The Journal of School Nursing
2021, Vol. 37(1) 6-16
© The Author(s) 2020
Article reuse guidelines:
DOI: 10.1177/1059840520971806
Simone Jaeckl, MSN, RN, LLB, PhD Student, and Kathryn Laughon, PhD, RN, FAAN
As trusted health care providers in the school setting, school nurses are positioned uniquely to identify children at risk for or victims of commercial sexual exploitation of children (CSEC). Nevertheless, many victims go unrecognized and unaided due to inadequate provider education on victim identification. This review provides a comprehensive overview of the major risk factors for CSEC of girls aged 12–18, the largest group of CSEC victims in the United States. A search of four databases (Web of Science, CINAHL, PsychINFO, and PubMed) yielded 21 articles with domestic focus, published in English between January 2014 and May 2020. While childhood maltreatment trauma was found most relevant, a variety of other risk factors were identified. Future nursing research is called to address the numerous research gaps identified in this review that are crucial for the development of policies and procedures supporting school nurses in recognizing victims quickly and intervening appropriately.
domestic minor sex trafficking (DMST), commercial sexual exploitation of children (CSEC), school nursing, sex trafficking, indicator, child*, adolescent*, risk factor*
Sex trafficking, a subtype of human trafficking, is nationally and internationally recognized as both a human rights violation and a crime (Chaffee & English, 2015). There is substantial and compelling evidence that sex trafficking of minors in the United States is a serious problem with immediate and long-term adverse consequences (Institute of Medicine [IOM], National Research Council, 2013). Reliable prevalence estimates of victims are not available due to the covert and transient nature of the crime alongside challenges of data collection, such as victim’s fear to disclose their status, lack of identification by service providers and legal authorities, lack of a centralized database, and variations in definitions and data collection methods (Barnert et al., 2017; Finklea et al., 2015; IOM National Research Council, 2013). The Polaris Project, however, offers insight. In 2017, the project received 7,277 potential sex trafficking referrals in the United States; 2,764 of these cases (38%) involved minor victims of whom almost 89% were female (Polaris Project, 2018). Girls aged 12–18 are the largest group of minor sex trafficking victims in the United States (Havlicek et al., 2016; Naramore et al., 2017; Varma et al., 2015).
Legislative efforts to address the problem in the United States started in 2000 with the Victims of Trafficking and Violence Protection Act [TVPA] (TVPA, 2000), which recognizes sex trafficking, in particular of children and adolescents, as one of the most severe forms of human trafficking. Under federal law, the statutory definition of sex trafficking is met when anybody receives anything of value due to a sex act involving a minor, even if the minor was not forced, defrauded, or coerced. Specifically, commercial sexual exploitation of children (CSEC) is defined by the U.S. Department of Justice as “sexual abuse of a minor for economic gain.” It includes “physical abuse, pornography, prostitution and the smuggling of children for unlawful purposes” (National Institute of Justice Office of Justice Programs, 2007, p. 1). This definition clarifies and reconceptualizes sex trafficking of children to mean the child is no longer committing a crime (i.e., prostitution) but is rather repeatedly victimized for profit (Naramore et al., 2017). This shift is further consolidated by the recent Preventing Sex Trafficking and Strengthening Families Act of 2014, the first federal bill to situate commercial sexual exploitation and sex trafficking of children as organized sexual abuse of children and adolescents (Preventing Sex Trafficking and Strengthening Families Act, 2014).
Children who are sex trafficked suffer a range of acute and chronic physical and mental health sequelae including injuries, sexually transmitted infections (including HIV), unintended pregnancies, abortions, anxiety, depression, post-traumatic stress disorder, and suicide (Chaffee & English, 2015; IOM National Research Council, 2013; O’Brien et al., 2017; Varma et al., 2015). Health care providers, in particular school nurses, may interact with victims who are seeking care and often still under their trafficker’s control. Nevertheless, many victims go unrecognized and unaided due to inadequate healthcare provider education in victim identification and trauma-informed approaches, along with the lack of effective screening and response strategies and policies (Barnert et al., 2017; Chaffee & English, 2015; Finklea et al., 2015).
Among health care providers, school nurses could play a pivotal role in CSEC prevention as well as in victim identification. Since girls are on average 12–15 years old at their initial victimization to CSEC, many continue to attend school, even if some more sporadically than others (Goldblatt Grace et al., 2012). Because of their open-door policies, school nurses readily gain students’ trust (Goldblatt Grace et al., 2012). Also, school nurses have the opportunity to observe students across time on a regular basis and thus potentially notice changes in behavior or appearance that may be indicative of CSEC (IOM National Research Council, 2013). As trusted health professionals in the school setting, school nurses are uniquely positioned to identify youth at risk for or victims of CSEC (Fraley et al., 2018; Goldblatt Grace et al., 2012). The National Association of School Nurses (2018) emphasizes that school nurses serve as health experts on the school team. They increase staff awareness, educate school personnel on indicators of CSEC, and increase parent and student awareness of risks and realities of trafficking. School nurses may, however, lack awareness of CSEC or hold misperceptions about the behavior of trafficked youth or they may even deny that CSEC occurs altogether (Fraley et al., 2018; Goldblatt Grace et al., 2012). It is therefore important for school nurses to have an understanding of risk factors for CSEC to provide at-risk children or CSEC victims with access to safety and health.
