Sexual exploitation of young men: Background characteristics and needs from a life-course perspective

BACKGROUND

Sexually exploited young men are prevalent, yet underrepresented in clinical practice, policy and research. There are multiple barriers that often prevent young men to disclose and to seek or receive support, such as gender norms, limited awareness of victimization and feelings of guilt and shame.

OBJECTIVE

By gaining more insight into the background characteristics of young men who experienced sexual exploitation and their needs, this study aims to raise awareness and to better inform policymakers, care- and educational professionals on adequate prevention and intervention efforts.

METHODS

Twenty-six young men (age 14-32) who experienced sexual exploitation or other forms of sexual violence in their youth or were at high-risk, participated in this qualitative study that was conducted in The Netherlands. By means of semi-structured interviews and case-file analyses, data was collected to identify risk and protective factors in their life-course and support needs.

RESULTS

Several vulnerabilities (e.g. previous experiences of abuse and neglect, household dysfunction, social rejection, running away, substance use) and a lack of positive and supportive relationships led young men into high-risk situations. Among these were involvement in pay dates, criminality and having to survive from day to day, which contributed to victimization. Prevailing gender norms and experiences of stigmatization were often a barrier to express vulnerabilities and to disclose victimization. There was a wide variety in support needs, including peer-to-peer support, therapy, support with day-to-day practices and anonymous support.

CONCLUSIONS

These results will contribute to adequate prevention and trauma-informed intervention strategies that meet the unique needs of young men at risk for, or victim of sexual exploitation.

Identification and responses by nurses to sexual exploitation of young people

BACKGROUND

Nurses are uniquely positioned to identify and respond to the sexual exploitation of young people. They treat sexually transmitted infections, unplanned pregnancies, and mental health issues, often collaborating with social services and law enforcement to safeguard young people.

AIM

This narrative review explores the pivotal role of nurses in identifying and responding to sexual exploitation among young people.

METHODS

Empirical evidence from 1997 to 2021 was examined through a comprehensive search of databases such as CINAHL-EBSCO, ASSIA, PubMed (including Medline), and manual screening of abstracts. The PRISMA guideline was applied. Thematic analysis of 12 selected studies revealed three overarching themes.

FINDINGS

The themes identified were the influence of technology on the sexual exploitation of young people, identification and response to sexual exploitation in both clinical and non-clinical settings, and organisational support.

CONCLUSION

These findings shed light on sexual exploitation and underscore the significance of a person-centred approach to nursing care that addresses the health and social impacts of sexual exploitation. It emphasises the importance of interagency collaboration and appropriate clinical interventions to effectively support young people at risk. Increased professional development, support, and supervision for nurses are relevant to identifying, responding to, and preventing the sexual exploitation of young people.

Experiences of Exploitation and Associations With Economic Abuse in Adolescent Dating Relationships: Findings From a U.S. Cross-Sectional Survey

Adolescent relationship abuse (ARA) (i.e. physical, sexual, psychological, or economic abuse in the context of romantic relationships) is associated with adverse health outcomes, including anxiety, depression, suicidality, unintended pregnancy, and substance misuse. A related phenomenon, reproductive coercion involves interference with the reproductive decision making of a partner with the intention of promoting pregnancy or controlling outcomes of a pregnancy. Reproductive coercion is associated with unintended pregnancy, partner violence, and sexually transmitted infections. Little is known about the intersection between economic ARA, sexual exploitation, and reproductive coercion. This paper explores the intersections between reproductive coercion, transactional sex, and economic abuse victimization in adolescent dating relationships. In an online survey, 1,752 adolescents (ages 13-17) were asked about economic adolescent relationship abuse (educational, employment and financial interference), transactional sex, reproductive coercion, and contraceptive access within their relationships. We assessed associations with chi-square tests and logistic regression analysis. Youth who experienced economic ARA (70%, 1,232) reported financial dependence on their partner, contraceptive access, and reproductive coercion (74-83%; p-values<0.001) more often than their counterparts without economic ARA. Adolescents experiencing economic abuse were more likely to report transactional sex (aOR = 2.76, CI [2.12, 3.60], p < .001), depending on a partner to pay for contraception or birth control (aOR = 2.20, CI [1.71, 2.84], p < .001), and reproductive coercion (aOR = 3.20, CI [2.37, 4.32], p < .001). Youth-serving providers and agencies should be aware of intersections between economic ARA, transactional sex, financial dependence, and reproductive coercion, particularly for adolescents with health-related social needs.

