants were more likely to attempt suicide
compared to youth who used other substances.35 Evidence from these studies shows a need for

suicide prevention initiatives that help street youth in obtaining assistance with mental health,
particularly those struggling with substance abuse.
Gender and Race
While it is difficult to ascertain exact prevalence rates of victims across gender and racial
categories, researchers estimate that 70% of victims are female (n = 30,407).2,36 Based on reports
from the Federal Bureau of Investigation, approximately 43,000 individuals were charged with
sex crimes as adults in 2011, of which 46% were between 18 and 24 years old an additional 760
individuals identified as minors. 34 Approximately two-thirds (n = 483) of charged minors
identified as black compared to 35.3% (n = 268) white and 1.2% (n = 9) as “other” races. Despite
the high prevalence of victimization among African American minors, there are more adult
victims who identify as white (53%) compared to black (43.3%).37 With respect to Native
American victims, Farley et al (2011) showed that this racial group has high rates of sexual and
physical assault, and that racism compounds the stress of prostitution, sexual assault, and mental
and physical health.33
As it relates to African American DMST victims, researchers contend that there are a myriad
of factors unique to their experience. For example, African American minors experience more
difficulties in their attempts to escape sex trafficking compared to other races.37 The likelihood
of poverty is also greater among African American DMST victims, which alludes to the racial
disparities that exist in accessible resources.38 As it relates to skin complexion, two research
studies show that lighter-skinned African American females are more at-risk for trafficking than
darker skinned African American females based on buyers’ preference for a victim of lighter
skin; however, this concept requires further examination in future studies.37

Overall, research shows that there are a myriad of microlevel factors that impact a victim’s risk
for sex trafficking, including substance abuse, housing instability, attempted suicide, gender, and
race.2,38 Researchers note that these factors may precede sexual exploitation or become comorbid
conditions as a result of the exploitation itself.2 While many research studies show an association
between childhood trauma and sexual exploitation, the effects of sexual exploitation itself can
exacerbate any existing trauma that exists within the victim, leading to additional mental health
complications.2 An example of this is the aforementioned risk for runaway youth to be sexually
exploited: while runaway youth are more likely to be sexually exploited than other youth, the act
of sexual exploitation can lead to housing instabilities.2 Consequently, researchers are urged to
further explore these individual risks and consequences as mitigating factors for DMST victims.2
Mezzolevel Characteristics of DMST
While it is important to examine the individual risks of DMST to better comprehend
person-specific factors, researchers must also consider victims’ interpersonal relationships as
contributors to DMST.2 These mezzolevel characteristics can shape the ways in which victims
are identified and their accessibility to healthcare services.2 As previously discussed, some
victims are not familiar with their trafficker before being kidnapped; however, many victims are
exploited by close family or friends.2 This section will discuss the interpersonal relationships that
contribute to the perpetuation of victimization among this population.
Dysfunctional Family Dynamics
A dysfunctional family is described as one that fails to meet the basic needs of its
members, which includes an absence of safety, love, security, self-esteem, and a sense of
‘belonging’.39 If these needs are not met, researchers believe individuals will not be able to

function effectively in society, often struggling with mental and emotional complications as a
result.39 While one could think that dysfunctional families are drawn away from one-another as a
result of the dysfunction, research actually shows the opposite: dysfunctional families tend to
“stick together”.39 Researchers believe this sense of connectedness occurs because the
dysfunction serves as a security blanket for those involved—in essence, if someone is only
exposed to a negative familial environment, then he or she does not know how to exist outside of
that environment.39 While some flee from this pattern, most perpetuate it, thus resulting in a
cycle of codependency among victims and their family members.39
Dysfunctional family social systems involving intimate partner violence, addiction, or
other visible manifestations of mental problems in the home, serve as pathways into prostitution
among youth.40 41 Victims may be forced, coerced, or pressured to trade sex in order to support
themselves or their family members.33 Research shows that family members may restrict a
victim’s movement from the home or monitor her contact with individuals outside the family. 42
In many cases, traffickers are friends of the family or family members themselves, which also
limits the victim’s access to outside resources for help.5 In cases involving traffickers who are
not family members, some victims are blamed for their circumstances, thereby reinforcing low
self-esteem, already a common issue among at-risk youth in general.43 A study by Raphael et al
(2010) explored the relationship between pimps and victims and found that 16% of respondents
were recruited into trafficking by family members.41 This finding is also shared by the U.S.
Department of Justice who reported that 14% of sex trafficking cases involved family
members.44 This data shows that a youth’s family members can not only contribute to her
introduction to sex trafficking, but they also possess the power to keep her involved in that
lifestyle.

