Assessing exploitation experiences of girls and boys seen at a Child Advocacy Center.

The primary aim of this study was to describe the abuse experiences of sexually exploited runaway adolescents seen at a Child Advocacy Center (N=62). We also sought to identify risk behaviors, attributes of resiliency, laboratory results for sexually transmitted infection (STI) screens, and genital injuries from colposcopic exams. We used retrospective mixed-methods with in-depth forensic interviews, together with self-report survey responses, physical exams and chart data. Forensic interviews were analyzed using interpretive description analytical methods along domains of experience and meaning of sexual exploitation events. Univariate descriptive statistics characterized trauma responses and health risks. The first sexual exploitation events for many victims occurred as part of seemingly random encounters with procurers. Older adolescent or adult women recruited some youth working for a pimp. However, half the youth did not report a trafficker involved in setting up their exchange of sex for money, substances, or other types of consideration. 78% scored positive on the UCLA PTSD tool; 57% reported DSM IV criteria for problem substance use; 71% reported cutting behaviors, 75% suicidal ideation, and 50% had attempted suicide. Contrary to common depictions, youth may be solicited relatively quickly as runaways, yet exploitation is not always linked to having a pimp. Avoidant coping does not appear effective, as most patients exhibited significant symptoms of trauma. Awareness of variations in youth's sexual exploitation experiences may help researchers and clinicians understand potential differences in sequelae, design effective treatment plans, and develop community prevention programs.

Sexual exploitation is a severe form of child abuse that has profound effects on the immediate and long-term physical and mental health of youth. In this paper, sexual exploitation is defined as the exchange of sex for some type of consideration, including but not limited to: money, housing, food, clothes, transportation or a mobile phone. Exact numbers of sexually exploited youth are difficult to estimate (Stransky and Finkelhor, 2008) but given the number of youth who endorse having exchanged sex for goods in surveys of homeless youth and in school-based surveys (Saewyc, Drozda, Rivers, MacKay, & Peled, 2013), more information is needed regarding the context in which youth are first exploited, their exploitation experiences, co-occurring risk behaviors, and trauma symptoms. Child Advocacy Centers are one setting where youth who have been exploited can be interviewed, identified and receive comprehensive health care.

Background

Prevalence and Characteristics of Sexually Exploited Youth

Estimating the number of sexually exploited youth is difficult due to challenges in defining exploitation, as well as in sources for sampling. Most estimates of exploitation have derived from samples of homeless female youth, or those using shelters, with data primarily collected from large urban centers. Homeless and street-involved youth are disproportionately more likely to be sexually exploited, with estimates ranging from at least one in five (Halcon & Lifson, 2004; Wilson & Widom, 2010), to as many as one in three who have traded sex for money, drugs, or shelter (Saewyc, MacKay, Anderson, & Drozda, 2008). However, population-based school surveys in Canada and the United States estimate that up to 3% of students may have been sexually exploited (Edwards, Iritani, & Hallfors, 2006; Homma, Nicholson, & Saewyc, 2012). Studies in suburban and rural communities suggest the prevalence of sexual exploitation may be similar to that of urban communities, although perhaps more hidden. For example, both a nine-community survey of street-involved youth in Western Canada and an alternate education student survey in seven of those same communities found similar rates of sexual exploitation in rural communities as well as in suburban communities outside of Vancouver (Saewyc et al., 2008). Similarly, a school-based survey of students in grades 7–12 in the rural East Kootenay region of Western Canada found 2–3% of boys and girls reported trading sex for drugs or alcohol (Homma et al., 2012), which is similar to the rate found among high school students in Quebec City, and in the National Longitudinal Study of Adolescent Health in the US (Edwards et al., 2006). Importantly, large-scale studies of both street-involved youth and those attending school have found nearly equal numbers of males and females exchanging sex (Homma et al., 2012).

Youth who are sexually exploited come from a variety of backgrounds, ethnicities and genders (Smith, Varaman, & Snow, 2009; Spangenberg, 2001). In the U.S., African American youth appear to have a disproportionate risk of being sexually exploited (Kaestle, 2012; Reid and Piquero, 2014). Youth in foster care are another vulnerable group (Saewyc et al., 2008); being homeless for more than one month can also increase risks for sexual exploitation (Nadon et al., 1998). Lesbian, gay, and bisexual (LGB) youth make up 20–40% of the homeless adolescent population, and are more likely to be exploited (Gangamma, Slesnick, Toviessi, & Serovich, 2008; Saewyc et al., 2008). Rates of sexual exploitation have been found to be as high as 67% among transgender youth (Wilson et al., 2009).

Types of Exploitation

Some research has begun to examine the venues and experiences of sexual exploitation (Holger-Ambrose, Langmade, Edinburgh, & Saewyc, 2013; Scott & Dedel, 2006). Street-based sexual exploitation may represent less than a fifth of all sites for sexual exploitation (Scott & Dedel, 2006). Saewyc and colleagues (2008) found that 20% of youth in western Canada were living at home when they were first exploited; although Mitchell, Finkelhor, and Wolak (2010) were unable to report a reliable percentage due to missing data from police records, they also documented youth who lived at home while being exploited. In a study examining homeless youth transitioning from the traditional economy to the street economy, Gwadz and colleagues (2009) reported that 17.9% of girls and 14.6% of boys were recently involved in sex work. In another small qualitative study of recently exploited homeless youth in Minnesota, the victims reported experiencing exploitation in a variety of venues, ranging from private homes, spas, hotels, and street prostitution (Holger-Ambrose et al., 2013). Nearly all youth in Holger-Ambrose and colleagues’ study used the internet to advertise sexual services, and youth felt the internet provided more access to find purchasers; Mitchell et al. (2010) also found 14% of exploited youth in their study used the internet to find purchasers.