Syndemic Profiles and Sexual Health Risks Among Sexually Exploited Adolescent Girls in Taiwan: A Latent Class Analysis

Sexually exploited adolescent girls are disproportionately affected by adverse psychosocial conditions, such as intra-familial child physical and sexual abuse, extra-familial violence and sexual assault, alcohol and drug use, and suicide. Syndemic theory suggests that these adverse psychosocial or syndemic conditions are concentrated and co-occurring in socially marginalized populations, including sexually exploited adolescents, and increase their sexual health risks, including pregnancy, abortion, and the acquisition of sexually transmitted diseases (STDs). To examine clusters of syndemic conditions, latent class analysis (LCA) was conducted to classify 335 sexually exploited girls in Taiwan into subgroups based on their probability of experiencing each syndemic condition. We used syndemic class membership to predict their sexual health outcomes, specifically pregnancy, abortion, and the acquisition of STDs. The results of LCA revealed three classes, which were "low-risk syndemic," "moderate-risk syndemic," and "high-risk syndemic." The risk of acquisition of STDs among sexually exploited girls in the "high-risk syndemic class" and "moderate-risk syndemic class" was 239% and 135% higher, respectively, than the risk of acquisition of STDs among sexually exploited girls in the "low-risk syndemic class." Differences between these three classes in pregnancy and abortion were not significant. Our findings support the syndemic theory that a pattern of syndemic conditions is associated with an increased risk of acquiring STDs. Interventions aimed at reducing the acquisition of STDs among sexually exploited girls in Taiwan should adopt a comprehensive approach to address co-occurring conditions.

Victims of sexual exploitation and violence in Brazil

At least 8.9% of Brazilian women have already suffered some type of sexual violence in their lives. Every hour, Brazil has 2.2 cases of sexual violence against children and adolescents. Of the approximately 35,000 cases of violence against children and adolescents in 2021, in around 12,000 ethnic groups were not identified, 10,064 were white, 9634 were brown, 2505 black, 141 yellow, and 61 indigenous. If compared to age groups, boys from zero to 6 years reach 30%, but when the age is 12 to 18, women reach 91% of the victims. The whistleblowers are almost always anonymous, unlike in the case of violence against women, which are usually the victims themselves who complain or when they are third parties, they are usually identified. According to official data, around 96% of sexual violence takes place at home. The data are frightening and prove that sexual violence is the result of a scenario of gender inequality because it affects the lives of girls and women in a much more profound way.

Implementation of a screening tool for child sex trafficking among youth presenting to the emergency department - A quality improvement initiative

BACKGROUND

Identification of sex-trafficked youth in the emergency department (ED) is difficult and routine screening is uncommon.

OBJECTIVES

Our Quality Improvement (QI) Project aimed to increase ED screening and identification of high-risk youth using the Short Screen for Child Sex Trafficking (SSCST).

PARTICIPANTS

Youth (11 through 17 years) seeking care at two metropolitan EDs with a high-risk chief complaint triggering a best practice alert (BPA).

METHODS

A BPA prompted administration of the SSCST and referral of screen 'positive' youth for comprehensive evaluation for child sex trafficking by the forensic nurse examiner (FNE). Targeted QI interventions defined three study periods (SP). Outcomes measures included screening 50% of high-risk youth with 50% of those youth referred for FNE evaluation.

RESULTS

Over three study periods, 5454/13,956 (39.1%) youth triggered a BPA for high-risk chief complaint; 4354 (78.6%) received the SSCST screen; 1336 (76.0%) of screen-positive youth were referred for FNE evaluation. Outcomes measures were exceeded during all three study periods. SSCST modifications to increase specificity led to a significant decrease in the percentage of positive screens (42.8% SP1 vs 29.4% SP3). Financial programmatic support and further staff training led to an increase in FNE evaluations (86.4 SP3 vs 5.7% of referred youth SP1). Identification of trafficked patients increased from 1.3% of screen-positive youth to 11.3% (SP1 vs SP3; p < 0.0001).