To further examine the role of family on a victim’s risk for trafficking, researchers Reid
et al (2011) created a “structural equation model” looking at the connection between “parental
strain and child maltreatment” among 174 African American women.42 Responses were analyzed
across three areas: (1) whether caregiver strain is kinked to child maltreatment; (2) if
experiencing maltreatment is associated with risk-inflating behaviors or sexual denigration of
self/others; and (3) if these behavioral and psychosocial dysfunctions are related to vulnerability
to commercial sexual exploitation.42 Results showed that child maltreatment increased as
caregiver strain increased.42 Similarly to other studies, Reid et al found an association between
child maltreatment and running away from home, early substance use, and sexual denigration of
self, which is associated with feelings of low self- esteem, already a compounding issue among
at-risk youth.32,43
Intimate Partner Violence (IPV)
As previously discussed, most victims are familiar with their trafficker before their
initiation into the lifestyle.2 More specifically, traffickers are often a close friend that the victim
considers to be a romantic partner.2 Based on reports from the National Opinion Research
Center, most law enforcement respondents stated that the boyfriends of adolescent victims
eventually became their pimps.44 In a Chicago study, 64 out of 100 women believed their pimp
to be their “boyfriend”, of which 23 reported that this “boyfriend” was the primary recruiter for
clientele.41 Another study showed that victims believed that trading sex was a “favor” they were
performing for their boyfriend, which they considered to be socially acceptable.45
Researchers believe that traffickers and those who commit intimate partner violence
utilize overlapping methods of power and control among their victims.2 The stages of sexual
exploitation mirror the stages of IPV, including a honeymoon phase, a second stage in which the

trafficker enacts violence and threats, and a third phase in which the victim is willing to defend
her abuser.2,46,47 During the honeymoon phase the abuser shows love and affection toward the
victim in an effort to gain her trust.46 Once that trust is gained, the abuser inflicts violence onto
the victim in the forms of physical, emotional, or mental abuse.5 This is the phase in which the
abuser becomes someone that the victim fears, which is vital to her remaining under his control
during trafficking.2,5 the final phase was referenced in the “Trafficker Characteristics and
Initiation of Victims” section as the “Stockholm Syndrome Phase”, at which point the victim is
willing to defend her perpetrator (to police and courts of law) as a result of her devotion and
fear.5 This loyalty to her trafficker proves to be a paramount characteristics that prevents the
victim from leaving or receiving help.2 The effects of intimate partner violence are mentally
debilitating and require substantial treatment from trained health professionals, which will be
discussed in the “Methods of Treatment” section of this review.
Macrolevel Characteristics of DMST
Along with individual and interpersonal risk factors, structural characteristics also affect
a youth’s pathway into trafficking, and her access to health services.2 As such, researchers
interested in this population must examine the social factors that allow sex trafficking to exist in
the first place, and the ways in which these factors impact a victim’s individual exploitation.2
This section will discuss these “macrolevel” characteristics, including the economic costs of sex
trafficking, national social norms, and the ways in which CSEC is desired among the public at
large.
Economic Costs
Researchers state that sex trafficking is currently the fastest growing criminal industry in
the world, profiting more than $32 billion in revenue each year. 48 Despite that sex trafficking is
a national problem, economic “costs” in relation to sex trafficking often only apply to the price

of traveling visas, asylum hearings, or other legal options for foreign-born victims.2 To this end,
researchers estimate that the U.S spends nearly $29 million annually on interventions for sex
trafficking; however, most funds are awarded for immigration visas and residential shelters for
U.S and foreign-born victims.49
While researchers cannot estimate the number of illegal brothels exist in the U.S, they
propose that one medium-sized brothel can revenue over $1 million a year.50 This estimate is
based on a total of four victims providing services for five customers at $160 a session
($160/session × 5 customers × 4 women = $3200/day × 365 days = $1,168,000) and is adjusted
according to the size of the brothel.50 Researchers highlighted the revenue capacity of one
particular brothel to show the profitability of this industry. For this example, a prostitution ring
in Oakland, CA had a total of 218 minors who were being trafficked by 155 men at a minimum
quota of $500 per day.2 Typical with common practice, all of the monetary earnings from each
customer were given to the pimps, leading researchers to estimate an annual profit of
$32,700,000 for that brothel alone.2
As mentioned in earlier sections, traffickers are the sole
recipients of monies earned by victims, rarely reporting their full revenues to national or state
government.2 As victims do not receive any of the profits, they are left penniless to fend for
resources during and after sex slavery. Because structural reformations in the sex trade are not
realistic or humane, the only option is for health workers to design programs that provide
resources to victims post-trafficking.12
As it relates to economic costs of trafficking, researchers have extensively examined
hospital and health care costs for treatment, although specific figures are not available in existing
literature.2 Despite this limitation in available data, is has been shown that fundamentally, sex
trafficking often involves physical injuries that can be expensive to treat, particularly for this

poverty-stricken population, including bone fractures, gastrointestinal disorders, infections,
dental problems, malnutrition, unintended pregnancy, and many gynecological complications
and disorders.51 Along with these expensive physical injuries, adolescent victims also have
elevated rates for sexual assaults, diseases, and clinical disorders that require treatment.3,10,52
Due to the limitations in data on specific health costs for this population, researchers use
data from victims of IPV as a method of estimation.2 For example, one study showed that IPV
victims spent an average of $1700 more in health care costs than women without a history of
IPV.53 Rivara et al (2007) conducted a study of 1546 women who experienced IPV and showed
that IPV victims utilize more healthcare resources more than non-IPV women, and that this
healthcare use decreases over time.54 Specifically, the study showed that annual healthcare costs
were 19% higher in women with a history of IPV (amounting to $439 annually) compared to
women without IPV.54 Even though findings are specific to adult females, Rivara et al estimated
that healthcare costs are upwards of $19.3 million per year for every 100,000 women.54
Researchers contend that financial estimates for victims of sex trafficking will be easier to
calculate as victims become easier to identify.54
Social Norms
The ways in which males and females are “supposed to act” in society heavily impacts
the manifestation and perpetuation of gender-based violence in America.2 Similarly to violence
against women, sexual exploitation is reliant on the promotion of male dominance and privilege
across all levels of society.2 Although gendered relations have improved since the “Leave-it-to-
Beaver” ideologies present during the 1950s, women still face an uphill battle in being valued
with the same respect as men.2 Consistently, institutional discrimination and violence against

