Exiting Commercial Sexual Exploitation

Review question/objective The objective of this review is to describe commercial sexual exploitation as experienced by adolescents in the United States. The specific review question is: how do adolescent victims of commercial sexual exploitation in the United States describe their experiences with regard to their abuse and their engagement with the legal, health care and social service systems? Background Human trafficking is defined as any act that involves “the recruitment, abduction,…[and] sale or receipt of persons within national or across international borders, through force, coercion, fraud, or deception.”1(para5) Commercial Sexual Exploitation of Youth (CSEY) is a component of human trafficking that refers to the sexual abuse of a child or adolescent (under 18 years of age) for financial gain. This sexual abuse can take the form of physical abuse, child pornography or prostitution.2 In Africa, Asia, Australia, Europe and North and South America, human trafficking is recognized as a global problem.3–7 The International Organization for Migration collects data on the individuals assisted through counter trafficking programs implemented in more than 100 countries worldwide. Of the human trafficking victims included in the database, 27% were sexually exploited and 36% were under the age of 18.8 Estimates of the true prevalence of this crime are difficult to obtain for a variety of reasons. Perpetrators are able to evade law enforcement by frequently moving child and adolescent victims across borders and by the use of discreet online advertising to market them.9 Law enforcement agencies are unable to detect many cases because the victims are young, often recruited between the ages of nine and 12 when they are particularly vulnerable and as a result are unlikely to report their abuse. Furthermore, victims might appear older than their stated age or carry false identification.10 In a report regarding CSEY in the United States, Canada and Mexico, Estes and Weiner identified several groups at risk for exploitation as minors.11 The groups included: runaways, homeless youth, gang members, transgender street youth, unaccompanied minors or those brought into the United States illegally, abandoned, forced to leave home or are living within close proximity to a Mexican or Canadian border city. Among these groups, Estes and Weiner conservatively estimate that more than 244,000 youth are at risk for commercial sexual exploitation. In California, a border state with high rates of human trafficking cases, there are nine statewide taskforces dedicated to increasing the identification of victims, investigations and arrests for human trafficking. Between the years 2010 and 2012, 1277 child and adolescent victims were identified.10 Fifty-six percent of those cases involved sex trafficking. The Human Trafficking Reporting System is an agency that compiles information gathered from local and state law enforcement agencies on human trafficking in the United States. Although there are no estimates of the overall number of child and adolescent victims, the data indicates that 82% of suspected trafficking incidents are sexual in nature and greater than 1000 of the incidents reported between 2008 and 2010 involved CSEY.12 Characteristics of victims of commercial sexual exploitation Several characteristics of CSEY victims have been identified in research literature. According to two sources, CSEY victims were most likely to be female (≥99%), 16–18 years of age and African American (66%) and to have previous involvement with either the criminal justice or foster youth systems.13–14 Internationally, poverty is a common characteristic of victims3–7 and could be a contributing reason for the racial disparity in the United States. In a study of 113 previously sexually exploited minors, 75% reported experiencing child abuse or neglect, more than half (55%) had been abandoned by parents or guardians, and many were exposed to parents' criminal/prostitution activities or substance use.15 According to the authors of the report, the experience of these disruptive family processes can lead to maladaptive coping strategies. Participants reported severe substance abuse (31%), self-injurious behaviors (35%), and having run away (62% reporting having done so multiple times each month) as some of the most destructive behaviors. Frequently, running away had led to exposure to unsafe environments and engaging in dangerous or illegal activities as well.15 Although the majority who reported substance use did not meet the criteria for a disorder, substance use is common, with 70–100% of CSEY victims using alcohol, marijuana or ecstasy as drugs of choice.16 Substance use was a common theme in multiple studies indicating that victims of CSEY are more likely to not only use substances more frequently than adolescents who are not commercially sexually exploited, but to begin use at a younger age and to sell drugs as well, thus adding to their risk for legal repercussions associated with illegal activities.17–18 Sequelae of commercial sexual exploitation and barriers to breaking the cycle In a nationwide United States study examining characteristics of CSEY victims compared to child sexual abuse victims, multiple forms of trauma were identified in both groups, including physical and emotional abuse, neglect and domestic violence in addition to sexual trauma.19 A report produced by the West Coast Children's Clinic in California identified the mental health consequences of CSEY associated with the experience of ongoing trauma. The most common disorders diagnosed among CSEY victims were depression, anxiety, anger