Building on a systematic review (Choi, 2015) and on a meta-analysis (De Vries & Goggin, 2018), both of which assess only a few CSEC risk factors specifically for girls, the purpose of this review of the literature is to provide a comprehensive overview of the major risk factors for CSEC of girls aged 12–18, the largest group of victims of CSEC in the United States, as well as to critically appraise the quality of the literature.
This integrative review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). Eligible for inclusion were quantitative and qualitative original, peerreviewed research reports, conducted in the United States and published in English between January 2014 and May 2020. We chose 2014 to coincide with the passage of the Preventing Sex Trafficking and Strengthening Families Act of 2014, which situates CSEC as organized sexual abuse of children. Studies included were limited to those conducted in the United States to identify cultural, social, and political aspects potentially unique to the United States. Due to the scarcity of high-quality evidence on the topic in the literature, a wide range of study methodologies was included. The phenomenon of interest was commercial sex trafficking of children in the United States. The population of interest was girls in the United States, aged 12–18, and outcome of interest was risk factors.
With the assistance of a senior medical research librarian, the search strategy was developed, combining Medical Subject headings and keywords. Searches were carried out within the electronic databases of CINAHL, PsycINFO, and Web of Science and within the academic search engine Google Scholar using the following search terms and search strategy: (“human trafficking” OR “sex trafficking” OR “sexual exploitation” OR prostitut* OR “sex work*”) AND (child* OR adolescen* OR juvenile* OR youth*) AND (risk* OR predictor* OR causality). Searches with similar search terms were also conducted in the PubMED electronic database: (human trafficking OR “sex trafficking” OR “sexual exploitation” OR prostitut* OR sex work) AND (child OR adolescent OR juvenile* OR youth*) AND (risk OR predictor* OR causality).
A search of four electronic databases (Web of Science, CINAHL, PsychINFO, and PubMed) between May 15, 2020, and May 31, 2020, returned 2,698 results, and two additional results were retrieved from the first 200 records of the academic search engine Google Scholar. After removal of duplicates, the titles and abstracts of all resulting articles (N = 1,746) were screened for phenomenon, population, and outcome variables of interest. Studies were excluded if they were published before 2014, did not qualify as original research, if they did not examine risk factors, did not provide results specific to domestic sex trafficking of minors in the United States, focused prevalently on labor trafficking or failed to distinguish between results for labor and sex trafficking, explored solely commercial sexual exploitation of adults, or failed to separate the findings for adults and juveniles when data were collected from both adults and minors. Based on research that suggests “social and neurobiological differences in boys and girls that may influence their expression as well as their experience of traumatic stress” (Sprang & Cole, 2018, p. 191), studies were excluded if they only assessed boys or failed to separate the results between girls and boys when data were collected from both groups. Lastly, research focusing on traffickers or buyers of CSEC with no original data regarding the victims was also excluded.
Title and abstract screening returned 104 eligible articles that were subjected to full-text review for the inclusion criteria. Hand screening yielded one additional record. A total of 21 studies qualified for inclusion in this integrative review (Online Table 1). A five-phase PRISMA flow diagram (Moher et al., 2009) depicting the study selection process is presented in Figure 1.
The 21 studies that met inclusion criteria were examined for study design, categories of risk factors explored, and terminology used to describe CSEC. A literature table (see Online Table 1) was used to organize these aspects and to present the studies in chronological order. To determine categories of risk factors, variables reported in the studies were identified and grouped by thematic similarity using a constant comparative approach (Whittemore & Knafl, 2005). The Johns Hopkins Research Evidence Appraisal Tool (Dang & Dearholt, 2017) was used to evaluate the quality of the studies reviewed. Studies were given a quality rating of high, good, or low following the Johns Hopkins Research Evidence Appraisal Tools. Levels of evidence and quality rating of the studies reviewed are presented in Online Table 1.
Twenty-one studies were reviewed. All were Level III studies using a variety of descriptive designs. Overall, the studies were of low quality, utilizing largely small convenience samples. The risk factors identified in the studies reviewed were summarized into four categories: demographic risk factors, environmental risk factors, childhood maltreatment trauma, and behavioral and mental health risk factors (see Online Table 1).