women has become a normative facet of American life, serving as a pathway for sexual
exploitation among adolescent girls in particular.50,55,56
As best practices, researchers recommend that one must examine multiple layers of a
girl’s identity to begin to comprehend her mounting obstacles as a female at risk for trafficking.2
To this end, researchers must not only consider the impact of sexism on a girl’s risk, but the
impact of racism and classism as well.2 Research shows that when reporting sexual assaults,
minority victims are forced to either report their race or their sex, especially if the perpetrator is
another person of color.57 This is problematic because most research studies show higher rates of
violence toward women of color, particularly African American women, compared to whites.2
Additionally, minority adolescents are disproportionately affected by limitations surrounding
socioeconomic status, and are thereby more vulnerable to sexual exploitation.2,10 As discussed in
earlier sections, girls with limited economic resources are forced to believe there are no
alternatives for their survival. While some victims may believe their slavery is a form of informal
employment, the deception and fraud surrounding sex trafficking could leave them worse-off
than where they started.2 Overall, this research proves that sexism, coupled with racism and
classism further oppress those who are already disadvantaged politically, socially, or
economically.2
Social Desirability of Sexual Exploitation
Hughes et al describe that there are three components driving sexual exploitation: (1) the
men who buy commercial sex acts, (2) the exploiters who make up the sex industry, and (3) the
culture that tolerates or promotes sexual exploitation.50 Traffickers are able to exploit at rapid
rates because there is a high demand for sex with females in America.2,50 An example that
substantiates this claim is Wilson and Dalton’s 2008 Pennsylvania truck stop study.58 These

researchers found that the demand for sex with victims was so high that victims were earning
enough money to pay their arrest fees at their time of arrest, which was greater than
$1,000/night.58 Although at face value, these results seem to pose sex trafficking as a lucrative
business for the victim; however, readers are encouraged to remember that all transactions occur
through the trafficker and that victims are not the recipients of these monetary resources.2
Researchers believe the glamorization of pimping in American culture has contributed to
the “normalization and tolerance” of sexual exploitation-- particularly the objectification of
minority women.2 This objectification occurs through a number of mediums, including song
lyrics, videos, and television programs. These mediums inherently reinforce the culture of
pimping and further perpetuate the objectification of women as “meat to be devoured”.2 An
example of this is the Academy Award winning song called “It’s Hard Out Here For A Pimp”,
which was featured in the hit movie Hustle and Flow.2 Critics believe songs similar to this one
show a general disdain for women, and promote the fantasy of pimping.2 To this end, Janson et
al examined how buyers of sex feel about the objectification of women.2 Overall, results showed
that buyers of sex are in agreement with violence against women and that victims’ forced
enslavement was justified based on the victim’s nature of employment.2 It is the goal of many
community health workers to discourage these objectifying ideals, eventually eradicating sex
trafficking in America. To this end, the next section of this review will discuss best practices for
treating victims of DMST based on reports from community health respondents.
CSEC Prevention and Victim Identification, Assessment, and Treatment
Researchers, health officials, and policymakers are becoming increasingly involved in
public health awareness campaigns to inform the public about child sexual exploitation in the
areas of prevention and treatment.1 This section will discuss common methods of CSEC

prevention by critiquing the “interventionist framework” that focuses on anti-trafficking
interventions versus the “human-rights” interventions that highlight the relevance of the
economic and social rights of youth.1 This section will also review best practices for treating
victims’ mental health disorders, by utilizing individual and group therapy methods.17,59,60
CSEC Prevention
Researcher Angela Duger (2015) believes that fellow researchers should prioritize
examining the underlying causes of CSEC to design their prevention programs, rather than using
the symptoms of CSEC alone to guide the development of their programs.1 In her review, Duger
identifies three problems with the current approach to CSEC in the U.S, including the following:
(1) the current use of evidence-based responses proliferates funding for victim identification; (2)
the current anti-trafficking approach focuses heavily on legal responses to CSEC; and (3) private,
not-for-profit organizations lack funding and focus on CSEC response rather than CSEC
prevention.1 Duger also identifies various national level instruments that provide assistance with
identifying and assisting victims.1 She concludes her review by describing a “human-rights”
based approach to CSEC prevention in the U.S, and discusses the ways in which it can be
enacted.1 Duger’s discussion of these topics will be explored in this section of the review.
Critiques of Current Approaches to CSEC in the U.S
Child welfare responses, along with state and municipal law enforcement vary from state
to state, which poses a problem for CSEC prevention and treatment.1 Most states have varying
definitions for what CSEC is, and in the past, have criminalized it, deeming it “juvenile
prostitution”.1 Recently, states have made reformations to the laws that frame victims as
criminals, enacting what has been referenced as “safe harbor laws”.1,12 [These] laws are intended
to provide victims with protection and rehabilitation assistance.1,12 Safe harbor laws provide two