CONCLUSIONS

Routine screening for child sex trafficking can be implemented in the ED setting and increases the identification of at-risk youth.

Human trafficking and violence: Findings from the largest global dataset of trafficking survivors

BACKGROUND

Human trafficking is a recognized human rights violation, and a public health and global development issue. Violence is often a hallmark of human trafficking. This study aims to describe documented cases of violence amongst persons identified as victims of trafficking, examine associated factors throughout the trafficking cycle and explore prevalence of abuse in different labour sectors.

METHODS AND FINDINGS

The IOM Victim of Trafficking Database (VoTD) is the largest database on human trafficking worldwide. This database is actively used across all IOM regional and country missions as a standardized anti-trafficking case-management tool. This analysis utilized the cases of 10,369 trafficked victims in the VoTD who had information on violence.

RESULTS

The prevalence of reported violence during human trafficking included: 54% physical and/or sexual violence; 50% physical violence; and 15% sexual violence, with 25% of women reporting sexual violence. Experiences of physical and sexual violence amongst trafficked victims were significantly higher amongst women and girls (AOR 2.48 (CI: 2.01,3.06)), individuals in sexual exploitation (AOR 2.08 (CI: 1.22,3.54)) and those experiencing other forms of abuse and deprivation, such as threats (AOR 2.89 (CI: 2.10,3.98)) and forced use of alcohol and drugs (AOR 2.37 (CI: 1.08,5.21)). Abuse was significantly lower amongst individuals trafficked internationally (AOR 0.36 (CI: 0.19,0.68)) and those using forged documents (AOR 0.64 (CI: 0.44,0.93)). Violence was frequently associated with trafficking into manufacturing, agriculture and begging (> 55%).

CONCLUSIONS

An analysis of the world's largest data set on trafficking victims indicates that violence is indeed prevalent and gendered. While these results show that trafficking-related violence is common, findings suggest there are patterns of violence, which highlights that post-trafficking services must address the specific support needs of different survivors.

Sex and the streets: the open secret of sexual abuse among Pakistan's two million street children

BACKGROUND

About two million children live on the streets in Pakistan. Their complicated past and dire living conditions make them susceptible to many psychological and physical problems, including sexual abuse.

MAIN BODY

With little research on the topic, the prevalence of sexual intercourse among street children is reported to be as high as 88% in Pakistan. With commercial sex a common practice among the street children, public places such as bus terminals and parks have become foci of prostitution and sexual exploitation. A growing concern is the spread of HIV/AIDS among the affected children due to a general lack of awareness about the disease and its prevention and high prevalence of unsafe sexual practices. The generally apathetic attitude of the society towards this issue and the affected children, combined with a lack of commitment and limited resource allocation by the government, has contributed in deteriorating the situation further.

CONCLUSIONS

A comprehensive multi-pronged strategy involving government, societal and international stakeholders is crucial to tackle the current crisis.

Children's exposure to trafficking, sexual exploitation and community-based violence in Canada: A narrative summary and policy perspective

BACKGROUND

Given the formidable health burdens associated with children's exposure to community-based violence (CBV) and trafficking and exploitation (TE), continued investments in determining their epidemiology constitute an important focus for Canada.

OBJECTIVE

The objective of the present study is to provide a narrative summary and policy perspective concerning the quantitative studies reporting on the risk and protective factors and prevalence of children's (<18 years) exposure to CBV and TE in Canada.

METHODS

To identify literature, we searched eight electronic databases. English and French citations from database inception to December 2018 were included; this was supplemented with citation chaining for peer-reviewed publications and grey literature up to December 2019. Evidence is synthesized via a narrative summary.

RESULTS

There are few studies that have investigated children's exposure to TE and CBV in Canada. Self-reported exposure to these forms of violence varies according to the type investigated, with estimates ranging from 2 % - to - 23 % and 5 % - to - 53 % for TE and CBV, respectively. Literature focused on risk and protective factors for these forms of victimization are also limited.

