1


Introduction

Commercial sexual exploitation and sex trafficking of minors in the United States are frequently overlooked, misunderstood, and unaddressed domestic problems. In the last decade, they have received increasing attention from advocates, the media, academics, and policy makers. However, much of this attention has focused internationally—the media tell stories of girls being exploited on the streets of Cambodia or sold as mail order brides from Russia. This international focus has overshadowed the reality that commercial sexual exploitation and sex trafficking of minors also occur every day within the United States.

Commercial sexual exploitation and sex trafficking of minors are not only illegal activities, but also result in immediate and long-term physical, mental, and emotional harm to victims and survivors. A nation that is unaware of these problems or disengaged from solving them unwittingly contributes to the ongoing abuse of minors and all but ensures that commercial sexual exploitation and sex trafficking of minors will remain marginalized and misunderstood.

Although a modest amount of research and noteworthy practices and programs have emerged, far more needs to be known if commercial sexual exploitation and sex trafficking of minors in the United States are to be adequately addressed. This report aims to offer a comprehensive picture of what is currently known about these problems by connecting the dots between more established fields of research and practice and the emerging body of work on commercial sexual exploitation and sex trafficking of minors in the United States. This information can provide the much-needed scientific underpinnings for future practice, policy, and research efforts and



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1 Introduction Commercial sexual exploitation and sex trafficking of minors in the United States are frequently overlooked, misunderstood, and unaddressed domestic problems. In the last decade, they have received increasing atten- tion from advocates, the media, academics, and policy makers. However, much of this attention has focused internationally—the media tell stories of girls being exploited on the streets of Cambodia or sold as mail order brides from Russia. This international focus has overshadowed the reality that commercial sexual exploitation and sex trafficking of minors also oc- cur every day within the United States. Commercial sexual exploitation and sex trafficking of minors are not only illegal activities, but also result in immediate and long-term physical, mental, and emotional harm to victims and survivors. A nation that is un- aware of these problems or disengaged from solving them unwittingly con- tributes to the ongoing abuse of minors and all but ensures that commercial sexual exploitation and sex trafficking of minors will remain marginalized and misunderstood. Although a modest amount of research and noteworthy practices and programs have emerged, far more needs to be known if commercial sexual exploitation and sex trafficking of minors in the United States are to be adequately addressed. This report aims to offer a comprehensive picture of what is currently known about these problems by connecting the dots between more established fields of research and practice and the emerging body of work on commercial sexual exploitation and sex trafficking of minors in the United States. This information can provide the much-needed scientific underpinnings for future practice, policy, and research efforts and 19

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20 Commercial Sexual Exploitation and Sex Trafficking of Minors help raise awareness on an issue of national importance with serious health and safety implications. STUDY CONTEXT Despite the gravity of commercial sexual exploitation and sex traffick- ing of minors in the United States, these problems currently are not well understood or adequately addressed. Many factors contribute to this lack of understanding. For example, commercial sexual exploitation and sex traf- ficking of minors in the United States may be overlooked and underreported because they frequently occur at the margins of society and behind closed doors. Their victims often are vulnerable to exploitation. They include children who are, or have been, neglected or abused; those in foster care or juvenile detention; and those who are homeless, runaway (i.e., children who leave home without permission), or so-called thrown-away (i.e., children and adolescents who are asked or told to leave home). Children and ado- lescents affected by commercial sexual exploitation and sex trafficking can be difficult to reach. The absence of specific policies and protocols related to commercial sexual exploitation and sex trafficking of minors, coupled with a lack of specialized training, makes it difficult to identify victims and survivors of these crimes. Victims and survivors may be distrustful of law enforcement, may not view themselves as “victims,” or may be too traumatized to report or disclose the crimes committed against them. Moreover, most states continue to arrest commercially exploited children and adolescents as criminals instead of treating them as victims, and health care providers and educators have not widely adopted screening for com- mercial sexual exploitation and sex trafficking of minors. Finally, a lack of awareness among those who routinely interact with victims and survivors ensures that these crimes are not identified and properly addressed. As a result, the true scope of commercial sexual exploitation and sex trafficking of minors within the United States is difficult to quantify. Despite the challenges of identifying these youth, a number of efforts are under way to serve child and adolescent victims and survivors of com- mercial sexual exploitation and sex trafficking. This report highlights sev- eral noteworthy and emerging, albeit isolated, examples. The report also underscores how a lack of research on commercial sexual exploitation and sex trafficking of minors hampers work in this area. For example, little is known about how much trauma is sustained by victims and survivors of these crimes and the mental, physical, educational, and financial implica- tions of such trauma over time. Furthermore, few studies have evaluated the effectiveness of treatment programs. As a result, evidence-based prevention or intervention programs are lacking, as is consensus on specialized services for victims and survivors of these crimes.