types of protections for victims. The first type prevents victims from criminal prosecution for
“prostitution” by processing them in the criminal justice system in a way that does not lead to a
criminal record.1,61 The second type of protection provides victims with supportive no-cost
rehabilitation services through child welfare, state, or private sources.1,12 As discussed, no
national, singular policies exist for CSEC victims—rather, policies for victims vary from state-
to-state.1 However, there are similarities in the strategies that states employ to address CSEC.1
Duger provides three critiques for the strategies that various states are using for victims.1
First, Duger (2015) believes that states emphasis on evidence-based responses leads to a
“proliferation of funding for identifying and quantifying the number of CSEC victims in the
U.S.”1 While it pertinent to have programs that both identify and treat victims, Duger believes
that an emphasis on identification alone can deter funds away from designing programs that can
prevent sex trafficking in the first place.1 When states favor victim identification, less funds are
available for first responders and healthcare providers who provide vital services to victims.1
Because CSEC is inherently a secretive business that occurs “behind closed doors”, victims are
often overlooked or underreported.1,62 As mentioned in the Risk Factors section of this review, a
limitation of current research is that it fails to adequately capture data that accounts for the
“marginalization of victims”, which has led to non-representative, biased, and therefore,
unreliable data on this population.1
Duger’s (2015) second critique is that the current approach to CSEC focuses heavily on
states’ legal responses to victims, which is inconsistent from state-to-state.1 As discussed, some
states have passed, or reformed, previous laws that appropriately treat child victims of sex
trafficking as victims rather than criminals under state law.1 However, the large majority of states
still view victims as criminals, which is not in line with the current victim-focused approach to

sex trafficking.1 While reformed laws are essential to aiding victims post-trafficking, they do not
single-handedly fix structural problems or prevent any underlying factors that put victims at-risk
for trafficking in the first place. This concept highlights the need for programs that help address
those microlevel, mezzolevel, and macrolevel risk factors impacting victims.
Duger’s (2015) last critique is that the private, nonprofit organizations, that are often the
first providers of health services to victims, are underfunded and lack the capacity to serve a
large population of victims.1 Duger contends that these organizations act as responders to
victims rather than supporters of programs for at-risk youth, failing to prevent victims’ initiation
into sex trafficking.1 Duger believes that these organizations are aware of this limitation, but are
unable to enact more preventive programs due to budgetary constraints, which further limits
victims’ access to adequate resources, an issue already plaguing this population.1 This lack of
preventive programming indicates that this approach is not sustainable over time, nor does the
approach fix the underlying structural problems that put certain youth at-risk.1
Overall, these three problems arise from a common issue: current responses often only
address the symptoms of CSEC rather than its underlying causes.1 Most programs are
intervention-focused rather than prevention-focused, and are, therefore, insufficient. There
should be a balance of programs in the U.S that address both the prevention of sex trafficking
and treatment for girls who happen to become victims. Preventive programs should focus on
strengthening girls who are at higher levels of vulnerability by encouraging them to be resilient
to becoming victims.1 While Duger (2015) believes a prevention-focused approach is best for
this vulnerable population, interventions still prove vital to the health of girls who become
victims, which will be discussed in the Mental Health Treatment section of this review.

Instruments for Trafficking Prevention
The U.S is part of the Palermo Protocol, an international instrument that is focused on
preventing and combatting trafficking, specifically among women and children.1 The Palermo
Protocol is part of the United Nations Convention against Transnational Organized Crime, and
serves as the first international, “legally binding instrument with an agreed definition on
trafficking in persons”.1 Section three, Articles 9-13 of this instrument requires all U.S states to
design policies and programs to “prevent trafficking”.1,63 However, the meaning of “prevention”
is not clearly identified within this report. Anne Gallagher who is considered an expert on human
trafficking identifies limitations of this instrument, stating that it fails to address or discuss the
root causes, or risk factors, for trafficking.1 Therefore, [she] believes that the concept of
preventing trafficking is secondary in this Protocol, highlighting the gap in instruments that both
clearly and adequately allocate resources to victims.1
Additionally, the Trafficking Victims Protection Reauthorization Act (TVPRA) which
was enacted by President Clinton, provides funds for victims of severe forms of trafficking.64
The TVPRA promotes awareness initiatives and technical support for law enforcement and funds
various alternative initiatives to “deter trafficking”, including programs that ensure girls are
enrolled in school, women’s participation in making economic decisions, job skills training, and
programs to advance the ways in which women are viewed publicly.64 The U.S government
renewed this act in 2003, 2006, and 2008 and in 2013, the act became part of the Violence
Against Women Act.65
Lastly, Article 19 of the Convention on the Rights of the Child (CRC), the only risk-
focused statute of the three discussed, requires that states take all necessary “legislative,