CONCLUSIONS

Canada has the infrastructure in place to make significant gains in their data collection and monitoring of children's exposure to TE and CBV via five national-level studies. To help realize the goal of ending all forms of violence against children by 2030, incorporation of reliable measures of these forms of exposure in new and ongoing national-level data collection systems is urgently needed.

Evaluating student knowledge about sexual exploitation using an interprofessional approach to teaching and learning

The aim of this study was to qualitatively assess student perceived impact of a novel interprofessional approach to delivering education on sexual exploitation (SE). This article reports on research that we designed, delivered and evaluated to develop an interprofessional community of learning, enabling SE to be discussed with second-year undergraduate students. Participants came from a broad range of specialties. Following the study, students reported an increased level of awareness, understanding and confidence when working with SE. This interprofessional education session has since been incorporated into the nursing, midwifery and allied health programme in a local university and is part of a second-year undergraduate module on knowledge and skills for safe practice.

Pre-positioning an evaluation of cash assistance programming in an acute emergency: strategies and lessons learned from a study in Raqqa Governorate, Syria

Background

Conducting ethical and rigorous research to measure the effectiveness of humanitarian programs is urgently needed given the global level of displacement and conflict, yet traditional approaches to evaluation research may be too slow and disruptive for acute humanitarian settings. The current case study utilizes an experience of implementing a mixed methods evaluation conducted between March–August 2018 in northern Raqqa Governorate, Syria. The key research objectives were to examine the influence of an unconditional, three-month cash transfer program on household basic needs and women’s wellbeing, including experiences of violence. This setting was selected for the research as it shared many aspects of an acute emergency within a protracted conflict given its recent opening of access to humanitarian aid programming following the withdrawal of ISIS as well as influxes of internally displaced persons fleeing airstrikes and fighting in Raqqa City in late 2017.

Discussion

The current case study was scientifically important as the use of cash assistance in emergencies has increased exponentially in recent years. Yet, little is still known about how cash assistance designed to help households meet their basic needs may also influence women’s overall wellbeing in the home. Challenges of conducting the research included selecting an emergency site appropriate for research, implementing an evaluation that would not delay or disrupt critical cash assistance programming, and measurement of sensitive violence against women outcomes. Four strategies were identified to meet the challenges of conducting an evaluation in such a setting, which included: (1) developing clear decision-making criteria for assessing feasibility; (2) frontloading processes to reduce time lag in launching research; (3) integrating the research approach within programming; and (4) closely collaborating with practitioners throughout the study, especially for research on sensitive topics like violence against women. Conclusions

Advance consideration of these factors through a pre-positioning process will allow for timely, ethical, and rigorous research to be implemented in the immediate aftermath of a crisis. Such studies should be prioritized to ensure the highest effectiveness and efficiency of humanitarian aid for populations grappling with acute emergencies.

Share our stories: An exploration of the healthcare experiences of child sex trafficking survivors

BACKGROUND

The trafficking of children and adolescents is widespread, and pediatric providers are on the front line. Current research demonstrates that trafficked children do access health care. However, few studies describe these interactions from their perspectives. In order to elucidate the healthcare experiences of sex trafficked children, we designed a qualitative study utilizing semi-structured interviews to explore their health care interactions.

PARTICIPANTS AND SETTING

Homeless youth currently aged 18-21 who were sex trafficked before age 18.

METHODS

Semi-structured interviews were conducted with seventeen youth who met the study criteria. Interview transcripts were coded and analyzed using constant comparative methods. Themes were inductively extracted by consensus with the study team, and thematic saturation was determined when no new themes emerged.

RESULTS

Themes included: victims endured serious injuries and illnesses without being brought to medical attention, traffickers limited victims' access to care, logistical barriers limited access, traffickers directed victims to lie to providers, and medical providers rarely separated victims to interview them separately resulting in missed opportunities.

CONCLUSIONS

These themes illustrate the experiences of sex trafficked youth experiencing homelessness and provide pediatric practitioners the opportunity to become more informed and equipped to recognize them. They also highlight serious health consequences of not being identified and egregious examples of providers exhibiting denial or inappropriate responses to their disclosure.