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Introduction 21 In addition, the current evidence base (i.e., research published in peer- reviewed journals) has notable limitations. These include, among others, few evaluations of interventions and services for victims and survivors of commercial sexual exploitation and sex trafficking (e.g., to determine the essential components and duration of treatment and other services), lim- ited analysis of the adequacy of laws (e.g., to assist victims, deter demand, or prosecute offenders), few longitudinal studies (e.g., to demonstrate the long-term impact and effectiveness of interventions), a lack of baseline data, and an overreliance on unsubstantiated findings and numerous com- peting estimates (e.g., numbers cited to describe the extent of commercial sexual exploitation and sex trafficking of minors in the United States). Moreover, research on commercial sexual exploitation and sex trafficking of minors necessarily spans a variety of disciplines and lacks a well-defined or common peer-reviewed literature. These limitations are exacerbated by inconsistent use of terminology. Finally, divergent social and political per- spectives on many of the issues underlying commercial sexual exploitation and sex trafficking of minors may influence the approach to conducting and reporting research on these topics. It is in this context that the committee conducted its study. Statement of task and study scope Recognizing the challenges of addressing commercial sexual exploita- tion and sex trafficking of minors in the United States, the Department of Justice’s Office of Juvenile Justice and Delinquency Prevention requested an in-depth, independent examination of these problems in the United States. In fall 2011, the Institute of Medicine and the National Research Council, through collaborative efforts between the Board on Children, Youth, and Families and the Committee on Law and Justice, formed the Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. The committee’s statement of task is shown in Box 1-1. In the course of its deliberations, the committee identified a number of necessary caveats on the charge shown in Box 1-1. First, the committee’s charge specifically states that the focus of its study was to be “on the com- mercial sexual exploitation and sex trafficking of children who are citizens or lawful permanent residents of the United States [emphasis added].” The focus on U.S. citizens and legal permanent residents was specified in the committee’s charge to ensure that commercial sexual exploitation and sex trafficking of minors would be examined, recognized, and understood as domestic as opposed to international issues with domestic implications and solutions. More to the point, the charge directed the committee to examine what is known about children in the United States—whether they are living at home, in protective custody, on the streets, or in some other

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22 Commercial Sexual Exploitation and Sex Trafficking of Minors BOX 1-1 Statement of Task The U.S. Department of Justice has requested that the Institute of Medicine and the National Research Council convene a committee of experts to conduct a study on the commercial sexual exploitation and sex trafficking of children who are citizens or lawful permanent residents of the United States. The study will be conducted by a committee of independent experts who will review relevant research and practice-based literatures that will inform future policy and practices within law enforcement, human services, and health care agencies. As part of its work, the committee will examine the following topics: 1.  What is known about the scope and severity of commercial sexual exploi- tation and sex trafficking of U.S. citizens or lawful permanent residents of the United States (under age 18); 2.  Data on causes and consequences for victims and offenders, including the gateways to commercial sexual exploitation and sex trafficking for both populations, as well as the impact of these experiences on future criminal behavior and health outcomes; 3.  xperiences with commercial sexual exploitation and sex trafficking E among populations served by child welfare and juvenile justice systems; 4.  Evidence associated with selected efforts in human services, health care, education, and law enforcement settings to prevent commercial sexual exploitation and sex trafficking of minors and to intervene with victims and offenders; 5.  Identify lessons learned through international, national, state, and local advocacy efforts that contribute to successful intervention and prevention strategies; and 6.  Assess the adequacy of current state and federal laws for addressing the commercial sexual exploitation and sex trafficking of minors and recom- mend new legislative approaches, if necessary, to address this issue. Based on Its examination of the preceding topics, the committee will make recommendations in the following areas: 1.  Strategies to respond to commercial sexual exploitation of U.S. minors, including policies and practices for human services, health care agencies, juvenile justice agencies, law enforcement, and the judiciary; 2.  New legislative approaches, if necessary; and 3.  research agenda to guide future studies in this field. A