administrative, social, and educational measures to protect children from exploitation”.66
Although researchers in the U.S describe an interest in preventive efforts, the U.S. is not one of
the parties that has enacted this policy, which is a limitation of U.S law.1 This act describes
prevention as (1) reducing the vulnerability of children by eliminating the risks to which children
are exposed and (2) increasing the resilience of children to resist those risks.66 Duger believes the
issue with this statute is that it frames at-risk youth as soon-to-be-victims.1 In this way, she
believes “law enforcement initiatives and awareness campaigns are reasonable prevention
strategies”.1 However, the risk factors discussed in previous sections of this review highlight
much broader conditions that make children vulnerable to exploitation.1 Duger recommends
improvements in education, increased access to healthcare resources, and the utilization of a
human rights-based approach to prevent sex trafficking in adolescents.1 This human rights
approach will be discussed in the next section of this review.
Human-Rights Approach to CSEC Prevention
Duger (2015) describes a human-rights approach as one that “critiques current norms and
reshapes our understanding of a problem and approaches to redressing it.”1 Alicia Ely Yamin, a
human rights researcher, states that a rights approach involves re-conceptualizing our thinking of
human rights and “challenges underlying premises of justice and power”.1 A human-rights
approach requires that service organizations reanalyze their missions and operational approaches
so that they are able to empower their service recipients.1 With this approach, organizations must
examine the ways in which inequality, oppression, and exclusion can affect the organization’s
services and the outcomes of those services.1 Duger states that in order for organizations to have
sustainable results among their service recipients, they must examine factors surrounding social
inequality, discrimination, poverty, and socio-cultural determinants.1 To this end, this approach

involves researching a child’s social relations and power structures to capture their overall
wellbeing.1 Duger describes that a child-rights approach views children as “rights-bearing
individuals” rather than just a potential victim of sex trafficking, which is a useful concept for
policymakers nationwide.1
Enacting this approach in the U.S would involve examining macrolevel factors, such as
structural inequality and gender discrimination. Duger describes that current efforts to transform
these inequalities often face difficulties in the areas of program initiation and sustainability
because these structural concepts are so deeply embedded into society.1 Complicating this issue
is that government entities have been reluctant to view trafficking as an issue of poverty,
discrimination, and gender-based violence, and often view it as a “law and order” problem that
should focus on a “criminal justice response” to trafficking.1 The following is a quote by the
founder of the Girls Educational and Mentoring Service (GEMS), a nonprofit organization that
provides victims of sex trafficking with educational support, counseling, and housing services.
The author of this quote, Rachel Lloyd believes approaches to preventing CSEC should examine
the role of inequality and poverty.67
“ I do… strongly believe that we can significantly
decrease the commercial sexual exploitation
and trafficking of girls and young women, but it
will not come through salacious news coverage,
huge stings, or rescue-focused work, but through
the infinitely less sensational work of building
resilience in the lives of vulnerable children,
creating resources and support for under-served
communities and ultimately addressing the
inequities that girls and young women face.” 1 67
As the quote describes, a human rights approach focuses on victims’ violation of social
rights.1 Duger (2015) believes that in order to protect youth from becoming victims, the systems

that leave them marginalized “must be overcome”.1 The Committee on the Rights of the Child
describes administrative and legislative measures that should be applied in the U.S as prevention
efforts, which are described in Table 2.1 Overall, Duger (2015) believes the U.S should employ a
human-rights based approach to preventing CSEC, which analyzes the social and cultural factors
mitigating CSEC and examines interventions that can lead to sustainable outcomes in this
population.1 This approach is focused on promoting equality across all structural levels of society
and considers vulnerable children to be “rights-holding individuals” who should be viewed as
more than just potential victims.1 Through this approach, Duger believes that at-risk adolescents
can be given a “voice”, and will be taught how to exhibit resilience to rise above their structural
circumstances.1
Table 2-Administrative and Legislative Efforts toward CSEC Prevention1
Category Description
Administrative “…Actors will either need to develop new and creative
approaches to collaborating, or possibly seeklegislative
or administrative reform to authorize collaboration in
their mandates or permit information
sharing. Previously excluded partners,including
community-based groups,schools,and health care
centers,should be included in prevention strategies.
Training on CSEC prevention can be included
in professionaltraining curricula, including for
medical personnel,teachers,and social workers
who are often on the front lines of service provision
to children.
Legislative “…Prevention measures should outline concrete
obligations for all involved agencies and dedicate specific
budget allocations for implementation of those
obligations.” 1
**Note: The following table was developed based on recommendations posed by Duger (2015)

Victim Identification, Assessment, and Treatment
Ijadi et al (2016) uses existing field literature to make recommendations for healthcare
providers in an effort to help them efficiently identify, understand, and treat adolescent victims
of sex trafficking.4 It is pertinent for healthcare providers to have knowledge of these “best
practices” so that they can improve detection and care for members of this population. In most
cases, mental health providers have their first interactions with victims in healthcare facilities,
such as emergency rooms, through the juvenile justice system, and through the child welfare
system.4 Overall, Ijadi et al (2016) believe providers should use a “trauma-informed” approach
that combines evidence-based practice with case coordination during their treatment procedures.4
It is vital that victims feel safe and supported by providers, which is why Ijadi et al (2016)
recommend that providers interview each victim individually upon their arrival to the healthcare
facility, remain empathetic and nonjudgmental during all interactions with the victim, and avoid
any discussions that could “re-victimize” them.4 The utilization of these techniques will be
further explored in this section.
Before providers can sufficiently care for their victims, they must first have an
understanding of the socioecological factors that pushed the victims into sex slavery, particularly
victims’ involvement with the child welfare and juvenile justice systems.4 As described earlier,
foster youth have higher rates of exploitation because they are more likely to have a history of
abuse, and are also more likely to be in settings that make them vulnerable to traffickers (i.e.,
foster or group homes).4,68 Additionally, despite that some victims are being diverted out of the
juvenile justice system, many victims still acquire a criminal record either during or before being
trafficked, leading to a lifetime of negative rapport with the criminal justice system.4 To this
end, most adolescent victims are not identified as “potential victims” until they are arrested for