There is little literature on sexual exploitation of youth that compares potential differences between youth who are connected to a pimp/trafficker and youth who are exploited but not connected to a trafficker. Drug use may be fostered by traffickers to facilitate control of the youth (Brayley, Cockbain, & Laycock, 2011; Chase & Statham, 2005). However, drug use may also be part of a homeless youth’s introduction into the cultural street economy, separate from sexual exploitation (Gwadz et al., 2009). Other health risk behaviors such as lack of condom use, sexually transmitted infections, suicidal ideation, suicide attempts and self-harm have not been compared between exploited youth who are linked to a trafficker and those who are not.

Assessing and Treating Victims of Sexual Exploitation

In line with the UN Convention on the Rights of the Child (1989), most countries recognize sexual exploitation is a severe form of child abuse. Therefore, Child Advocacy Centers (CACs) and their multidisciplinary teams that investigate abuse and provide resources for abused youth can play a central role in assessing sexual exploitation and providing victim-centered care. Child Advocacy Centers provide forensic interviews, medical care, victim advocacy, trauma-focused psychological care, and knowledgeable connections to resources in local communities (Edinburgh, Harpin, Garcia & Saewyc, 2013; Walsh, Cross, Jones, Simone, & Kolko, 2007).

Presently, there is a dearth of literature on which questions by interviewers may yield new and useful information from sexually exploited children and adolescents to aid investigators, psychologists and health care providers in providing necessary information for law enforcement and developmentally appropriate and supportive interactions with victims. Although there is evidence that structured forensic interview protocols can improve the quality of forensic interviews (Lamb, Orbach, Hershkowitz, Esplin, & Horowitz, 2007), questions that may yield valuable information in a single perpetrator sexual assault may not provide the same information from youth who have been exploited by many different adults and in multiple venues. Traumatic experiences may be too numerous to easily differentiate. Obtaining information about how technology may have facilitated the crime against them or helped youth find safety may also be more relevant in these cases.

Much of the current research about sexually exploited youth draws from street youth service programs, foster care or youth accessing shelter services. Health care providers and CACs may reach different populations of sexually exploited youth. Qualitative studies provide information on relatively rare phenomena, and can inform providers on the breadth and variation of sexually exploited youths’ experiences, by describing how they were first exploited, types of victimization experiences, traumatic responses and coping strategies. Further, qualitative studies can identify the variation of information that youth are able to provide about their victimization in such settings as the forensic interview, to help improve legal investigations.

Purpose

This study, therefore, had three aims. First, we document the contexts and experiences of sexual exploitation among youth presenting at a CAC. Second, we identify the presenting physical findings, risk behaviors and trauma symptoms of sexually exploited boys and girls, including when sexual exploitation was facilitated by a trafficker. Third, we evaluate how the questions asked during standard forensic interviews elicit useful or less helpful responses when the type of abuse is sexual exploitation with multiple perpetrators.

Methods

We conducted a retrospective, mixed methods study to explore the experiences described by youth (N = 62) during forensic interviews, matched with their other chart data, between 2006 and 2013. Based on the research questions and relative rarity of sexual exploitation among cases seen at CACs, the qualitative interview data are the primary focus of the study, but are triangulated (Creswell, 2009) with the other clinical assessments, including lab results, self-reported assessments on scales and tools, and physical examinations.

Participants

All youth, age 12–17 years old, who were referred to an urban hospital-based Child Advocacy Center for assessment of possible sexual exploitation. At registration, parents signed consent forms for assessment and treatment, and whether they allow medical records to be used in research. Prior to the beginning of the exam, all patients were informed by the clinician that they can refuse any aspect of the exam, including the forensic interviews, and can refuse to answer any question on assessments. Between 2006 and 2013 an additional 8 patients were seen who police, shelter staff or other professionals felt had been sexually exploited, but who denied exploitation and refused a forensic interview, and so were not included in this analysis. The Internal Review Board at Children’s Hospital and Clinics of Minnesota approved this study. See Table 1 for demographic descriptions of the sample.

Table 1

Demographic characteristics, full sample and by gender.

		Total, n = 62Mean (SD) or %	Boys, n = 7Mean (SD) or %	Girls, n = 55Mean (SD) or %
Age	Range = 12–19	15.0 (1.56)	15.9 (1.07)	14.9 (1.58)
Grade	Range = 6–12	9.6 (1.43)	10.3 (0.76)	9.5 (1.47)
Ethnicity
White		21.0	14.3	22.5
African American		21.0	27.6	18.3
Hmong/Asian		17.7	–	29.6
Hispanic/Mexican		3.7	14.3	5.6
American Indian		7.4	14.3	4.2
Multiethnic		20.4	27.6	14.1
Don’t know/missing		12.9	–	5.6
Housinga
Living with at least 1 parent	Yes	53.4	28.6	43.6
Homeless	Yes	32.2	71.4	27.3
Incarcerated	Yes	1.7	14.3	3.6
Lives with a pimp	Yes	26.2	–	29.6
Individual education plan	Yes	40.4	50.0	39.1
Free/reduced lunch	Yes	81.5	66.7	83.3

Options are not mutually exclusive.

Assessment Methods at the Child Advocacy Center

Prior to health assessment, youth complete a self-administered questionnaire with items about health behaviors, risk behaviors, and various scales related to supportive family and school and other adult relationships, as well as measures of trauma symptoms and problem substance use. The assessment items include questions from the Minnesota Student Survey (Minnesota Departments of Health and Education), such as a validated measure of problem substance use based on the DSM-IV criteria (Fulkerson, Harrison, & Beebe, 1999); the UCLA PTSD Trauma screen (Steinberg, Brmer, Decker, & Pynoos, 2004) which was only implemented from 2011 on; and the Child’s Report of Parenting Behavior Inventory support and control subscales (Schludermann and Schludermann, 1988). These assessments are considered part of routine patient care. The psychometric properties of these measures have been evaluated in a number of studies, including with this group (Saewyc & Edinburgh, 2010).