Race. Studies produced conflicting evidence regarding differences in risk for CSEC related to race. An analysis of a large national probability sample (N = 814 of which 38 reported CSEC) identified no racial differences (O’Brien et al., 2017). The majority of studies, however, found African American girls at greater risk than White girls (e.g., see Cecchet & Thoburn, 2014; Chohaney, 2016; Fedina et al., 2019; Havlicek et al., 2016; Kenny et al., 2020; Landers et al., 2017; Naramore et al., 2017; Reid, 2014). Differences ranged from 53% versus 35% in a study of 419 children evaluated for CSEC (Havlicek et al., 2016) to 65% versus 26% in a study of 115 participants who had been sex trafficked as a child (Fedina et al., 2019). More specifically, Fedina and colleagues (2019) found that the odds were more than twice as high for CSEC victims to be a racial minority compared to White children (OR = 2.31, 95% confidence interval [CI] = [1.17, 4.55]). It is important to note, however, that the studies supporting minority race as a risk factor are likely to reflect the characteristics and limitations of their samples. Most samples were obtained by convenience or respondent-driven sampling; none of these studies used probability samples. Consequently, considering the conflicting evidence, as well as the design of the studies reviewed, no definitive conclusions can be drawn regarding minority race as a risk factor.
Education. Research identified that many CSEC victims were enrolled in school (Cecchet & Thoburn, 2014; Fraley & Aronowitz, 2019; Kenny et al., 2020; Reid, 2014; Shaw et al., 2017). For example, of 56 confirmed CSEC victims in a study by Kenny and colleagues (2020), 60% were enrolled in school. There were mixed results, however, concerning educational attainment. Two studies found CSEC victimization not correlated with educational attainment (Cecchet & Thoburn, 2014; Reid, 2014). A small qualitative retrospective study found that four of the six CSEC victims interviewed had at least some college education (Cecchet & Thoburn, 2014). A mixed-methods study with 40 CSEC survivors (Reid, 2014) reported that girls successful in school were also victimized to CSEC, but that exploitation had ceased by adulthood among two third of those who had completed high school. Several other studies, however, found a low-level educational achievement or dropping out of school significantly correlated to CSEC victimization (Chohaney, 2016; Edinburgh et al., 2015; Fedina et al., 2019; Fraley & Aronowitz, 2019). For example, in Chohaney’s (2016) study (N = 328), one third of participants dropped out of school before their involvement in sex work (OR = 2.14, 95% CI [1.31, 3.49], p <.002).Fedinaand colleagues (2019) noted 44% of CSEC victims (N = 115) had dropped out of school without clarifying the point in time relative to their CSEC victimization. A qualitative study of CSEC survivors (N = 25) reported chronic absence of student CSEC victims with one survivor stating,
The busiest time for me and my work [being trafficked] was the lunch period, and so I would go for a few hours in the morning and then I would leave [lunch] because I had to go work [trafficking] ...sometimes I did not make it back. (Fraley & Aronowitz, 2019)
Vulnerability to CSEC victimization may also manifest in a child’s disengagement and deviant behavior, as evidenced by a study of CSEC victims (N = 25) that revealed suspensions from school for more than half of the participants (Shaw et al., 2017). Landers and colleagues (2017; N = 87) support these findings; more than two thirds of CSEC victims exhibited moderate to severe behavior problems in school, thus risking expulsion, and about one third missed at least 2 days of school per week on average. Thus, while low educational attainment was not a strong risk factor for CSEC, academic difficulty, as well as behavior problems in school, was found to constitute noteworthy predictors of CSEC.
Most studies found an association between dysfunctional home and family environments and increased risk for CSEC (e.g., see Cecchet & Thoburn, 2014; Chohaney, 2016; Cimino et al., 2017; Fedina et al., 2019; Fraley & Aronowitz, 2019; Naramore et al., 2017; O’Brien et al., 2017; Perkins & Ruiz, 2017; Reid et al., 2015, 2017; Varma et al., 2015). Family environmental factors spanned a broad spectrum from lack of more general parental or guardian supervision to neglect or abuse as well as domestic violence, parental substance use, family members or peers trading sex, and poverty. Naramore and colleagues (2017) specifically examined adverse childhood experiences (ACEs), reporting that the highest ACE score of 10 was scored by 83% of their cohort of 102 CSEC victims. More generally, findings from qualitative interviews with female survivors (N = 25) suggested that youth’s vulnerability to CSEC may be increased by a lack of parental or guardian supervision, including unsupervised access to social media (Fraley & Aronowitz, 2019, p. 12).
Parental substance use. A connection between parental substance use (alcohol or drugs) and CSEC was corroborated by several studies (Cole & Sprang, 2015; Perkins & Ruiz, 2017; Sprang & Cole, 2018). Perkins and Ruiz (2017) identified parental drug use for one third (n = 13) of their 40 adjudicated juvenile female participants. In addition, Sprang and Cole (2018) proposed that parental drug use and familial CSEC (cases where the trafficker is a family member) are tightly intertwined. For their study of CSEC victims (N = 31) aged 6–17, they confirmed 82% of the victims’ parents trafficked their children for drugs. Furthermore, they suggested that maternal substance use greatly increased the odds of CSEC victimization: The mother was the trafficker in over two thirds of cases, the father in one third (Sprang & Cole, 2018). Similarly, in a study by Reid and colleagues (2015), in 58% (n = 11) of 19 familial sex trafficking cases, the biological mother was the trafficker. In alignment with these findings, another study (N = 87) found that about half of the family members were not supportive of the CSEC survivor’s disclosure (Landers et al., 2017).