control issues and attachment disorder, with each individual diagnosis occurring in more than 50% of the sample.15 Despite the harm caused by these exploitative relationships, CSEY victims remain captive due to their basic need for food, shelter and safety. In Carr's study of 31 sexually exploited minors, participants reported strong motivations to continue prostitution, such as fear of physical abuse for refusing, lack of money for food, clothing and shelter, supporting a drug habit, or the exploiter wanting them to do so.20 Exploiters also used a variety of tactics to manipulate the victims. This included exploiting the relationship as a boyfriend/friend, requiring the payment of a debt, or forcing the victim to commit criminal offenses with the exploiter to maintain loyalty.21 Lack of confidence in academic skills, uncertainty about housing, and difficulty finding employment further contributed to the significant barriers to ending exploitative relationships and reintegrating into the community.16 The needs of CSEY victims are broad and varied. To develop effective support and treatment programs, it is necessary to understand the experiences of individuals affected by the abuse. The purpose of this review is to synthesize qualitative evidence with regard to commercial sexual exploitation and to strengthen the knowledge base for providers who treat the adolescent victims. A preliminary search of the Joanna Briggs Database of Systematic Reviews and Implementation Reports, the Cochrane Library, CINAHL and PubMed was conducted. While there was one abstract identified in the Cochrane Library that addressed internet-specific sexual exploitation of youth,22 there were no systematic reviews or protocols identified that addressed the experience of commercial sexual exploitation among adolescents in the United States from the perspective of the victim nor any focusing on qualitative evidence. Much of the research literature focused on screening and identification in primary care and emergency settings. Inclusion criteria Types of participants This review will consider studies that include participants who are or were victims of human trafficking, specifically commercial sexual exploitation, aged 18 years of age or younger at the time they experienced it. Types of abuse experienced in commercial sexual exploitation include, but are not limited to, physical abuse, child pornography and/or prostitution. Victims of child or adolescent sexual abuse or human trafficking who have not been commercially sexually exploited will not be included in this review. Phenomena of interest The phenomenon of interest is the self-reported experiences of victims of commercial sexual exploitation. Of particular interest is the effect of repeated traumatic experiences on mental and physical health as a result of the abuse and the identification of short- and long-term care needs for victims. Additionally, educational achievement, employment, and meeting basic needs for food and housing in the community are public health needs of this population and will also be considered. Ongoing involvement of victims with law enforcement will also be included in this review as continued engagement with the law enforcement system is prohibitive to meeting their other developmental needs. Context The geographic context for this review is commercial sexual exploitation that has taken place in the United States. Since commercial sexual exploitation is a covert and illegal activity, research involving victims might occur in a variety of social and cultural contexts, and health or community settings. Types of studies The review will focus on qualitative data from studies including, but not limited to, phenomenology, grounded theory, ethnography, action research and feminist research. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. First, we will conduct a limited search of PubMed, CINAHL, and PsycINFO to identify and analyze text words contained in the title and abstract, as well as index terms used to describe the article. Second, we will search all databases using all identified keywords and index terms. Third, we will search the reference list of all identified reports and articles for additional studies. Studies published in English since the year 2000 (the year the Federal Bureau of Investigation established the Crimes Against Children Program23 ) will be considered for inclusion in the review. The databases to be searched include: PubMed, CINAHL, PsycINFO, PsycARTICLES and ERIC. The search for unpublished studies will include: Google Scholar, PsycEXTRA, MedNar, ProQuest Dissertations and Theses and conference proceedings. Initial keywords to be used will be: commercial sexual exploitation, sex trafficking, human trafficking, prostitution, and sexual slavery in combination with adolescent, teen, youth, juvenile or minor. Assessment of methodological quality Two independent reviewers will assess the selected studies for methodological validity prior to inclusion in the review using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI), a standardized critical appraisal instrument (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, population, study methods, and outcomes of significance to the review question and objectives. Data synthesis Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent the experience of commercial sexual exploitation for adolescents. The findings will be aggregated and assembled according to the quality of studies and categorized on the basis of their similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Conflicts of interest The authors declare that there are no conflicts of interest.