After questionnaires were completed, all teens received comprehensive health assessments by Child Abuse Pediatricians or Advanced Practice Nurses. If a parent/caretaker accompanied the patient, additional health history was obtained from the adult separately. If abuse was disclosed during the health assessment, additional verbal assent was asked of the patient to video-record the remaining forensic interview. Forensic interviews are an approach to determine whether abuse has occurred and ensure the interviewer’s objectivity in asking non-leading questions with follow-up questions as needed to clarify the history of events (Lamb & Sternberg, 1998). Patients were told when the forensic interview was starting and when it ended; a recording light at eye level was a visual prompt that the history being reported was being recorded. The video-taped forensic interviews were transcribed as part of the medical record.

After the forensic interview, a physical exam was completed. When a sexual assault was reported within 72 h, biological evidence was also collected. Additionally, laboratory tests for pregnancy and sexually transmitted infections were done with all teens. Sexual exploitation was diagnosed as exchanging any form of sexual activity for money, substances or other goods. Other types of abuse were also diagnosed and charted if disclosed during the forensic interview. A typical comprehensive health care assessment with a forensic interview takes place over 2–3 h during a single office visit.

Analyses

As a mixed-methods design, it was important to integrate the analyses of the descriptive quantitative data and the forensic interview qualitative data during the iterative analytical process (Creswell, 2009). Qualitative analyses were performed first, then quantitative analyses. We used the Interpretive Description analytical method (Thorne, 2008), which is a qualitative approach designed for clinical research questions, and encourages triangulation of data, including quantitative data where relevant. The research team coded the forensic interview transcripts using ATLAS-TI software. First, all members of the team repeatedly read the interviews, then, as suggested by Interpretive Description, two research team members used the research questions as a framework to guide the coding. Transcripts were coded for types of sexual exploitation experiences, relationships with traffickers, and coping strategies, across cases and comparing boys and girls, and then comparing across major categories of experience as they emerged, for example, comparing exploitation with and without a trafficker. A third researcher on the team helped develop the overarching themes that emerged from the coding. We also evaluated the ways youth responded to various questions in the standard interview, especially their ability to provide meaningful information about their perpetrators and the crimes against them for planning for safety. The fourth member of the research team served as auditor in reviewing the coding decisions and themes that emerged, to help validate the analytic process. The qualitative findings informed the direction of the exploratory quantitative analyses.

For quantitative analyses, all of the variables extracted from the medical records and included in this study are listed in Tables 1 and 2. Because this is an exploratory study with a relatively rare occurring form of sexual abuse, hypothesis testing is not possible and the quantitative analyses are primarily descriptive. In Table 2, we report the prevalence of physical findings from colposcopic exams (injuries), STI and pregnancy test results, substance abuse and mental health symptoms, including PTSD, self-harm and suicidality. We also documented history of truancy and running away. Given the exploratory nature of the study and small sample size, we follow recommended practice and report effect sizes rather than significance testing (Kirk, 1996; Tramifow & Marks, 2015), including Hedges g for continuous variables and odds ratios for categorical data. Hedges g is interpreted akin to Cohens D to measure the comparative strength of association across two groups (Rosnow & Rosenthal, 1996). Effect size for Hedges g follows Cohen’s standard for small (.20), medium (.50), or large (.80) effect sizes (Huck, 2000).

Table 2

Characteristics of exploited youth, by gender.

	Boys, n = 7	Girls, n = 55	Hedges g/odds ratios
Family connectedness	1.00 (1.67)	2.10 (1.68)	0.66
Other adults care	0.71 (0.76)	1.40 (1.40)	0.51
School connectedness, 0–4 scale	0.94 (0.88)	2.10 (1.13)	1.05
Age of first drink, mean (SD)	11.8 (0.75)	12.8 (1.74)	0.60
Acute sexual assault (within 72 h)	0	4 (7.4%)	NC
GYN exam findings
Normal exam	4 (57.1%)	34 (63.0%)	.78
Healed hymenal laceration	n/a	11 (20.4%)	NC
Acute hymenal laceration	n/a	0	NC
No exam completed	3 (42.9%)	9 (16.7%)	3.75
Pregnancy screen positive, yes	n/a	4 (7.4%)	–
Chlamydia screen positive, yes	2 (28.6%)	20 (38.5%)	0.70
Sex partners
Opposite gender only	0	31 (55.6%)	NC
Same gender only	0	0	NC
Both genders	7 (100%)	24 (44.4%)	NC
DSM criteria for problem substance use	7 (100%)	25 (46.0%)	NC
Ever used alcohol	6 (85.7%)	53 (95.7%)	0.23
Binge drinking in the past 2 weeks
None	1 (14.3%)	34 (61.2%)	0.10
Once	1 (14.3%)	9 (16.3%)	0.67
Twice	3 (42.9%)	5 (8.2%)	7.50
3–5 times	2 (28.6%)	6 (10.2%)	3.27
6 or more times	0	2 (4.1%)	NC
Ever used marijuana	7 (100%)	47 (84.8%)	NC
Ever used methamphetamine	2 (28.6%)	14 (26.0%)	1.17
DSM criteria for PTSDa	2 (100%)	16 (76.2%)	NC
Self harm, past year	4 (57.1%)	41 (74.5%)	0.46
Suicide ideation, past year	5 (71.4%)	42 (76.5%)	0.77
Suicide attempt, past year	4 (57.1%)	26 (47.1%)	1.49
Self-reported truancy, past year
Never	0	11 (21.6%)	NC
1–10 days	0	17 (33.3%)	NC
More than 10 days	6 (100%)	23 (45.1%)	NC
Self-reported runaway from home, past year
Never	1 (14.3%)	6 (11.5%)	1.36
1–2	2 (28.6%)	16 (30.8%)	0.98
3–10	0	19 (36.5%)	NC
More than 10 times	4 (57.1%)	11 (21.2%)	5.33

Odds ratios reference group = girls.

NC = not calculable due to a 0 value in the 2 × 2 odds ratio table.

UCLA screening tool was instituted later in intervention. Denominator was 2 and 21 for boys and girls, respectively.