Peers and family members engaged in sex trading were found to increase the risk for CSEC victimization (Cecchet & Thoburn, 2014; Chohaney, 2016; Fedina et al., 2019). Two studies identified about one third of CSEC victims having peers or family members engaged in the sex trade. Chohaney (2016; N = 328 of which N = 61 CSEC victims) identified one third of CSEC victims having peers engaged in the sex trade. Fedina and colleagues (2019; N = 273; including N = 115 CSEC victims) found that having family members involved in sex work was a statistically significant risk factor for CSEC (χ2 = 4.28, p < .05); that is, one third of CSEC victims had family members engaged in sex work.
Witnessing domestic violence, more generally, was also suggested to increase children’s likelihood of CSEC victimization (Cimino et al., 2017; Landers et al., 2017; Reid et al., 2015, 2017). For example, Reid and colleagues (2017) confirmed a significantly greater odds of family violence (OR = 1.51, 95% CI [1.09, 2.09]) among their sample of 801 female CSEC victims compared to a matched sample of nontrafficked delinquent girls.
Familial poverty as a risk factor for CSEC was explored by several studies (Chohaney, 2016; Cole & Sprang, 2015; Reid et al., 2017). Cole and Sprang (2015) discerned poverty as structural risk factor for CSEC victimization in rural, micropolitan, and metropolitan areas, noting that poverty may be a determinant to entry into CSEC, as well as a reason for not escaping the exploitation, in that poverty increased the likelihood that the youth might trade sex (known as “survival sex”) to obtain food, shelter, money, or drugs. More specifically, Chohaney (2016) identified that one third of former and current CSEC victims (N = 328) lived in familial poverty before their involvement in CSEC. Reid and colleagues (2017) found that 44% of CSEC victims (N = 913) came from a family with an annual income of less than US$15,000. While the Choi (2015) systematic review suggested that CSEC victims come from all socioeconomic backgrounds, this observation does not contradict the previous findings which evidence the disproportionate familial poverty of CSEC victims. Consequently, the studies reviewed provide sufficiently strong evidence to confirm familial poverty as a risk factor for CSEC.
Juvenile justice and child protection involvement were identified as important predictors for CSEC (Chohaney, 2016; Cimino et al., 2017; Havlicek et al., 2016; Kenny et al., 2020; Landers et al., 2017; O’Brien et al., 2017; Perkins & Ruiz, 2017; Reid et al., 2015; Rothman et al., 2015; Varma et al., 2015). In-depth interviews (N = 4) revealed that CSEC victims were encouraged by partners and peers to engage in criminal activity (Rothman et al., 2015). Findings on juvenile justice involvement prior to CSEC ranged from two thirds of 27 CSEC victims (Varma et al., 2015) to 10% of 328 current CSEC victims or survivors (Chohaney, 2016). Others identified legal involvement, however, without specifying directionality, for almost 70% of 56 CSEC victims (Kenny et al., 2020).
A lack of child protective service (CPS) involvement was discerned by Cimino and colleagues (2017). While almost 62% (n = 20) of 31 CSEC victims were sexually abused by their parents/caregivers, only five cases were investigated by CPS, and only four children were removed from their homes. Entry into foster care, however, was also associated with increased risk for CSEC victimization. A study of 419 children with an investigated allegation for CSEC found that more than one fourth (n = 119) had been placed in foster care; of these almost half (n = 54) had allegations for CSEC during out-of-home care, while over 20% (n = 24) had at least one allegation for CSEC before and about one third (n = 36) after exiting out-of-home care (Havlicek et al., 2016). Thus, while CPS involvement constitutes an important marker for CSEC victimization, the direction of the relationship between foster care and CSEC, however, remains unclear, primarily due to small sample sizes.
In sum, adolescents living in unsafe family environments, as well as in familial poverty, were found to be at increased risk. Frequent encounters with child welfare systems, especially foster care, were identified as strong predictors for CSEC.
Childhood maltreatment trauma (sexual abuse, physical abuse, emotional abuse, and neglect) was the most prominent risk factor cluster for CSEC victimization supported by all studies.