trafficking or non-trafficking offenses.4 This concept indicates that there is a need for more
victim identification efforts that can access victims before they are ever arrested. Overall, Ijadi et
al (2016) believe providers must acknowledge that there is a “bidirectional flow of youth” from
child welfare systems to juvenile justice systems, which is necessary for providers to understand
before treating victims.4
In addition to understanding that victims are volleyed back- and- forth between the child
welfare and juvenile justice systems before being trafficked, psychiatric providers must also
understand that victims face other risk factors for trafficking, such as substance abuse, sexual
abuse, and intimate partner violence that require different treatment methods.2 Having this in-
depth understanding of the major risk factors that are found among trafficking victims will help
providers to curtail their treatment methods to fit victims’ individual treatment needs.4 As no two
victims are exactly the same, this level of understanding is vital to designing person-specific
treatment.
Upon initiation into treatment, many victims have difficulty trusting their psychiatric
interviewer, which can limit their willingness to share information. Further complicating this
matter is the fact that victims often feel like they have to protect their perpetrator, often
withholding information that could be instrumental in their treatment.4 For victims that are able
to escape trafficking, many are plagued with immense fear that their perpetrators will find them
and seek retribution for their departure, which further reinforces their silence.4 Moreover, the
vast amount of shame and stigma that is associated with the sex trade prevents victims from
wanting to expose themselves by seeking mental health treatment-- even despite the severity of
their symptoms.4 As a result of this, providers must interview victims alone, understanding that
exploiters commonly accompany the victim to their healthcare visits—although during

trafficking, victims are rarely taken to healthcare facilities at all.4 Researchers are encouraged to
remember that victims are always under the control of their trafficker during enslavement,
especially in settings that may allow the victim to escape, such as healthcare facilities.2,4
During treatment, it is pertinent that providers encourage victims to feel empowered and
in-control during all interactions. To this end, providers must stress the importance of
maintaining provider-patient confidentiality, which should include a discussion of the mandatory
“reporting laws” of that state.4 69 Providers must avoid judgmental thoughts, discussions, or
actions that could lead to the victim feel threatened in any way.4 It is vital that the victim feels
like she’s in a safe, comfortable, empathetic environment, so that she is able to establish a level
of trust with her provider.4 Establishing this trust can take a long time and numerous visits, so it
is important that providers remains steadfast in their commitment to fostering a trusting
relationship with the victim.4
During treatment, providers should avoid using extensive medical terms that the general
public could have trouble comprehending.4 In a qualitative study examining provider-patient
communication, adolescent victims reported that they preferred for providers to use “milder
language that more closely aligned with their own language”.4 For example, respondents stated
that they wanted providers to use terms like “working” or “engaging in the game” when
referencing the act of trading sex.4,70 In this study, respondents also expressed a desire for
providers to “listen and care”, which reinforces the importance of building and maintaining trust
with patients that are adolescent victims.70
Victim Identification
Most adolescent victims seek medical treatment at emergency rooms, reproductive health
clinics, and community centers, where they are connected with psychiatrists who initiate the

process of mental health treatment.4 These healthcare agencies are trained to identify warning
signs that an adolescent may be a potential victim, which are outlined in Table 4.4,69 Researchers
contend that the characteristics do not confirm or negate that an adolescent is being trafficked.4,69
Table 4- Common Characteristics of CSEC Victims the Present for Medical Treatment 4,69
Appearance/Behavior 4
 Patient is accompanied by someone
who does not want them to be
interviewed alone
 Patient appears withdrawn, frightened,
or guarded
 Patient provides vague/changing
demographic information
 Patient appears to have use substances
 Patient appears to have been branded
with tattoos that indicate ownership
 Patient has visible physical injuries
(scars, burns, lacerations, fractures,
traumatic brain injury)
 Patient is in poor physical health (skin
infections, malnourishment)
 Patient is visibly carrying large
amounts of money or expensive items
that appear beyond her means
Medical History 4
 Patient has a documented history of
multiple pregnancies, abortions,
ectopic pregnancies
 Patient has a documented history of
multiple sexually transmitted diseases
 Patient has frequent emergency room
visits
Mental Health Symptoms 4
 Patient has symptoms of depression
 Patient has history of/is suicidal
 Patient has symptoms of posttraumatic
stress disorder, traumatic stress, and/or
anxiety
 Patient has symptoms of a substance
use disorder
 Patient has visible/described self-
harming behaviors