In the process of analyzing the interview data, it became clear that not all sexual exploitation was facilitated by a pimp or trafficker. Therefore, we also compared physical findings, risk behaviors and mental health issues between patients who reported having a trafficker and those who exchanged sex for some type of consideration without a trafficker.

Results

Youth Demographics

Table 1 provides demographic characteristics of the sexually exploited patients seen. Most were female; they ranged in age from 12 to 17 years old, and boys were somewhat older than girls. Patients came from diverse ethnic backgrounds. Most lived at home with at least one parent, but nearly one-third reported homelessness, 1 in 4 reported living with a pimp, and three were incarcerated for a reason other than sexual exploitation.

Medical Chart Data

Table 2 presents the results from the examinations and assessments documented in the medical charts, separately for girls and boys. Of the 46 girls who consented to a video-colposcopic exam, 20% had a previous hymenal transection. While there were no acute genital injuries among the girls, only 7% had an exam within 72 h of disclosing a sexual assault as part of their sexual exploitation experience. Only 4 of the 7 boys consented to an anal video-colposcopic exam. Most females reported sexual behavior solely with opposite gender partners (54%), though 25 girls reported sex with women as well. All 7 boys reported sex with both genders. Only 32% used condoms during their most recent sexual intercourse. Among the young people tested for sexually transmitted infections, 37% tested positive for Chlamydia trachomatis (29% of boys versus 39% of girls; OR = 0.70), and one male tested HIV-positive.

These victims reported wide-ranging symptoms of emotional distress. Most admitted cutting or burning themselves, 3 in 4 reported suicidal ideation, and half had attempted suicide in the past year (57% of boys versus 47% of girls). Among those who completed the UCLA PTSD screening tool, 78% experienced PTSD symptoms severe enough to meet DSM IV criteria for PTSD. Most youth reported ever using alcohol or marijuana, and 1 in 4 had ever used methamphetamine. All of the boys and nearly half of the girls met the criteria for problem substance use.

Running Away: Precipitating Events and Experiences of Leaving Home

While most youth had run away from home at least once, they reported that they were living at home or returning to live at home when they were first exploited. Most youth ran away impulsively, and described uncertainty about what would happen when they ran away and the length of time they planned to be away. Some ran away because they were scared of violence in their own homes. One youth said: “I’m moving out, I’m scared of him, because if you know somebody is gonna beat you up, you’ll do anything just to like have their hands off of you.” Some also youth said their parents did not want them at home, kicked them out, or convinced the youth to leave home. One 15-year-old victim described that it would be better if she were not around because of the pain she caused her mother:

“My mom told me that if I was going to [use drugs], she didn’t want me around while I was using, and I understood that because I have little brothers and sisters in the house and stuff, and plus I just felt like I was, ‘cause I like to go out and party and stuff, so I felt like I was kind of, I don’t know, just putting unnecessary stress on my mom when I didn’t have to, when I could just live somewhere else and see her, but not put her through all the stress of having to see me come home drunk and high and all that other stuff. So, I just left kind of, but it was kind of gradually.”

Running away also happened because youth were “bored,” felt isolated, their home was not any fun, they wanted freedom, or were tired of their parents “yapping at them all the time.” One girl threatened that if she was made to follow the rules at home that she “would take off again and my family will not hear or see me for a year.”

Most youth described “couch-hopping” and staying with a variety of people; they did not seem afraid that they would not have a person to call or a place to stay. Long-term homelessness was uncommon. Developmentally, young adolescent victims did not always conceptualize their leaving home as running away, and these same youth denied being a runaway even as their parents filed missing person reports. A fourteen year old said: “I doesn’t have to run; [he] picks me up.”

Running away was not viewed as a solo event for girls. In most cases, there was an informal network of peers that provided places to stay, and other runaways to connect with. When the reason for running away was not related to violence in the home, or being locked out or thrown out of their home, some youth described feeling good about their situation. One girl said she wanted to “pretty much feel that rush, adrenaline stuff, I don’t know, I just wanted to get out and do something.”

Experiences of Exploitation from the Forensic Interviews

Youth were most often sexually exploited after running away or being kicked out of their home. Forensic interviews provided data on the common types of sexual exploitation experiences as well as the precursors to finding themselves recruited into exploitation situations. After being recruited, there were three main types of exploitation described by the youth interviewed: “small” transactions with faceless, nameless purchasers, exploitation by a pimp/trafficker, and self-managed transactions without a pimp. All of these are described below.

Recruitment: Older Girls, Men and Family Members

A number of youth were recruited into their sexual exploitation by older girls, who often were exploited themselves. For example, a sixth-grader explained that a 14-year old friend took her to a house across from her elementary school. Her first sexual experience was with a Mexican male at that home. After going there for approximately a week, the high-school age “girlfriend” gave her new recruit $600. She explained that she was having sex with these people to make money. Going forward, this sixth-grader’s exploitation continued through female friends relatively close to her age. A different victim explained that her female friend asked her to go to a job that called for a “two girl special.” She agreed because she “felt that I owed her”; this girlfriend claimed “I treat you good, I let you in.” Many of the victims reported never being abused or threatened by their female recruiters. However, the youth did feel a sense of indebtedness and a connection to their female trafficker.

In other situations, an older teen was both an exploited victim and recruiter. One teen explained that, while attending school, she “had four girls working for me.” This arrangement was discovered after her high school recruits began flaunting their earnings. Another girl said, “I found me some girl. Me and her got really close, like she was like my big sister, and she was a prostitute…she brought me to her pimp’s house and we just started then.” Male pimps that had direct contact with the teens during recruitment were viewed as boyfriends. Questions that were asked during the forensic interview framing the pimp as a perpetrator were not answered, or sometimes the youth outright denied the pimp’s involvement, as the trafficker was still viewed as a boyfriend or source of emotional or financial support.

