The experience of adolescent victims of commercial sexual exploitation in the United States: a qualitative systematic review protocol

Abstract

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.