Systematic review of social norms, attitudes, and factual beliefs linked to the sexual exploitation of children and adolescents

BACKGROUND

Despite growing interest in the role of social norms in perpetuating the harmful practice of sexual exploitation of children and adolescents (SECA), little is known about the state of the literature on this issue.

OBJECTIVE

This systematic review aims to summarize what associated norms, attitudes and factual beliefs have been identified by the SECA literature worldwide.

METHODS

Multiple database searches were conducted using controlled vocabulary and keywords referring to SECA.

RESULTS

Our searches identified 3690 unique references. After applying our exclusion criteria, 49 studies, including over 14,000 participants from 37 countries and most world regions, were included. Across studies we identified six injunctive norms perpetuating SECA: owning goods as a social status marker ; being sexually active; exchanging sex for favors; contributing financially to the household; stigma and discrimination against young people who experienced SECA; and lack of social sanctions for SECA perpetrators. These norms were supported by enhanced tolerance of SECA when it involved older or more physically developed adolescents and when it occurred in poverty-affected contexts. Beliefs around markers that denote adolescents' readiness for sex; men's entitlement to sex; and the perceived benefits of intergenerational relationships, also contributed to the maintenance and reproduction of SECA. Findings from all regions suggested that marginalized young people are particularly vulnerable to SECA.

CONCLUSIONS

Interventions to reduce SECA must consider individual, social, and structural factors and how they interrelate. Context-specific social norms interventions are needed to address harmful norms, promote protective norms, and improve services for those who have experienced SECA.

Feasibility and predictors of change of narrative exposure therapy for displaced populations: a repeated measures design

BACKGROUND

Displaced victims of interpersonal violence, such as refugees, asylum seekers, and victims of sexual exploitation, are growing in numbers and are often suffering from a post-traumatic stress disorder (PTSD). At the same time, these victims are known to benefit less from trauma-focused therapy (TFT) and to be less compliant to treatment. The objective of this paper is to describe the rationale and research protocol of an ongoing trial that aims to evaluate different variables that might influence the feasibility of TFT for the study population. Specifically, perceived daily stress, emotion regulation, and mood are investigated as predictors of change in PTSD symptoms during a trauma-focused therapy (narrative exposure therapy (NET)). The feasibility of administering measures tapping these constructs repeatedly during treatment will also be evaluated.

METHODS/DESIGN

Using an observational treatment design, 80 displaced victims of interpersonal violence will be measured before, during, and after partaking in NET. Several questionnaires tapping PTSD plus the aforementioned possible predictors of PTSD change will be administered: Post-traumatic Stress Disorder Checklist-5, Perceived Stress Scale, Difficulties in Emotion Regulation Scale-18 (pre-test, post-test, and follow-up),subscale impulsivity of the Difficulties in Emotion Regulation Scale-18, Perceived Stress Scale short version, Primary Care Post-traumatic Stress Disorder and a single Mood item (each session). Multilevel modelling will be used to examine the relation between the possible predictors and treatment outcome.

DISCUSSION

The present study is the first to examine the interplay of facilitating and interfering factors possibly impacting treatment feasibility and effectiveness in displaced victims of interpersonal violence with PTSD receiving NET, using repeated measures. The current study can help to improve future treatment based on individual characteristics.

TRIAL REGISTRATION

Netherlands Trial Register: NTR7353, retrospectively registered. Date of registration: July 11, 2018.

Community perspectives on the extent to which transactional sex is viewed as sexual exploitation in Central Uganda

Background

Definitions of child sexual exploitation vary. Sexual exploitation violates children’s rights and exposes them to mental and physical harm. There exist differences in views of behaviour that is considered exploitative, including transactional sex. This paper explores community perspectives on the extent to which transactional sex is considered exploitative.

Methods

In 2014, we conducted 19 focus group discussions and 44 in-depth interviews with young people and adults in two communities in Uganda. Participants were presented with vignettes describing sexual encounters between adolescent girls and young women and men to explore under what conditions participants considered the scenario to be exploitative and why. Interviews were conducted in Luganda using a semi-structured tool, audio recorded and transcribed verbatim. Analysis was thematic and complemented by constant comparison and deviant case analysis techniques.