In 5 of 62 cases (8%), a parent or close relative introduced their child to prostitution. One girl said her mom taught her “how to trick and how to have anal sex without it hurting as bad.” Another explained, “There was four or five guys that raped me at this one bedroom after they paid my father.” Of the five, one youth knew that her parent’s boyfriend was also a pimp; another was aware that her mother had been involved in prostitution. The three other girls were surprised to learn after the fact they were sold for money or drugs.

During forensic interviews, teens were asked about their mothers’ awareness that the abuse was occurring. One girl knew her mother was present on-site during her entire sexual exploitation experience. She explained that, “a mom is not supposed to do this to their kids. (They) suppose (sic) to be there to cherish them, love them, protect them when they fall.” Another teen explained that her aunt was aware of—and was paid for—her niece’s sexual participation:

[Exploited youth] My aunt.

[Interviewer] And how often would he come and get you?

[Exploited youth] A lot…like 3 times out of a week.

[Interviewer] And when you were with him, did he ever give you anything?

[Exploited youth] No.

[Interviewer] So what was he, what was happening in the relationship between he and your aunt?

[Exploited youth] He always gave her a lot of weed, like big sacks of it. I guess that’s how he paid her for, yeah.

These victims identified what their family members did to them as wrong; it was described as unwanted, and the recruitment and resulting prostitution was an unanticipated, startling event.

Small Transactions: Rapidity of Invitation

There were a variety of pathways by which youth who had run away ended up being sexually exploited. According to some of the victims, their exploitation seemed spontaneous—it “just happened.” Immediately after being approached, girls described being asked by a “john” (exploiter, purchaser of sex) “how far I was willing to go?” One youth described meeting someone, exchanging phone numbers, talking briefly and being asked “Are you interested?” moments after encountering a man looking to procure sex.

Similar exchanges occurred on-line via social networking sites. Such individuals offered money, drugs or lodging in exchange for a sexual act. Youth who met traffickers or purchasers on-line often described having hundreds of friends on social networking sites because they said “yes” whenever anyone asked to be connected. After first connecting with strangers on-line, victims seemed to readily agree to meet. Most of the teens were comfortable using technology, albeit with little regard for personal safety.

Faceless, Nameless Purchasers

Youth did not report being emotionally attached to or having relationships with purchasers. In forensic interviews, they mentioned their exploitation almost in passing, and were unable to provide their offenders’ full names, offering only vague descriptions of the purchasers: “Men would approach and offer money. (I) gave a man a hand job for $25. He told about another guy that would pay more money but (I) did not have time to meet with him.” This girl said she did not remember anything about this event or where it happened, and that she was “too busy to get caught up in this” and does “not have time to give hand jobs to anyone who just asks.”

In other instances, a girl might have nowhere to go or no transportation. When one teen wanted to go home, a customer said:

“I can’t bring you home, it’s a blizzard out there and nobody gonna want to drive you back home in this type of weather. I’m like, okay, well, can I get some bus fare, so I could go on the bus and leave. And he was like no, he was like you can stay here tonight or whatever, and your (unclear) will be mine. And I’m look at him like no.”

What may have started as a small transaction to gain money for survival resulted in being with a man who would not let her leave.

Pimp-managed Exploitation and Relationships

Pimps were seen by the youth as working on their own, and often viewed as boyfriends. If there was a larger criminal network or market that was involved with trafficking, this was not recognized by any of the youth. For example, one girl said, “It happened after I stayed the night with him when my sister was drunk. Smooth put up ads on BackPages and we got calls right away.” Once a teen was trafficked by a pimp, exploitation continued due to threatened or enacted violence. One girl who was thinking about what it would mean to say no to turning a trick said:

“Then ah, I’d wait like 30 seconds every time, you know, just debating whether I should open the door and then I thought back if I didn’t open the door I’d just get another beating. So, I ended up opening the door every time.”

Other times, pimps were viewed as providers. Some girls said that the pimp “would buy them everything they asked for.” But, in most cases the pimps were restrictive and took all the money that was made. One girl explained:

[Interviewer] And then it sounds like XX got the money, did you get anything?

[Girl] No.

[Interviewer] You got some clothes.

[Girl] Food, cigarettes,

[Interviewer] Anything else, marijuana?

[Girl] Oh yeah, and alcohol.

[Interviewer] Marijuana and alcohol, anything else that you can think of?

[Girl] No.

A different teen was asked if the pimp charged for the Ecstasy or just gave her the drug. She said, “They charged me for it, didn’t matter because I never had any money anyway, so I guess I paid for it by the money I earned.”

Youth with pimps frequently saw themselves as trapped, and experienced violence. One girl said the pimp “just abuses, yells and threatens.” Another girl described, “I jumped out of the car cause he was choking me and stuff. He said he was going to sell me to his friend for a thousand dollars, but he was like choking me and stuff.” But getting away was more complicated than simply leaving a violent relationship, because the victims also often had an emotional attachment to the pimp.

Many youth described unhealthy attachments to their trafficker. For example:

“I felt like anyone that cared loved me, they just loved me, and I used to, like, feel like mom and my dad, no one really loved me. So I just, I went out and I tried to find people that loved me or that I felt like loved me. And, um, now that I’m just learning that really, they didn’t love me, and it kind of hurts my feelings.”

Another youth said:

“I just made some money for myself and gave it to Major but it didn’t matter. I was greedy, thinking it would be for myself and gave it to Major but it doesn’t matter. I was greedy thinking it would be for me, but I shared it because I love Major. I thought I would get more but then I didn’t want to and I don’t any more. I wanted to do it; ain’t no abuse.”

The relationships with the traffickers were complicated and nuanced. Youth, by virtue of agreeing to be interviewed, shared very personal and intimate details of their abusive experiences. But questions such as, “tell me all about him,” or a direct question asking for the name of the person involved as a purchaser or pimp, elicited few identifying details. Often, when asked to identify the pimp, the youth would emphatically state, “No!”