Mental Health Treatment
As discussed throughout this review, victims are at higher risk for mental health
complications as a result of maltreatment, abuse, threats, isolation, and poor living conditions.4
Many victims develop PTSD, depression, and anxiety, among other disorders.3,4 Nearly two-
thirds of adult female victims report having issues with memory, which is further exacerbated by
substance use.4 Because of the scarcity of data available for adolescent victims, there is a need
for additional research on the most effective evidence-based practices for this population, which
can be identified through program evaluations.4 At the present time, most treatment
recommendations for adolescent sex trafficking victims come from research on other vulnerable
populations, including victims of domestic violence and torture.4 To this end, most research
indicates that a multidisciplinary, “trauma-informed” approach is best.4
A systematic literature review shows that effective treatment includes four components:
(1) a comprehensive needs assessment of survivors; (2) safety and confidentiality; (3) a trauma-
informed approach; (4) and comprehensive case coordination.4 Providers who use a trauma-
focused approach are aware that (1) people who experience similar trauma may exhibit similar
symptoms, (2) trauma can affect a person’s ability to cope, and (3) that they should avoid re-
traumatizing the victim.4
Among youth with PTSD, trauma-focused Cognitive Behavioral Therapy (TF-CBT) is
the most researched treatment method and is effective for treating exposure-related trauma.4
CBT helps victims to identify connections between their “thoughts, behaviors, emotions, and
physiologic responses”.4 Although this study was not conducted in the U.S., a randomized
controlled trial that utilized TF- CBT in the Democratic Republic of the Congo on sexually
exploited girls showed a reduction in their “trauma symptoms, anxiety, and depression, and

improved their prosocial behavior”.4 Researchers note that this treatment was “culturally adapted
and group-based”.4 The TF-CBT treatment was not facilitated by professionals with a
background in mental health, which may be a limitation, although facilitators underwent
facilitation training.4 Peer support from youth who experienced trauma contributed to these
positive findings.4 Researchers recommend that future TF-CBT models are adapted to be
culturally relevant to the specific target population of U.S adolescents.4
Other promising modalities for this population include Multisystemic Therapy (MST),
and Dialectical Behavioral Therapy (DBT).4 MST utilizes an ecological approach to treat
victims, taking into account the patient, and the patient’s “…family, school, and social service
advocates”.4 MST was initially created to treat antisocial behavior.4 DBT has been used on
domestic violence victims and victims of child abuse; however, researchers believe it may be
useful for sex trafficking victims.4 DBT allows individuals to learn distress tolerance,
mindfulness, and emotion regulation, which are recommended for youth who engage in self-
harming behaviors.4 Given that there are no existing guidelines for treating DMST victims,
researchers believe “pharmacologic and psychotherapeutic” methods should be patient-specific,
based on the patient’s “primary and secondary mental health needs”.4
In addition to these methods, various programmatic interventions are available for this
population that provide them with supportive resources and training on life skills.4 As the most
common age of victimization in this group is 12-14, most victims are initiated into trafficking
before they complete high-school.2,4 This limited education often causes victims to lack skills in
finance, leadership, and self-efficacy.4 Victims may also lack the ability to develop meaningful
relationships, activities, and hobbies.4 As a result, many community programs include activities
in which they can teach these skills to victims.4 Clawson and Grace (2007) evaluated four of

these programs, including Girls Educational and Mentoring Services (GEMS, previously
referenced in the quote on page 31), Transition to Independent Living Program, Standing
Against Global Exploitation, Children of the Night, and Angela’s House.2 71 Through interviews
with providers, Clawson and Grace (2007) identified certain common characteristics among
residential facilities, which include the following: (1) programs should hire staff who possess a
special expertise in providing services to trafficking victims; (2) programs should provide
individual case management; (3) programs should provide life skills and job training; (4)
programs should provide youth development; (5) programs should provide family reunification
services; and (6) programs should provide education.71
The aforementioned GEMS organization is a great example of an effective effort that
provides targeted services to child victims of exploitation. GEMS provides prevention and
outreach, along with direct intervention in the areas of holistic case management, transitional and
supportive housing, and court advocacy.72 The GEMS website allows any community health
workers, physicians, and other community stakeholders to refer victims to the organization
confidentially, without fear of judgment or stigma.72 GEMS has an array of public and private
funders that provide financial contributions to these programs. GEMS’ funders include faith-
based organizations (i.e., community churches), community organizations (i.e., colleges,
sororities, United Way), businesses and corporations (i.e., Macy’s, MTV Network), foundations
(i.e., Avon Foundation), and government agencies (i.e., Office of Juvenile Justice and
Delinquency Prevention).72 Similar organizations that are diving into this population should
develop partnerships with other organizations, like GEMS, to broaden the reach of their efforts.
Overall, research indicates that adolescent victims of sex trafficking are at higher risk of
mental health impairments compared to their counterparts; however, effective treatment