Commercial sexual exploitation (CSE) of young people (aged 6-26 years) poses a considerable public health and social challenge. Understanding how social network exposure to CSE influences CSE risk may inform targeted prevention strategies for at-risk youths. To examine the association between social network exposure to CSE and personal risk of experiencing CSE among youths, with a focus on how exposure interacts with childhood adversities. This cross-sectional study used data collected between January 1, 2015, and December 31, 2022, from a CSE program at a children's advocacy center in the northeastern US. Eligibility criteria included referral for suspected or confirmed CSE risk. Social relationships with offenders, peers, and others sharing residential placements were examined as potential sources of exposure. The final analyses were completed on March 20, 2025. Social network exposure to CSE among youths. Experiencing CSE was the main outcome. Logistic regression was used to assess associations between youth network exposure to CSE and the risk of experiencing CSE, and social network analyses were conducted to identify patterns in the connections between youths with and without CSE experiences. A total of 997 youth were included in the study (mean [SD] age, 14.7 [2.1] years; 903 female [90.6%]). Youths exposed to CSE through their social networks were significantly more likely to experience CSE (adjusted odds ratio, 2.92; 95% CI, 1.91-4.47). A significant interaction between social exposure and childhood adversities revealed that social network exposure was associated with higher CSE risk among youth with fewer adversities (adjusted odds ratio, 1.45; 95% CI, 1.22-1.74). Network analyses revealed that youth experiencing CSE were more likely to be connected to one another (β [SE], 0.32 [0.14]), highlighting the clustering of CSE within social networks. These findings suggest that prevention strategies should aim to reduce unmitigated exposure to individuals experiencing CSE and focus on fostering supportive and healthy relationships. This study underscores the potential for social network modeling to identify at-risk youth and inform prevention efforts.

Commercial Sexual Exploitation of Minors: Overlooked and Underreported

There has been little research into whether personality traits increase vulnerability to serious forms of recurring victimisation, such as commercial sexual exploitation of young people. To investigate whether impulsivity, emotional dysregulation or high psychopathy scale scores indicative of personality traits increase vulnerability to commercial sexual exploitation. Data were used from the longitudinal Pathways to Desistance Study 1170 justice-involved men who were aged 14-19 at baseline data collection. Ninety-eight (8%) reported having been commercially sexually exploited during adolescence or young adulthood. We investigated whether personality traits measured at baseline were related to such victimisation. Results of binomial logistic regression among the young men in this sample indicated that Factor 1 scores on the Psychopathy Checklist-Youth Version (PCL-YV), reflecting affective and interpersonal features, are associated with having been commercially sexually exploited, while impulsivity, emotional dysregulation and Factor 2 PCL-YV, reflecting antisocial activities, were not. Having been a victim of other violence and being a member of a cultural or ethnic minority group were also independently related to being exploited. Our findings show that individual differences in personality, such as fearless temperament and boredom susceptibility, could differentially disadvantage young people, and put them at greater risk of commercial sexual exploitation. This knowledge could be beneficial to prevention efforts supporting male adolescents at risk for victimisation by commercial sexual exploitation, and to shed new light on the theoretical understanding of vulnerability to it.