An Accomplishment, Not a Problem: Exploitation Without a Trafficker/Pimp

Seven girls and six of the seven boys exchanging sex for money without a pimp viewed their experiences as beneficial to them. In particular, they valued the money they earned and their independence. Several exploited youth described seeking to make money or receive gifts, and arranging these transactions themselves. They used Internet sites such as Back Pages, Craigslist, or Facebook, or Live Links (a phone chat line) to accomplish this. Several victims mentioned “Back Pages” as a “fast and easy way to make money.” One of the boys explained that he was “looking to find somebody that would be a friend and help me with money or something.” When talking with his friends, another boy explained:

“I went to a chat line and it was on this chat line that I met [him] and arrangements were made to meet at Foot Locker where the man bought [me] clothes and afterwards he asked [me] to masturbate.”

A girl described herself as charismatic and “being good at this.” These young people did not always identify their actions as prostitution. One boy saw himself as a prize to be won by adult men, explaining, “I won’t be a prostitute—that’s ugly, gross, weird. Who want earning in prostitution?”

These teens saw what they were doing as consensual, and indicated that what they were doing was a choice. During an interview, one youth said to the interviewer:

“Don’t make this so bad. It is what I want to do. No one is forcing me. I work for myself. This means I am smart. You can arrest me today but I am just going to do this again. I don’t want your pity or help.”

Another youth said, “I didn’t feel dirty. I felt rich, like it was a good quick way to make money. It was my idea, no one talked me into it.” One girl said, “I can make $2,000 a day. This is more money than my mom makes in a week.” Some victims assured the interviewer that they were “not going to give anyone their money and they were smart in being able to handle themselves in the prostitution business.” Youth trading sex on their own also thought of ways to make sure that they were paid. The same youth explained that “you only want to get paid in cash, you never take a check, would be stupid to do that.”

Characteristics Between Those With and Without a Pimp/Trafficker

Because of the qualitative differences in descriptions of pimp-managed exploitation and self-managed exploitation by the various exploited youth, we also compared these two groups’ reports of mental health distress symptoms, gynecologic findings, problem substance use, truancy and running away, and levels of supportive relationships in Table 4. While youth within both of these sub-groups had high levels of emotional distress, post-traumatic distress, and problem substance use, there were only a few issues where effect sizes reached moderate to strong levels, and they were mixed. For example, youth with a pimp had 6 times the odds of reporting suicidal thoughts in the past year, but minimal differences in suicide attempts during that same time period. In contrast, youth with a pimp had much lower odds of self-harm and diagnosable problem substance use than those without a pimp.

Table 4

Characteristics and symptoms of exploited youth with pimps versus those without.

	PimpN = 17	No pimpN = 45	Effect sizea
Age (range = 12–19)	15.5 (1.51)	14.8 (1.55)	−0.46
Gender			NCb
Boys	0	7 (100%)
Girls	17 (30.9%)	38 (69.1%)
Grade (SD) range = 6–12	10 (1.46)	9.4 (1.40)	−0.42
Parents care, mean (SD)c	1.87 (1.85)	2.05 (1.66)	0.11
Other adults in community care, mean (SD)c	1.71 (1.54)	1.19 (1.27)	−0.39
Other adult relatives care, mean (SD)c	1.47 (1.73)	2.12 (1.63)	0.39
Acute sexual assault	1 (5.9%)	3 (6.7%)	0.93
GYN exam findings
Normal	12 (70.6%)	26 (57.8%)	1.75
No exam completed	2 (11.8%)	10 (22.2%)	0.47
Positive Chlamydia screen	7 (46.7%)	15 (34.1%)	1.56
Ever drink alcohol	14 (100%)	36 (92.3%)	NCb
Problem substance use (per DSM criteria)	3 (25.0%)	21 (65.6%)	0.17
Ever used marijuana	14 (100%)	31 (81.6%)	NCb
Ever used methamphetamine	3 (20.0%)	12 (28.6%)	0.63
PTSD (per UCLA screen)d	7 (87.5%)	11 (73.3%)	2.54
Self harm, past year	8 (53.3%)	34 (79.1%)	0.30
Suicide ideation, past year	14 (93.3%)	30 (69.8%)	6.07
Suicide attempt, past year	8 (53.3%)	20 (46.5%)	1.31
Self-reported truancy, past year
None	4 (26.7%)	7 (16.7%)	1.67
1–10	4 (26.7%)	13 (31.0%)	0.76
More than 10 times	7 (46.7%)	22 (52.4%)	0.73
Runaway from home, past year
None	2 (13.3%)	5 (11.4%)	1.07
1–2 times	5 (33.3%)	13 (39.6%)	1.03
3–10 times	4 (26.7%)	15 (34.1%)	0.72
More than 10 times	4 (26.7%)	11 (25.0%)	1.12

Effect size comparison used was odds ratios for categorical variables and Hedges g for continuous variables. Odds ratio reference group = No pimp.

NC = not calculable due to 0 value in 2 × 2 table.

0–4 scale, higher number is ‘more connected’.

UCLA screening tool was instituted later in intervention. Denominator was 8 and 15 for pimp and no pimp, respectively.

Interview Questioning that Yielded New or Useful Information

There are multiple purposes for interviewing teens that may be victims of sexual exploitation. The primary purposes are to assure a teenager’s safety and identify health conditions that require medical and psychological treatment (Jenny & Crawford-Jakubiak, 2013). Interviews are also used to identify perpetrators or the scene of a crime for law enforcement and child protection (Lamb & Sternberg, 1998). We examined the questions and answers provided by the youth around sexual exploitation to suggest tailoring interview schedules for such clinical interactions. Table 3 includes sample questions from the transcripts, organized by different themes typically covered during a forensic interview. In general, youth had difficulty knowing where they were and exact dates when the sexual assaults occurred. They also could not provide names or many identifying details about purchasers or pimps. They did describe in detail how they viewed the transactions for sex on their end and how sexual exploitation events began and continued. They were able to answer questions about what sexual acts occurred and remembered if a specific request was odd or unusual. Answers to questions about how an event made them feel emotionally or physically often stopped or changed the flow of the narrative.