Childhood sexual abuse (CSA). More specifically, evidence strongly suggested CSA as a key risk factor for CSEC (Cecchet & Thoburn, 2014; Chohaney, 2016; Cimino et al., 2017; Cole & Sprang, 2015; Fedina et al., 2019; Fraley & Aronowitz, 2019; Havlicek et al., 2016; Kenny et al., 2020; Landers et al., 2017; O’Brien et al., 2017; Perkins & Ruiz, 2017; Reid, 2014; Reid et al., 2015, 2017; Shaw et al., 2017). Reid and colleagues (2017) found CSA to be the strongest predictor of trafficking victimization with the odds for CSEC 2.33 times greater for girls who experienced CSA (N = 801) compared to a matched sample (OR = 2.33, CI 95% [1.83, 2.98]). These findings were supported by Fedina and colleagues (2019) who reported a statistically significant association between CSA and CSEC (χ2 = 8.18, p < .01). CSA was experienced by 45% of the 115 CSEC victims (Fedina et al., 2019). Regarding familial CSEC, Reid and colleagues (2015) identified CSA in 88% of 19 familyfacilitated CSEC cases compared to 35% of 43 CSEC cases by nonrelative traffickers. In addition, several studies suggested that increased severity of CSA (such as rape or very young age of victimization) conferred greater risk for CSEC (Fedina et al., 2019; Havlicek et al., 2016; Landers et al., 2017; Naramore et al., 2017; Varma et al., 2015). For example, victimization started at age 5 or younger for almost 10% of 87 CSEC victims in the study by Landers and colleagues (2017), while almost half of the victims were between the ages of 6 and 12; half of the 115 CSEC victims in the Fedina and colleagues (2019) study experienced childhood rape (χ2 = 9.16, p < .01).
Physical and emotional abuse. For the most part, CSA was identified to occur in conjunction with physical and emotional abuse as well as with neglect (Cimino et al., 2017; Havlicek et al., 2016; Kenny et al., 2020; Landers et al., 2017; Reid et al., 2017). For example, over 30% of 419 children with investigated allegations for CSEC had a previous investigated allegation of physical abuse and almost 25% had an investigated allegation of sexual abuse (Havlicek et al., 2016). By comparison, nationally in the United States, 18% of children under the age of 18 were reported to child welfare authorities for physical abuse and 9% were reported for sexual abuse (U.S. Department of Health and Human Services, 2018).
Reid and colleagues (2017) underscored that emotional neglect increased vulnerability particularly for girls as they may seek support and affection outside of their home (OR = 1.37, 95% CI [1.10, 1.71]). In-depth interviews (N = 4) also revealed that unmet needs for love and belonging may increase girl’s risk for CSEC (Rothman et al., 2015). These findings are corroborated by Perkins and Ruiz (2017) who reported that youth (N = 40) voiced a strong “need to feel cared for,” which was oftentimes filled by “giving sex” (p. 177). Additionally, Landers and colleagues (2017) suggested that youth with a history of childhood abuse and neglect may fail to recognize their exposure to a trafficker as exploitation, thus increasing their vulnerability to CSEC. Almost 90% of CSEC victims in their study (N = 87) had been sexually abused and almost 60% had experienced moderate to severe levels of neglect, but half of survivors showed no awareness of their exploitation and almost 70% displayed indications for trauma bonding with their perpetrators (Stockholm Syndrome). In sum, CSA was identified as the strongest correlate of CSEC. CSA was frequently joined with other types of abuse, forming a strong risk factor complex.
Running away. The second most frequently studied risk factor, after CSA, was runaway behavior. The reasons for adolescents running away from home were found to be complex and manifold, ranging from running away after developmentally normal parent–child conflicts to cases of CSA by family members (Edinburgh et al., 2015; Fedina et al., 2019; Kenny et al., 2020; O’Brien et al., 2017; Perkins & Ruiz, 2017; Shaw et al., 2017). Overall, a high prevalence of runaway history was identified among CSEC victims, with findings ranging from almost 87% of 31 CSEC victims (Cimino et al., 2017) to 85% of 56 victims of CSEC (Kenny et al., 2020). Multiple studies evidenced running away from home as a key mediating factor between CSA and CSEC (Chohaney, 2016; Cimino et al., 2017; Edinburgh et al., 2015; Fedina et al., 2019; Naramore et al., 2017; O’Brien et al., 2017; Varma et al., 2015). Chohaney (2016) found that 42% of 328 current and former CSEC victims surveyed ran away from home before victimization to CSEC. Qualitative evidence supports this relationship as well. Survivors endorsed that fleeing danger at home was a key reason for running away and subsequently falling into CSEC (Cecchet & Thoburn, 2014; Rothman et al., 2015). Others, however, pointed out that many teen victims of CSEC may still be living at home during their victimization to CSEC. Findings ranged from 44% of 62 CSEC victims (Edinburgh et al., 2015) to almost 43% of 56 victims (Kenny et al., 2020).
In short, while many children were found to be living at home during CSEC victimization, running away was identified to be an important risk factor. It remains unclear, however, whether CSEC victimization occurred prior to, during, or after running away, primarily, because many studies examined only one type of risk factor, disregarding other important correlates of CSEC.