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

REVIEW QUESTION / OBJECTIVE The objective of this review is to describe commercial sexual exploitation as experienced by adolescents in the United States. The specific review question is: how do adolescent victims of commercial sexual exploitation in the United States describe their experiences with regard to their abuse and their engagement with the legal, health care and social service systems? INCLUSION CRITERIA Types of participants This review will consider studies that include participants who are or were victims of human trafficking, specifically commercial sexual exploitation, aged 18 years of age or younger at the time they experienced it. Types of abuse experienced in commercial sexual exploitation include, but are not limited to, physical abuse, child pornography and/or prostitution. Victims of child or adolescent sexual abuse or human trafficking who have not been commercially sexually exploited will not be included in this review. Phenomena of interest The phenomenon of interest is the self-reported experiences of victims of commercial sexual exploitation. Of particular interest is the effect of repeated traumatic experiences on mental and physical health as a result of the abuse and the identification of short- and long-term care needs for victims. Additionally, educational achievement, employment, and meeting basic needs for food and housing in the community are public health needs of this population and will also be considered. Ongoing involvement of victims with law enforcement will also be included in this review as continued engagement with the law enforcement system is prohibitive to meeting their other developmental needs. Context The TRUNCATED AT 250 WORDS

This chapter presents a case of an adolescent facing both commercial sexual exploitation and drug addiction. The chapter reviews existing research on substance use among youth impacted by commercial sexual exploitation. In particular, the chapter highlights the intersecting risks and contexts of substance use and commercial sexual exploitation, as well as opportunities and challenges in providing substance use treatment to youth impacted by commercial sexual exploitation. We conclude by emphasizing the need for compassionate care that diligently disentangles the intertwined patterns of substance use to promote healing for youth impacted by commercial sexual exploitation.

Trafficking for commercial sexual exploitation constitutes more than 59% of the entire trafficking industry. An efficient rehabilitation model reflects the utilization of the victim's coping mechanism to overcome the stress and trauma of past victimization. The main aim of the study is to explore various coping mechanisms utilized by both victims of commercial sexual exploitation and individuals vulnerable to commercial sexual exploitation at rehabilitation and protective homes in India. The research utilized the participatory action research with stress coping behavior scale to understand the various employed coping mechanism by the beneficiaries of rehabilitation and protective (R&P) homes. In total, 30 victims of commercial sexual exploitation and 30 individuals vulnerable to commercial sexual exploitation, aged 18-50 years, participated in the study. The statistical analysis identified pursual of specific coping by participants and measured risk ratio reflected the relative risk of alcohol and drug use over prior exposure to commercial sexual exploitation.

Identifying children and adolescents within child welfare at risk for commercial sexual exploitation (CSE) can ensure referrals to appropriate services. However, screening measures to understand the prevalence of CSE are missing in child welfare. We evaluated the classification accuracy of a screener developed for the purpose of this study, guided by the Sexual Exploitation among Youth (SEY) risk assessment framework used in practice with child welfare-involved young people, (1) to identify young people at high versus low risk for experiencing CSE and (2) to estimate the prevalence of CSE risk for child welfare-involved children and adolescents. We used extant data from the National Survey of Child and Adolescent Well-being study with a nationally representative sample of children and adolescents aged 11-17 years (n = 1054) investigated by child welfare from February 2008 to April 2009. The 26-item screener showed acceptable reliability (α = .73) and test-criterion validity evidence using a CSE proxy outcome (ie, narrowly defined as being paid for sexual relations). We used the receiver-operating curve to classify risk and calculate the optimal cutoff score. Higher scores on the SEY screener (range, 0-20 points) increased the odds of experiencing CSE by 34%. The screener was good at discriminating CSE risk at the 6-point cutoff, with 26.7% of child welfare-involved young people identified as being at high risk for CSE. Given the absence of accurate prevalence rates of CSE risk in the population, a theoretical cutoff index using an established method can provide an objective decision on how to distinguish risk levels. Prevalence estimates for CSE risk highlight the need for systematic screening in child welfare to identify and provide services for young people at risk.

Neste artigo, apresentam-se dados de pesquisa sobre a percepção dos Agentes Sociais que atuam no enfrentamento da exploração sexual comercial de crianças e adolescentes. As entidades caracterizam-se por Organizações Governamentais, Organizações Não-Governamentais, Sistema de Justiça e Instâncias de Direitos. Compõem uma Rede de 15 instituições e foram entrevistados 31 Agentes Sociais de 12 delas. Utilizou-se um questionário composto de questões abertas e fechadas sobre: Conhecimento do Sistema de Proteção; Percepção da ESCCA; Formas de Enfrentamento da ESCCA; Procedimentos e Medidas em casos de suspeitas, identificações, denúncias e notificações. A maioria dos Agentes Sociais tem conhecimento do papel da instituição, embora alguns desconheçam parte da Legislação e as formas de se efetivar na prática o papel daquelas e a articulação interinstitucional.