Table 3

Exemplar questions from the forensic interviews.

Question	Rationale and cautions
Introduction of the topic
Tell me about what happened that very first day.	Useful question to get started on information gathering as responses provided details about what was happening in the set up. For example, took them shopping, they took them out to eat, etc.
Tell me about the first time that happened. Were you given any instructions? How did you know what to do?	Responses provided details about who was involved in the process. Information such as greeting clients, obtaining money and who sets the charge for different types of contact.
How long have you been away from home? What made you leave home?	Effective question if it has been established that the teen has been away from home. Not all victims of sexual exploitation have run away from home. Teens were usually able to report the exact number of days away or at least the date they left. Reason for leaving usually helps to identify challenges the teen is experiencing.
How were you found?	Responses ranged from I accidentally called 911 from the hotel room to he came to pick me up at home once and my mom wrote down the license plate.
Elicit a free narrative
How did it start? And How did this stop?	These were successful questions that often did not relate to the exploitation but other factors such as violent experiences or other risky or dangerous situations.
What was he/she like when you first met him/her?	Responses were usually he was really nice, he listened; he said he would take care of me. However also included were threats regarding safety of family or self.
What does he know about you? What do you know about him? Is he married? Does he have children? Where does he live? What kind of job does he have?	Useful questions that tend to engage the teen in descriptions that may help in identifying the alleged offenders. They were often proud of what they knew about “him”. Be sure to include questions about whether he has any children as teens often have met the children or have seen pictures of them.
Did you ever have to do anything against your will?	This question did not elicit new or even useful information. Teens usually responded with: “I can take care of myself” or “No one can make me do anything”.
Did anyone take pictures of you? What they were used for? Do you know where the pictures might be now?	The question regarding pictures provided some potentially useful information for an investigation and required the follow up questions to elicit more details.
Has anyone ever offered or wanted to post an ad for you? If yes, where was the ad posted? Do you know what phone numbers were used? What did the ad say?	Effective questions to ask as teens were often able to provide details that could be accessed even when the phone was no longer available.
Tell me when you realized that it was something different than what you thought.	This was a beneficial question to elicit the narrative response to things like number of incidents, physical violence, etc., the other parts of the exploitation life.
Was there anything that happened to you that was physically violent? Did you witness any physical violence?	Some teens reported being choked, attempted kidnap, being slapped, hit or dragged by the hair. Some talked about witnessing others being injured.
Where were you when this happened? What was the hotel/house/car/building like? How did you feel when you were brought to a hotel?	This usually provided a great deal of information (not address) about the location. Hotel incidents included detailed information such as hot tub, swimming pool, etc. Reports of feeling “special” because they were brought to a hotel were common.
What was the scariest thing that happened to you while you were gone?	Exceptionally good question to ask, but only after you establish they have been away from home (aka on run). Do not ask until you have established rapport.
Question and clarify
Did you notice anything about your body? Or Did you notice anything when you went to the bathroom the next time?	Responses included physical symptoms such as bleeding. Care should be taken to accurately interpret the information as most girls who report bleeding following contact report that the bleeding was their period when it may have been from injury.
Did he ever want you to do something with his friends?	Additional sexual exploitation events were described but other situations such as going on a drug run, etc. were also frequently provided as a response.
What was the weirdest thing someone has asked you to do or asked to do to you?	Valuable responses regarding possible fetishes of the alleged offender.
How do you keep track of them?	Many teens provided information that could be useful for law enforcement such as I keep their number in my phone in case they call again.
Did you ever have to have sex with more than one person at a time? Any time you had to have sex with someone while someone else watched?	Helpful questions to identify possible witnesses as some talked about someone watching who did not have direct contact with them.
How did you decide how much to charge?	Provided information from feelings about what they felt the contact was worth, to “I charged more because he wanted underage.”
Closing
What do you want to do from here?	Empowering question to ask. Some asked to go to treatment or be placed somewhere they can get help.
Other considerations
How did that make you feel?	This question did not elicit new or good information. Responses included “It is what it is” or “I didn’t feel anything…it was just sex.”
When teens asked “Why do you need to know that?”	Good response is…It helps me understand your experiences.

Discussion

Sexually exploited youth had multiple health risk behaviors. However, there were few clear differences in risk behaviors, symptoms of emotional distress, PTSD or problem substance use between boys and girls, nor between youth with pimps and those without. As in other studies (Adams et al., 2007; Edinburgh, Saewyc, Thao, & Levitt, 2006) most sexually exploited girls in this study did not have gynecologic findings of penetrating trauma even though they had experienced this severe form of child abuse. One in 5 did, however, have transections of their hymen, which is similar to rates found among victims of gang rape (Edinburgh, Pape-Blabolil, Harpin, & Saewyc, 2014). A high rate of sexually transmitted infection was also identified during health evaluations of sexually exploited youth.

Most of the sexually exploited youth had few attributes associated with resiliency, as seen in their relatively low levels of connectedness to school, family and other adults. In most studies of adolescents in the general population, school and family connectedness are likely to be positively skewed, with mean scores at or above the upper quadrant of the scale range, rather than at or below the mid-range, as was found with this group of sexually exploited youth. Although previous research suggests sexual exploitation may be initiated during periods of homelessness (Saewyc et al., 2013) we found sexual exploitation often occurs when an adolescent lives at home (Saewyc et al., 2008). The reasons for youth leaving home were complex, ranging from teens running away after developmentally normal parent–child conflicts to extreme cases where they were sexually exploited by family members.

Sexual exploitation was not always linked to having a pimp or trafficker. Some youth “drifted” into prostitution, as reported elsewhere by Baker, Dalla, and Williamson (2010) and by Mitchell and colleagues (2010). A trafficker could be male or female, and youth tended to feel emotionally connected to their traffickers even if this person was violent and coercive. Nonetheless, many youth did not describe what happened to them as abuse, choosing not to identify their trafficker by name. Others have found that youth may not identify prostitution or sexual exploitation as abuse (Saewyc et al., 2008). Exiting prostitution is complex, and disclosures about the experience are nuanced, similar to how youth disclose other types of sexual abuse experiences (Baker et al., 2010).