Homelessness, poverty, and survival sex. Runaway youth are likely to experience homelessness and poverty, making them prone to exploitation. They may trade sex to meet basic needs such as money, food, shelter, or drugs (survival sex). Several studies corroborated the relationship between survival sex and CSEC victimization (Chohaney, 2016; Fedina et al., 2019; O’Brien et al., 2017; Perkins & Ruiz, 2017). One study (N = 328) found that one fourth of CSEC survivors had engaged in survival sex while running away (Chohaney, 2016). Another study (N = 40) reported that engagement in survival sex led to subsequent CSEC victimization for about one third of study participants (Perkins & Ruiz, 2017). Conversely, a qualitative study of CSEC survivors (N = 25) and school nurses (N = 18) found that youth who were being trafficked oftentimes experienced chronic hunger, as traffickers withheld food as a means of control; these victimized youth were found to be looking and asking for food as well as stealing food from other students in schools (Fraley & Aronowitz, 2019).
Substance use. Multiple studies indicated a high frequency of substance use among CSEC victims, including alcohol, tobacco, and illegal drugs (Chohaney, 2016; Cole & Sprang, 2015; Edinburgh et al., 2015; Fedina et al., 2019; Kenny et al., 2020; O’Brien et al., 2017; Reid, 2014; Reid et al., 2015; Shaw et al., 2017; Varma et al., 2015). The findings ranged from a confirmed diagnosis of drug abuse in 74% of 56 CSEC victims (Kenny et al., 2020) to substance abuse that interfered with life functioning in about half of 87 CSEC victims (Landers et al., 2017). National data for 2017 report 4.13% of youth having a substance use or alcohol problem (Mental Health of America, 2019). Most studies suggested substance use as an outcome of CSEC, not as a risk factor thereof (e.g., see Edinburgh et al., 2015; O’Brien et al., 2017; Shaw et al., 2017). For example, in a study involving 38 teen CSEC survivors, about 50% tested in the clinical range for substance use (O’Brien et al., 2017). Conversely, other studies proposed substance use as antecedent to CSEC. A case study of four former CSEC victims (Rothman et al., 2015) revealed initiation into drug abuse prior to CSEC as well as increasing dependence on illicit drugs. Others reported that youth engaged in survival sex prior to CSEC victimization, where sex may have been sold to obtain money for drugs and alcohol (Chohaney, 2016; Reid, 2014). Survival sex was found to be significantly correlated with substance use (rs = .469**, p < .01; Perkins & Ruiz, 2017).
In sum, the relationship between substance use and CSEC victimization remains unclear. While most studies suggested substance use as an outcome of CSEC or occurring simultaneous with CSEC, some found it to be antecedent, thus proposing that substance use may be a risk factor for CSEC.
Mental health disorders. There is evidence of high prevalence of mental health disorders among CSEC victims, including post-traumatic stress disorder (PTSD), self-injury, depression, anxiety, and suicidality. A study reviewing medical records (N = 27) identified a prior history of mental health disorders for almost 40% CSEC victims (Varma et al., 2015). Other studies reported mental health prevalence without specifying directionality (Edinburgh et al., 2015; Fraley & Aronowitz, 2019; Kenny et al., 2020; Landers et al., 2017; Shaw et al., 2017). For example, Fraley and Aronowitz (2019; N = 25) noted that CSEC survivors commonly shared stories of struggling with anxiety. Regarding frequent visits of CSEC victims to the school nurse office, one survivor stated, “ ...a lot of times the made-up stuff [cramps, stomach ache] is anxiety” (p. 11). More specifically, findings ranged from anxiety in about 50%, depression in 62%, and PTSD in 18% of CSEC survivors (Landers et al., 2017; N = 87) to PTSD in 76% of CSEC survivors (Edingburgh et al., 2015; N = 62). Edinburgh and colleagues also found that 71% evidenced cutting behaviors, 57% suicidal ideation, and almost half of CSEC victims had attempted suicide. For comparison, national data report that 9.2% of youth cope with severe depression (Mental Health of America, 2019), and the National Comorbidity Survey (National Institute of Mental Health, 2017) reports a prevalence of PTSD in female adolescents of 8.2%.
Several studies identified conduct disorder and anger control problems (Fraley & Aronowitz, 2019; Hershberger et al., 2018; Lander et al., 2017). Landers and colleagues (2017) reported these challenges in over half of 87 youthful CSEC survivors. More specifically, in another study (N = 25), CSEC survivors talked about being violent in schools during their trafficking experience. One participant stated: “ ... I was violent. ... I would smash your face into the pole, flagpole, or beat you with a sock full of quarters or something” (Fraley & Aronowitz, 2019, p. 11). In addition, that same study reported hypersexual behavior and promiscuity: One survivor shared about dressing provocatively at school and another called attention to children, aged 10–12, exhibiting sexual promiscuity and detailed knowledge on sex practices (Fraley & Aronowitz, 2019). It remains unclear, however, whether the exhibited behaviors contributed to CSEC victimization or were rather indicators of occurring CSEC victimization.
In summary, running away, homelessness, and survival sexwereidentifiedasriskfactors. Furthermore, studies found a high prevalence of mental health disorders and substance use among CSEC victims; however, the direction of these relationships remains unclear.