This article provides an overview of commercial exploitation, with a focus on commercial sexual exploitation of Black children and youth in South Africa. A literature review on research on the labor exploitation among youth globally and in South Africa and on the commercial sexual exploitation of South African youth is presented first. International and national policy proclamations related to South African youth are highlighted. Second, findings from a study of Black South African youth who engaged in commercial sexual activities in Cape Town are presented. Third, conclusions and recommendations to consider the complex social, educational, economic, and political aspects of child exploitation are offered. This includes implications for further research, policy, and programs to assist this group of youth and their families. The benefits of economic globalization, internationalization, and free trade have brought with them an unanticipated set of social problems. Among them is a dramatic rise world-wide in the incidence of child exploitation. Child sexual exploitation is one of the most virulent forms of this exploitation and includes child sexual abuse. Commercial sexual exploitation of children, is the other, and includes child pornography, juvenile prostitution, trafficking in children for sexual purposes, and child sex tourism (Estes, 2002). This article provides an overview of commercial exploitation of Black children and youth in South Africa, with an emphasis on commercial sexual exploitation. First, it includes a literature review in three areas: (a) labor exploitation among youth globally and in South Africa; (b) commercial sexual exploitation of South African youth; and (c) international and national proclamations related to South African youth. This includes abbreviated information from policy proclamations such as the South African Constitution, the United Nations Convention of the Rights of the Child, World Declaration of the Survival, Protection, and Development of Children, and the Declaration and Agenda for Action by the World Congress against Commercial Exploitation of Children. Second, selected findings from ethnographic research on Black urban street youth who engaged in commercial sexual activities in Cape Town, South Africa, are presented. Third, conclusions and recommendations to consider the complex social, educational, economic, and political aspects of child exploitation are offered. Major findings indicate that limited knowledge about HIV/AIDS did not translate into safer sexual practices. This includes implications for further research, policy, and programs to assist this group of youth and their families. LITERATURE REVIEW Labor Exploitation among Youth Globally and in South Africa The International Labor Organization (ILO) in May 2002 found that 179 million children worldwide are exposed to the worst forms of child exploitation-labor, slavery, debt bondage, prostitution, pornography, drug trafficking, forced armed military conflict, and other illicit activities. These activities are self-explanatory although debt bondage may not be widely known. It refers to payment to an adult authority figure in a child's life in exchange for a child with the proviso that the child will have to earn the money back. The expectation of both child and parent (or guardian) is usually that the child will be released once the debt has been paid. Regarding child labor, the widespread exploitation of millions of children in the workplace has become a global concern resulting in a worldwide effort to abolish child labor. The ILO reports that 250 million children, globally, between the ages of 5 and 14 are forced to work. Child labor is most widespread in Asia, an area where nearly 153 million children, over half of the global total, are forced to work under hazardous conditions (Budlender & Bosch, 2002). South Africa has approximately 44 million people with one-third under 15 years of age, the age at which, legally a child in South Africa may begin work (United Nations Office of Drugs and Crime, n. …

This study aimed to assess whether, and to what extent, the commercial sexual exploitation of female adolescents placed in residential care predicted different manifestations of an altered sense of self in emerging adulthood while considering the possible confounding effects of child maltreatment and perceived stigmatization. Data were gathered in a broader longitudinal study conducted among a sample of 124 female adolescents placed in residential youth care centers. Commercial sexual exploitation was self-reported during adolescence. Altered sense of self was self-reported in emerging adulthood with the following dependent variables: sense of failure, sense of defensiveness and shame, lack of self-awareness, and other-directedness. Findings suggest that, even after accounting for the significant effects of confounding variables, commercial sexual exploitation increases specific vulnerabilities pertaining to identity development. This creates unique intervention needs among young women. Our study adds to the literature by highlighting the unique influence of commercial sexual exploitation experiences among vulnerable female adolescents on their sense of self in young adulthood. Our results point to the relevance of considering the intersection of trauma and stigmatization when working with and providing services to adolescent females with a history of commercial sexual exploitation.