modalities are available for this population, including TF-CBT, MST, DBT, and various
community programs.4 Despite that most members of this population do not self-identify as
victims, healthcare providers can assist them in various healthcare, juvenile justice, and child
welfare settings.4 Mental health providers are needed to help identify, assess, and treat victims, in
and potentially aid them in exiting enslavement.4 Many post-trafficking victims have become
advocates, providing supportive services for current victims.4 Researchers recommend
partnerships between past victims, healthcare providers, and community programs to sufficiently
aid the mental health of this population.4
Conclusions and Recommendations
Adolescent sex trafficking is an increasing concern in the field of public health because
of its detrimental effects on victims. Researchers estimate that approximately 50,000 adolescents
become victims of sex trafficking each year, which is steadily increasing.5 The covert nature of
sex trafficking, combined with the lack of a national ‘best practices’ data collection tool to track
victims, makes it difficult to report accurate prevalence rates.9 Additional factors limiting
prevalence data include the misidentification of victims by healthcare workers, conflicting state
and federal laws regarding criminalization, victim perceptions, and the absence of public
awareness on sex trafficking.5 As a result of this limitation, all prevalence rates discussed in this
review, and related literature reviews, should be considered an underrepresentation of actual
victim prevalence.5
When initiating research on this population, one must first understand the myriad of
terms that are used to describe victims, including “severe sex trafficking”, “child sexual
exploitation”, and “prostitution”. In short, severe sex trafficking is the forced engagement in sex
acts and is carried out through coercive acts of sexual exploitation.6 Additionally, all girls who

are labeled as “prostitutes” should be considered victims, as all form of exploitation leave
victims powerless and voiceless in their interpersonal relationships and society at large. As
research shows, metropolitan communities have higher rates of identified victims, which
indicates a need for more sex trafficking awareness campaigns, more training for healthcare
workers in non-metropolitan communities, and more research on effective practices to treat the
trauma of trafficking.13 Additionally, healthcare workers should target their efforts to locations
that traffickers commonly utilize for recruitment, and also design safe methods for victims to
report family members who are involved in sexual exploitation.5
As discussed throughout this review, while victims incur a myriad of metal health
complications due to the trauma of trafficking, the most common disorders among this
population are PTSD, depression, and anxiety.3 Victims who experience longer trafficking
durations have higher levels of depression and anxiety, which decreases as the “duration since
trafficking” increases.3 These mental health disorders are elevated in cases that involve sexual
violence during trafficking, which occurs in many victims.3 Currently, there is a need for
programs and legislative reformations that prevent sex trafficking before it begins, in comparison
to efforts that focus on treatment after trafficking has occurred.1 The Social Ecological Model
should be used to examine microlevel, mezzolevel, and macrolevel factors that perpetuate
adolescent sex trafficking to accurately assess sociocultural determinants of health in this
population.2
Consistent with literature on other vulnerable populations, efforts toward sex trafficking
could best be utilized if they are focused on decreasing the aforementioned risk factors that place
particular adolescents at high risk for trafficking in the first place.1 A major issue of concern is
that private, nonprofit organizations, that are often the first providers of health services to

victims, are underfunded and lack the capacity to serve a large population of victims.1 Due to
limited funds and resources, these organizations only have the capacity to serve as responders to
victims rather than supporters of community programs that target at-risk youth, which fails to
prevent their initiation into sex trafficking.1 To this end, there is a need for more preventive
programs that strengthen girls who are at higher levels of vulnerability by encouraging their
resilience and self-efficacy.1
A human-rights approach requires that service organizations reanalyze their missions and
operational approaches so that they are able to empower their service recipients.1 With this
approach, organizations must examine the ways in which inequality, oppression, and exclusion
can affect the organization’s services and the outcomes of those services.1 For sustainable
results, organizations must examine factors surrounding social inequality, discrimination,
poverty, and socio-cultural determinants.1 This approach is focused on promoting equality across
all structural levels of society and considers vulnerable children to be “rights-holding
individuals”.1 Through this approach, at-risk adolescents can be given a voice, and will be taught
how to exhibit resilience to rise above their structural circumstances.1
While research shows that a prevention-focused approach is best for this vulnerable
population, treatment interventions still prove vital to the health of these victims. Having an in-
depth understanding of the major risk factors that are found among trafficking victims will help
mental health providers to curtail their treatment methods to fit victims’ individual treatment
needs.4 During treatment, it is vital that victims feel safe and supported by providers, so it is
recommended that providers interview each victim individually upon their arrival to the
healthcare facility, remain empathetic and nonjudgmental during all interactions with the victim,
and avoid any discussions that could “re-victimize” them.4 Common treatment methods for

similar populations (i.e., victims of domestic violence) includes TF-CBT, MST, and DBT which
treats victims’ health-impeding “thoughts, behaviors, emotions, and physiologic responses”.4
Although these methods have been successful within similar populations, there is no data on the
efficacy of these treatment methods for American, adolescent victims of trafficking; therefore,
these methods require additional testing with this population.
In addition to these treatment methods, there are a multitude of programmatic
interventions that target adolescent victims of sex trafficking, providing them with supportive
resources and training on life skills.4 The goal of these community programs is to encourage
victims to have meaningful and healthy relationships, activities, and hobbies during or post-
trafficking.4 Many post-trafficking victims have become advocates against sex trafficking and
provide supportive services for current victims through these programs.4 In addition to mentoring
programs for victims, this population is in need of collaborative partnerships between
policymakers, community organizations, and healthcare providers. This review shows the
complex issue of adolescent sex trafficking can only be aided through a multitude of awareness,
prevention, and trauma-informed treatment.

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