This review identified multiple risk factors for CSEC. Childhood maltreatment trauma (sexual abuse, physical abuse, emotional abuse, and neglect) was identified as most important set of risk factors. Running away, homelessness, and the resulting use of survival sex were also strong predictors. Findings were mixed for other risk factors such as racial minority status, educational achievement challenges, and dysfunctional home environments, as well as for mental health disorders and substance use. Frequent encounters with the juvenile justice system and with child welfare systems were identified as predictors.
Childhood maltreatment trauma posed the strongest risk factor for CSEC, supported by the majority of studies (e.g., see Chohaney, 2016; Franchino-Olsen, 2019; Havlicek et al., 2016; O’Brien et al., 2017; Reid, 2014; Reid et al., 2015), thus corroborating findings of an earlier systematic review by Choi (2015) and a meta-analysis by De Vries and Goggin (2018). School nurses, as trusted health professionals in the school setting, are uniquely positioned to identify the signs and symptoms of child maltreatment trauma, as child victims of CSA or other forms of abuse are likely to see their school nurse for related physical and psychological health complaints. Running away from home was the second most prominent risk factor for CSEC, and there is preliminary evidence supporting the relationship between childhood maltreatment trauma, running away, and CSEC (Cimino et al., 2017; Naramore et al., 2017; O’Brien et al., 2017). Physical and emotional abuse as well as neglect, including the lack of monitoring or support, increase the risk for CSEC victimization, as children may flee the dangers at home and/or turn to exploitative peers, acquaintances, or strangers in search for support and affection. While familial poverty constitutes a risk factor for CSEC (Chohaney, 2016; Cole & Sprang, 2015; Reid et al., 2017), particularly running away and the associated risks of homelessness increase the likelihood of children engaging in survival sex to meet their basic needs. Runaways frequently feel indebted to peers or strangers—oftentimes traffickers—to offer sex in exchange for shelter and food (Fedina et al., 2019; Landers et al., 2017).
Hunger was identified as a risk factor, driving some children to trade sex for food, but it was also noted that children who are already being trafficked oftentimes experience chronic hunger, thus looking and asking for food as well as stealing food from other students in schools because traffickers withhold food as a means of control (Fraley & Aronowitz, 2019). Chronic hunger was not only identified in runaways but also in victims of familial CSEC living at home (Fraley & Aronowitz, 2019). Consequently, chronic hunger and homelessness, identifiable by a change in personal hygiene or by the possession of hotel keys (Fraley & Aronowitz, 2019), are risk factors for CSEC as well as indicators of CSEC victimization that school nurses are particularly well positioned to identify. It is noteworthy, however, that running away is not the only pathway to CSEC victimization. School nurses should bear in mind that a large percentage of CSEC victims were living at home (Edingburgh et al., 2015; Kenny et al., 2020; Landers et al., 2017), thus maintaining a façade of normalcy. In this context, research has shown that neglected youth may engage in sex out of a need to feel cared for (Kenny et al., 2020; Perkins & Ruiz, 2017), thus making them vulnerable to CSEC victimization. Others may be victims to familial sex trafficking, where the trafficker is a family member, oftentimes the mother; more than half of these victims were found to be very young, that is between the ages of 5 and 12 (Sprang & Cole, 2018; Landers et al., 2017; Reid et al., 2015). The identification of victims of familial CSEC requires particular awareness and vigilance of school nurses because family members, especially mothers, may not be suspected of trafficking their children and it may be equally unsuspected that children may be trafficked at such a young age. In addition, youth oftentimes do not recognize—and consequently not disclose—that they are victims of sexual exploitation because they have peers or family members trading sex, which may normalize the sex trade and the related violence for these children (Checcet & Thoburn, 2014). CSEC victims may also feel loyalty to their trafficker. In fact, half of CSEC victims were found to show no awareness of their exploitation, and almost 70% displayed some indications of trauma bonding with their perpetrators (Stockholm syndrome; Landers et al., 2017). Consequently, school nurses need to know that children are unlikely to self-identify as victims or to denounce their perpetrators.
Mental health disorders and substance use were found to constitute noteworthy predictors of CSEC (e.g., see Edingburgh et al., 2015; Naramore et al., 2017; O’Brien, et al., 2017; Shaw et al., 2017). Since most of the studies used cross-sectional designs (case-control or case series), it is, however, difficult to identify risk trajectories. Additional research is needed to understand the temporal relationship among behavioral problems, substance use, and CSEC, as child victims grappled with consequences of maltreatment trauma and developed coping strategies, such as substance use. School nurses may observe students across time on a regular basis, positioning them to assess changes in behavior, such as hypersexuality or symptoms of substance abuse.
Frequent encounters with CPS were also identified as predictors for CSEC (Chohaney, 2016; Cimino et al., 2017; Havlicek et al., 2016; Varma et al., 2015). CPS are tasked with protecting children; however, they were found to have investigated less than 10% of cases of children sexually abused by parents or caregivers (Cimino et al., 2017) and almost half of the children placed in out-of-home care were found to be victimized to CSEC during foster care (Havlicek et al., 2016). The evidence suggests that child protection authorities are failing these children despite their mandate. School nurses are positioned to address this gap. Because of their open-door policies, school nurses have the opportunity to build relationships of trust with students (Goldblatt Grace et al., 2012), creating an opportunity to obtain information about environmental risk factors.