Commercial sexual exploitation occurs when anything of value is given in exchange for a sex act. Sex trafficking involves the commercial sexual exploitation of individuals by means of force, fraud, or coercion. Due to the illegal nature of commercial sexual exploitation, there is a profound dearth in the literature. To develop a deeper understanding of the experiences of adult survivors of commercial sexual exploitation, investigators analyzed 1,264 unique case files collected between 2011 and 2021. Key predictors included mental health diagnoses, childhood sexual abuse, and educational achievement, while relevant outcomes included age of entry into sexual exploitation, length of exploitation, number of arrests, cycling into and out of commercial sexual exploitation, and program placement outcomes. Regression analyses (e.g., linear, binomial, or zero-inflated Poisson) were conducted. Results suggest that educational achievement is a potential protective factor against exploitation. Higher number of arrest and higher number of children had a bidirectional relationship with longer experiences of exploitation. Further, diagnoses of bipolar disorder and neurodevelopmental disorders were related to higher rates of cycling (i.e., repeated attempts to exit exploitation), and neurodevelopmental disorders and schizophrenia spectrum disorders were related to poorer placement outcomes. The findings provide a more authentic portrait of contextual influences on commercial sexual exploitation across a lifespan, informing services, interventions, and policy and supporting survivors in their promising futures.

Human trafficking is a form of modern day slavery. Globally, an estimated 20.9 million persons are exploited for their labor in a multitude of industries, including the commercial sex industry. In the United States, the prevalence of human trafficking is unknown and published figures vary widely based on definitional criteria and data sources used. This chapter focuses specifically on the commercial sexual exploitation and sex trafficking of minors in the United States. Minors under the age of 18 years account for one of the groups most vulnerable to exploitation in the commercial sex industry. In the United States, 100,000–300,000 minors are at risk for commercial sexual exploitation each year. Minors who have experienced complex trauma in their childhood are particularly vulnerable to these forms of polyvictimization. Their complex traumatic experiences as young children not only elevate their risk for re-victimization through commercial sexual exploitation and sex trafficking but also give rise to a destructive cycle of stigmatization that permeates their lives before, during, and well beyond their exploitation. The short- and long-term physical and mental health effects of commercial sexual exploitation and sex trafficking are profound, and the cumulative effects of complex trauma and stigma place victims and survivors at a disadvantage in a number of health metrics. Trafficked minors are challenged by unfavorable social determinants of health, high-risk health behaviors, poor health outcomes, numerous barriers to health care, and retraumatization in the health care setting. Indeed, sex trafficking of minors is thought to be the most underreported form of child abuse. Through education and training, health care providers who are knowledgeable about the experiences of trafficked minors and trained to provide trauma-informed care can help break the cycle of trauma and stigmatization, lessen health care disparities, and contribute to their healing and recovery.

Commercial sexual exploitation (CSE) is a form of sexual abuse with significant implications for public health and social equity. CSE occurs when a person obtains sexual access to another person through an exchange of something of perceived value (e.g., money, housing, food, clothing, drugs, protection). CSE includes sex trafficking, the strip club, and pornography industries, as well as brothel, familial, street, gang, and hotel-based exploitation. As a result of high rates of violence and abuse perpetrated by sex buyers, pimps, traffickers, third-party exploiters, and others, and from frequent sexual use, studies indicate that survivors of CSE endure recurrent medical injuries and illnesses and negative health outcomes. Medical providers may encounter survivors of CSE more frequently than other profession. Despite these encounters, disclosure and identification is rare. Furthermore, standards of care for working with survivors of commercial sexual exploitation though needed do not yet exist. This chapter draws largely from interviews with survivors of CSE and experts in the field to provide insight and recommendations for physicians working in the USA to more effectively engage and treat commercially sexually exploited patients.