Among those youth who did not have a trafficker, many posted their own ads on Back Pages, or connected with purchasers using social media or phone chat lines. These youth did not identify themselves as victims in need of help, and some even appraised their experiences as positive, or freely chosen. Yet, similar to those exploited by traffickers, most youth without traffickers had clinically concerning levels of trauma symptoms, including PTSD, problem substance use, self-harm and suicidal ideation and attempts. Their perspectives may be evidence of cognitive dissonance (Festinger & Carlsmith, 1956), the changed perceptions and beliefs about their behaviors that can arise when individuals are forced by social circumstances into behaviors they would not choose otherwise. Other studies have also found contradictory perceptions among exploited youth in the case of those with pimps, viewing them as protective, even when they are violent or coercive (Holger-Ambrose et al., 2013; Kennedy, Klein, Bristow, Cooper, & Yuille, 2007). Clinicians and outreach workers who encounter youth who experience these types of exploitation should be aware that youth may not be asking for help and may be resistant to offers of intervention. Further work in developing trusting relationships and harm reduction approaches may be needed to initiate clinical intervention.

Clinical Recommendations

Many questions asked during the forensic interview of a sexual exploitation victim are similar to those asked of a child victim of sexual abuse or even sexual assault. However, there are some questions we identified that provide new information, and others when asked that did not appear to be a good fit for this population, and should be used with caution or avoided. The sample questions presented in Table 3 include rationales for each question, as well as cautions, as appropriate. This collection of interview prompts should be considered suggestions, and not a protocol per se. The list is not meant to be comprehensive, but rather a reflection of the interview questions used during the evaluations at one hospital-based CAC.

As well, the principles of forensic interviewing as outlined by Lamb and Sternberg (1998) still apply. It is important to establish rapport and review the ground rules for the interview to assure a common understanding of the expectations regarding accurate reporting and interpretation of information. It is especially important to ensure that any question asked is well thought out, as there may be unintended consequences for the victim based on his or her response. Before interviewing sexually exploited youth, the multidisciplinary team at the Child Advocacy Center will need to think through how they will question teens about illegal events where the teen is also pulled into illegal behavior such as theft, selling and using drugs. It is essential that providers recognize the teen may have been involved in illegal activities during the time they were abused, but it is key to treat youth as victims of the exploitation they experienced.

Special consideration should be given to this population regarding the timing and length of the interview, as well as the possibility of additional interviews, as the information is often multifaceted and difficult to access during one interview. The goal should be to provide the best opportunity to elicit the information in a supportive structure, and to identify what type of health evaluation and future treatment will be needed.

Most youth had significant levels of traumatic responses, including problem substance use and self-harming behavior. Nearly all youth had symptoms of PTSD. Child Advocacy Centers need to ensure their own psychological services and their partners are ready to care for sexually exploited youth. These youth are more likely to have co-morbid psychiatric diagnoses.

Limitations

As with all research, there are limitations to this study that should be considered in assessing the transferability of these findings to other clinical settings. First, the data all came from retrospective chart reviews, where inconsistencies can create missing data. During the forensic interviews, the same questions were not asked to each teen, though we saw consistent interview prompts and reliability as a result of evaluating transcripts for this study. Findings may be limited to adolescents who have experienced sexual exploitation within the Midwestern United States, and in other regions of the US or other countries exploitation may have different contexts and features. The clinical cases comprised a relatively small sample, albeit nearly the entire population of sexual exploitation cases seen in this CAC over 7 years. Sexually exploited adolescents who are referred to a CAC may differ significantly from those who are sampled through police case data, or from programs or services. Their experiences may complement information from other sources. Finally, there were very few sexually exploited boys who were referred for evaluation, yet other research suggests that among street-involved youth and those in school, there are equal rates of boys and girls experiencing sexual exploitation (Edwards et al., 2006; Saewyc et al., 2013). Given the small sample of boys for comparisons by gender, even our attempts to report effect sizes were not possible for some of the categorical variables, because odds ratios could not be computed where there was a universal response (all or none) from the boys. Thus, our findings about boys should be viewed with caution.

Child Advocacy Centers must be aware of the co-morbid health conditions experienced by sexually exploited youth, such as Post Traumatic Stress Disorder (PTSD), depression, suicidal ideation, self-harm, interpersonal violence, problem substance use and STIs. In this sample, only one female teen presented in a time frame where a Sexual Assault Nurse Examiner would have been indicated to find DNA evidence of an assault. Child Abuse Specialists and specialists in delivering adolescent health care should be part of every clinical CAC team serving this population. Guidelines should be developed that address the interviewing process and multi-disciplinary team response in order to provide the most successful outcomes for these youth. It is imperative that clinicians refrain from judgments and blame, and focus their efforts to identify appropriate care and referrals for these youth. Ground rules for adolescents, confidentiality in health care, as well as possible outcomes regarding information disclosed should be reviewed with each teen. Providers must be familiar with state and local laws that apply to youth who have experienced child sexual exploitation, including reporting obligations.

Sexual exploitation is a form of child abuse that may go unrecognized, or the experiences of youth may be misunderstood without awareness of the range exploitative experiences. CACs are ideally suited to assess runaway youth for this less common but serious form of child maltreatment. Comprehensive health care evaluations are necessary, and the care that these youth require to manage their complex health conditions goes beyond the scope of forensic examinations by SANEs or what can be accomplished in an emergency department visit. Recognizing the varieties of sexual exploitation experiences and types, as well as knowing effective questions to elicit cooperation and disclosure are necessary to be able to plan for the individual client’s treatment Given the high prevalence of severe health symptoms among these sexually exploited youth, access to trauma-informed specialist health care services is important for their assessment and treatment.