Results

Definitions by multilateral, bilateral, and non-governmental organisations of the sexual exploitation of children shared similarities with community conceptualisations of wrong or unfair sex. Although in community conceptualisations there was no consensus on what constituted sexual exploitation, transactional sex was condemned to the extent to which it involved sex with a minor or misled a naïve or immature girl; involved lack of consent, particularly in relationships characterised by power differentials; or worsened the pre-existing status of the girl. Also relevant was the extent to which a man’s intentions were considered inappropriate; the adolescent girl or young woman was considered vulnerable; and the adolescent girl or young woman was considered responsible for ‘her situation’.

Conclusions

Existing social norms that condemn sex with a minor or sex that involves deception, sexual coercion or misleading an immature girl, present opportunities to mobilise communities to protect adolescent girls and young women at risk. Any intervention must, however, be designed with full cognisance of the social and structural drivers that underlie transactional sex and limit adolescent girls’ and young women’s opportunities to provide for themselves without recourse to sexual relationships with men. Interventions must also be designed to recognise that girls in transactional sex relationships may not consider themselves as exploited, thus requiring engagement with them based on their own concerns, aspirations, and expectations.

Minor sex trafficking of girls with disabilities

Purpose –

The purpose of this paper is to investigate the associations between minor women' (girls') disability status and victimization via minor sex trafficking.

Design/methodology/approach –

This investigation used data from the National Longitudinal Study of Adolescent to Adult Health, a large, nationally-representative sample of in-school adolescents in the USA that began in 1994. The analysis included bivariate associations between physical disability status or low cognitive ability and minor sex trafficking among female survey respondents (n = 5,430).

Findings –

Girls with any disability had a higher prevalence of minor sex trafficking than their peers without disabilities. Odds of minor sex trafficking were significantly higher for those with severe physical disabilities (5.83) and for those with low cognitive abilities (4.86) compared to the odds of their peers without their respective disabilities. Results for girls with mild or moderate physical disabilities were not statistically significant compared to peers without disabilities.

Social implications –

These nationally-representative survey data reinforce the trends present in smaller populations and case study research: female adolescents with disabilities are at a heightened risk for sex trafficking. On both a national and global scale, the human rights gaps in policy and practice must be addressed to adequately reach, intervene and protect this vulnerable population.

Originality/value –

Research about minor sex trafficking typically relies on small-scale surveys and/or convenience samples. This study used a nationally-representative survey to demonstrate the link between disability status and women's experiences with minor sex trafficking.

Featured Counter-Trafficking Program: The Minnesota Runaway Intervention Program

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes the Minnesota Runaway Intervention Program (RIP), a Minneapolis-St. Paul based program dedicated to supporting youth aged 12-17 who have run away and experienced sexual violence, including sexual assault and exploitation. It is a comprehensive, health care focused intervention, embedded within a hospital-based Child Advocacy Center. RIP is developed and led by nurse practitioners who provide services tailored to participants' diverse needs, including health care, case management services, and a therapeutic empowerment group.

A systematic review of the state of the literature on sexually exploited boys internationally

This systematic review assessed the current state of the literature on sexually exploited boys internationally. We aimed to describe what is known about sexual exploitation of boys, identify gaps in the literature, provide implications for practice, and make recommendations for future research. Multiple database searches were conducted using a combination of controlled vocabulary and keywords to capture child and adolescent sexual exploitation. Our search identified 11,099 unique references and excluded studies that did not include male participants less than 18 years old or disaggregate results by relevant age groups and/or by sex. This review identified 42 studies from 23 countries, providing evidence that sexual exploitation of boys is an issue in both high- and low-income countries. Seventeen articles had sexual exploitation as their primary variable of interest, the majority of which sampled boys who accessed services (i.e., shelters, health care, social, and justice services). Boys' experiences of sexual exploitation varied in terms of venue, exploiters, and compensation. Compared to their non-sexually exploited peers, sexually exploited boys more commonly reported experiences of child abuse, substance use, conduct problems, and mental health problems such as anxiety, depression, and self-harm. Despite increasing evidence that boys are sexually exploited around the world, the current literature provides limited data about the antecedents, sequelae, and the specific features of sexual exploitation experiences among boys. Further research is needed to inform, policy, social services and health care delivery specific to the needs of sexually exploited boys.