Racial minorities, particularly African American, were found to be at increased risk for CSEC victimization by the majority of the studies (see, e.g., Fedina et al., 2019; Havlicek et al., 2016; Naramore et al., 2017); however, these findings may have been related to the study methodologies applied. Studies were mostly case control or case series with respondent-driven sampling or with predominant access to the research study settings by specific racial groups, thus increasing the likelihood of racially biased study samples. Consequently, further research is mandated to determine if and how race and ethnicity are related to risk for CSEC.
Lastly, low educational achievement, another risk factor for CSEC notable to school nurses, was reported by several studies (Chohaney, 2016; Edinburgh et al., 2015; Fraley & Aronowitz, 2019). Poor academic performance, possibly resulting from other risk factors, is likely due to lower self-esteem (Estes & Weiner, 2001; Lloyd, 2011). As youth may seek validation elsewhere, their lack of self-esteem makes girls more vulnerable to recruitment by sex traffickers who discount school attendance and academic success (Goldblatt Grace et al., 2012; Rothman et al., 2015). Conversely, poor academic performance may also constitute an indicator for CSEC, as a CSEC victim’s school attendance was found to be marked by truancy, sometimes even sporadicity, resulting in academic difficulty (Fraley & Aronowitz, 2019; Kenny et al., 2020). Thus, while the direction of the relationship between CSEC and low-level educational achievement remains unclear, the research suggests an association and school nurses are well placed to identify this risk factor. The watchfulness of school nurses must, however, not focus only on children with poor academic performance, as there are also CSEC survivors with some college education (Cecchet & Thoburn, 2014; Reid, 2014). Consequently, the necessary vigilance must include children of all academic achievement. Lastly, the overall relevance of educational attainment for long-term outcomes must be highlighted. Exploitation is likely to have ceased by adulthood for the majority of CSEC survivors who obtained a high school degree (Reid, 2014).
Limitations of this review result primarily from the scarcity of original research on CSEC. Methodological weaknesses of the studies reviewed limit the generalizability of the findings, for example, small sample sizes, convenience sample, and mostly cross-sectional designs. Some studies examined only one type of risk factor, neglecting to measure potentially relevant correlates. Other studies used retrospective methods with adult samples, thus risking recall bias. Lastly, the terminology describing the phenomenon varies widely. A strength of this review consists in the systematic approach applied to analyze the literature. Quantitative and qualitative studies were included as well as various study designs, allowing a broad, inclusive perspective. Studies included a variety of regions of the United States, thus taking into account potential regional variations. Finally, this review points out gaps in the nursing literature with regard to CSEC and it emphasizes implications for school nursing practice and research.
This integrative review of the literature identified a comprehensive list of risk factors and indicators associated with CSEC that school nurses need to be aware of to quickly and accurately identify and refer children at risk for or victims of CSEC. Professional development for school nurses needs to include risk factors as well as signs and symptoms of CSEC. Educational offerings must be victim-centered, traumainformed, and include content on implicit bias. Furthermore, school nurses need to know whom to contact as well as referral options for victims, including the National Trafficking Hotline (Tel: 888-373-7888, text message: HELP to BEFREE [233733], or website: https://humantraffickinghotline.org/; Grace et al., 2014). School nurses also need to be aware that some children may exhibit no apparent risk factors, other than their normal neurodevelopmental stage, making them prone to impulsivity and risk-taking (Barnert et al., 2017). Consequently, it is paramount for school nurses to be mindful that all children may be at risk for CSEC, independent of their socioeconomic background, race, school performance, or behavior.
Overall, it is noteworthy that of the 21 peer-reviewed studies only two were published by nurses (Edinburgh et al., 2015; Fraley & Aronowitz, 2019) and none by school nurses. The paucity of nursing research into CSEC presents an opportunity for school nurses to engage in confronting CSEC in their practice and in research. Addressing the numerous research gaps identified in this review is crucial for the development of laws, policies, and protocols regarding the identification, reporting, and referral of CSEC victims, so school nurses may recognize CSEC victims quickly and intervene appropriately.
Simone Jaeckl contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Kathryn Laughon contributed to conception, design, acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental material for this article is available online.
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Simone Jaeckl, MSN, RN, LLB, is a PhD student at School of Nursing, University of Virginia.
Kathryn Laughon, PhD, RN, FAAN, is an associate professor of nursing and director of the PhD Program at School of Nursing, University of Virginia.
1 School of Nursing, University of Virginia, Charlottesville, VA, USA
Corresponding Author:Simone Jaeckl, MSN, RN, LLB, PhD Student, School of Nursing, University of Virginia, 225 Jeanette Lancaster Way, Charlottesville, VA 22903, USA. Email: sj9k@virginia.edu