Domestic Minor Sex Trafficking

Commercial sexual exploitation of children and child sex trafficking is a major public health issue globally. Domestic minor sex trafficking has become increasingly recognized within the United States. Sexually exploited minors are commonly identified as having psychosocial risk factors, including histories of abuse or neglect, running away, substance use or abuse, and involvement with child protective services. Youth also suffer a variety of physical and mental health consequences, including posttraumatic stress disorder, depression, anxiety, and suicidality. Child psychiatrists and other medical providers have the opportunity to identify, interact, and intervene on behalf of involved and at-risk youth.

Rethinking research on sexual exploitation of boys: Methodological challenges and recommendations to optimize future knowledge generation

Research and policies on child and adolescent sexual exploitation frequently focus on the sexual exploitation of girls and fail to recognize the experiences of sexually exploited boys, including their potentially unique health care and social support needs. This oversight limits the ability of health care and social service providers to offer both targeted and evidence informed care to sexually exploited boys. As a first step in a larger grant to understand the experiences of sexually exploited boys and to develop interventions for this specific population, we conducted a systematic review to address the question, "What is the state of the research on sexually exploited boys internationally?" As we undertook this review, we faced a number of significant challenges that made the process more difficult than anticipated. In this paper we discuss four key methodological challenges we encountered: lack of a consistent definition of child and adolescent sexual exploitation, difficulties in differentiating sexual exploitation as a specific concept within child sexual abuse, failure to disaggregate data usefully across multiple variables, and limited epidemiological studies to inform prevalence. We reflect on how these challenges limited our ability to systematically analyze, synthesize, and interpret the available research. We conclude by making recommendations to improve the state of the research regarding sexually exploited boys with the aim of better informing future policy and practice.

Sex Trafficking of Minors

Sex trafficking is an increasingly recognized global health crisis affecting every country and region in the world. Domestic minor sex trafficking is a subset of commercial sexual exploitation of children, defined as engagement of minors (<18 years of age) in sexual acts for items of value (eg, food, shelter, drugs, money) involving children victimized within US borders. These involved youth are at risk for serious immediate and long-term physical and mental health consequences. Continued efforts are needed to improve preventive efforts, identification, screening, appropriate interventions, and subsequent resource provision for victimized and high-risk youth.

Boys are not exempt: Sexual exploitation of adolescents in sub-Saharan Africa

Research on youth sexual exploitation in Africa has largely neglected the experiences of exploited boys. To date, much of the research in sub-Saharan Africa continues to consider boys mainly as exploiters but not as exploited. Using the only publicly available population-based surveys from the National Survey of Adolescents, conducted in four sub-Saharan African countries - Burkina Faso, Ghana, Malawi, and Uganda-we assessed factors associated with transactional sexual behaviour among never-married adolescent boys and girls. We also examined whether boys' reported sexual exploitation was linked to similar risky sexual behaviours as has been noted among girls in sub-Saharan Africa. Results from our analyses indicated that even though adolescent girls have a somewhat higher likelihood of reporting sexual abuse and exploitation, the odds of trading sex were significantly elevated for previously traumatized boys (that is those with a history of sexual and physical abuse) but not for their female counterparts. Just like adolescent girls, transactional sexual behaviour was associated with the risk of having concurrent multiple sexual partners for boys. These findings support the reality of boys' sexual exploitation within the African context, and further highlight the importance of including males in general and boys in particular in population-based studies on sexual health, risk, and protective factors in the sub-Saharan African region. Understanding the factors linked to sexual exploitation for both boys and girls will help in developing policies and programs that could improve the overall sexual and reproductive health outcomes among adolescents and youth in sub-Saharan Africa.

Sex trafficking and sexual exploitation in settings affected by armed conflicts in Africa, Asia and the Middle East: systematic review

Background

Sex trafficking and sexual exploitation has been widely reported, especially in conflict-affected settings, which appear to increase women’s and children’s vulnerabilities to these extreme abuses.

Methods

We conducted a systematic search of ten databases and extensive grey literature to gather evidence of sex trafficking and sexual exploitation in conflict-affected settings. International definitions of “sexual exploitation” and “sex trafficking” set the indicator parameters. We focused on sexual exploitation in forms of early or forced marriage, forced combatant sexual exploitation and sexual slavery. We extracted prevalence measures, health outcomes and sexual exploitation terminology definitions. The review adhered to PRISMA guidelines and includes quality appraisal.

Results

The search identified 29 eligible papers with evidence of sex trafficking and sexual exploitation in armed conflict settings in twelve countries in Africa, Asia, and the Middle East. The evidence was limited and not generalizable, due to few prevalence estimates and inconsistent definitions of “sexual exploitation”. The prevalence estimates available indicate that females were more likely than males to be victims of sexual exploitation in conflict settings. In some settings, as many as one in four forced marriages took place before the girls reached 18 years old. Findings suggest that the vast majority of former female combatants were sexually exploited during the conflict. These studies provided various indicators of sexual exploitation compatible to the United Nation’s definition of sex trafficking, but only 2 studies identified the exploitation as trafficking. None of the studies solely aimed to measure the prevalence of sex trafficking or sexual exploitation. Similar descriptions of types of sexual exploitation and trafficking were found, but the inconsistent terminology or measurements inhibited a meta-analysis.

Conclusions

Findings indicate there are various forms of human trafficking and sexual exploitation in conflict-affected settings, primarily occurring as early or forced marriage, forced combatant sexual exploitation, and sexual slavery. The studies highlight the extraordinary vulnerability of women and girls to these extreme abuses. Simultaneously, this review suggests the need to clarify terminology around sex trafficking in conflict to foster a more cohesive future evidence-base, and in particular, robust prevalence figures from conflict-affected and displaced populations.

BREACHING THE SEXUAL BOUNDARIES IN THE DOCTOR-PATIENT RELATIONSHIP: SHOULD ENGLISH LAW RECOGNISE FIDUCIARY DUTIES?

In this article, I argue that sexual exploitation in the doctor-patient relationship would be dealt with more appropriately by the law in England and Wales on the basis of a breach of fiduciary duty. Three different types of sexual boundary breaches are discussed, and the particular focus is on breaches where the patient's consent is obtained through inducement. I contend that current avenues of redress do not clearly catch this behaviour and, moreover, they fail to capture the essence of the wrong committed by the doctor-the knowing breach of trust for self-gain-and the calculated way in which consent is induced. Finally, I demonstrate that the fiduciary approach is compatible with the contemporary pro-patient autonomy model of the doctor-patient relationship.

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.

The 'dirty downside' of global sporting events: focus on human trafficking for sexual exploitation

OBJECTIVES

Human trafficking is as complex human rights and public health issue. The issue of human trafficking for sexual exploitation at large global sporting events has proven to be elusive given the clandestine nature of the industry. This piece examines the issue from a public health perspective.

STUDY DESIGN

This is a literature review of the 'most comprehensive' studies published on the topic.

METHODS

A PubMed search was done using MeSH terms 'human traffickings' and 'sex trafficking' and 'human rights abuses'. Subheadings included 'statistics and numerical data', 'legislation and jurispudence', 'prevention and control', and 'therapy'. Only papers published in English were reviewed.

RESULTS

The search showed that very few well-designed empirical studies have been conducted on the topic and only one pertinent systematic review was identified. Findings show a high prevalence of physical violence among those trafficked compared to non-trafficked women. Sexually transmitted infections and HIV AIDS are prevalent and preventive care is virtually non-existent.

CONCLUSION

Quantifying human trafficking for sexual exploitation at large global sporting events has proven to be elusive given the clandestine nature of the industry. This is not to say that human trafficking for sex as well as forced sexual exploitation does not occur. It almost certainly exists, but to what extent is the big question. It is a hidden problem on a global scale in plain view with tremendous public health implications.