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Introduction 23 situation—who are at risk of or victims or survivors of commercial sexual exploitation and sex trafficking. Over the course of the study, however, the committee found that examining the commercial sexual exploitation and sex trafficking of minors as an issue focused exclusively on U.S. citizens and legal permanent residents would be challenging and potentially coun- terproductive. For example, the committee found that researchers do not routinely differentiate in their research between undocumented minors and those who are legal permanent residents. Similarly, health care and victim service providers may not make such distinctions among victims and sur- vivors in need of assistance; therefore, it is difficult—if not impossible—to determine the residence or citizenship status of the populations they serve or study. Moreover, the committee was uncomfortable with the idea of ex- amining the best evidence available and reserving its findings and solutions for a subset of victims and survivors. Therefore, this report and the recom- mendations offered herein focus on the commercial sexual exploitation and sex trafficking of minors who are citizens or lawful permanent residents of the United States and its territories, as directed by the committee’s charge. However, it is the committee’s consensus opinion that all instances of com- mercial sexual exploitation and sex trafficking of minors that occur within the United States deserve equal attention and that all victims and survivors of these crimes deserve the same protections and services. Therefore, it is the committee’s strong desire that readers of this report consider the broader implications of its recommendations as they apply to all children and adolescents. Second, while its charge limits the focus of this study to minors, or in- dividuals under age 18, the committee faced considerable scientific, ethical, and practical difficulty in limiting its examination to this age group. The emphasis on minors in the committee’s charge was meant to ensure that the study would focus on the systems that are responsible for or interact with minors (e.g., child welfare and juvenile justice). However, the com- mittee faced ethical and scientific considerations in examining commercial sexual exploitation and sex trafficking exclusively with respect to individu- als under age 18. For example, evidence from recent studies demonstrates that brain development continues beyond traditionally accepted notions of adolescence well into an individual’s 20s (Casey et al., 2008; Steinberg, 2008); investigators often did not limit their studies to individuals age 18 and younger. Further, the range of ages used to determine when adolescents are treated as minors and when they are treated as adults—which varies considerably from state to state—raised a number of ethical questions for the committee. For example, if a 17-year-old being sold for sex is a victim of commercial sexual exploitation or sex trafficking, is he or she no longer a victim on the day that he or she turns 18? Or if a 16-year-old who trades sex for food, shelter, or something of value is a victim, is a 19-year-old

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24 Commercial Sexual Exploitation and Sex Trafficking of Minors engaged in the same behavior a criminal? While questions of this nature go beyond this committee’s charge, they underscore the complexity of ad- dressing commercial sexual exploitation and sex trafficking exclusively as they affect minors. The committee therefore urges readers to consider the broader implications of its recommendations—not just as they apply to children and adolescents who are minors, but also as they apply to young adults. Third, other important activities, populations, and efforts related to human trafficking fall outside the scope of this study. For example, labor trafficking is another form of human trafficking that has both international and domestic victims, some of whom are minors. Similarly, some portion of sex trafficking into the United States involves minors. However, labor traf- ficking and international sex trafficking are beyond the scope of this study. Therefore, the committee did not include labor trafficking or international sex trafficking in its examination except in cases where it was impossible to separate them from commercial sexual exploitation and sex trafficking of minors in the United States (i.e., the relevant research or organization addressed all forms of human trafficking). As directed by the committee’s charge, lessons learned from international efforts to prevent and address commercial sexual exploitation and sex trafficking of minors are included as examples, but were not a primary focus of this study. In addition, the committee was not charged with examining issues related to prostitution or sex work in general, and recommendations on prostitution or sex work would go beyond the scope of this study. Fourth, child pornography—the sale or trade of sexually explicit im- ages or videos of children under age 18—is a serious form of child sexual abuse and exploitation that warrants attention and action, but this study does not focus on it. While child pornography and sex trafficking can oc- cur together (e.g., pornographic images are used to coerce a child to engage in sexual servitude), the committee determined child pornography to be beyond the scope of its charge. This determination was made for a num- ber of reasons. First, the committee learned that, with limited exceptions, the majority of child pornography for sale or trade originates overseas (Holman, 2012), and the committee’s charge did not encompass non-U.S. jurisdictions. Next, the committee found that the law enforcement response to child pornography and commercial sexual exploitation and sex traffick- ing of minors differs greatly. For example, victims of child pornography are not arrested, whereas many victims of commercial sexual exploitation and sex trafficking are. The often punitive response to victims of commercial sexual exploitation and sex trafficking of minors was one of the key issues that the Department of Justice asked the committee to address in this study. Therefore, the committee decided to focus primarily on the exploitation of children and adolescents through prostitution.

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Introduction 25 Fifth, while an examination of mandatory reporting was not part of the committee’s official charge, it is an important issue with complex legal, ethical, and practical implications that are directly related to the com- mittee’s review of commercial sexual exploitation and sex trafficking of minors in the United States. Box 1-2 provides a detailed explanation of the complexities of mandatory reporting of commercial sexual exploitation and sex trafficking of minors in the United States in the context of the current practices of the legal, health care, and support service sectors. Sixth, the committee was charged with examining only commercial forms of child sexual exploitation and sex trafficking. Therefore, other forms of child sexual abuse, including incest and rape, are included as risk factors for commercial sexual exploitation and sex trafficking of minors, but are not a primary focus of this study. Seventh, although men, women, and children may all be trafficked for a range of purposes, commercial sexual exploitation and sex trafficking often are described as gender-based crimes, inextricably linked to the larger issues of violence against women and girls. Because the committee was charged with studying commercial sexual exploitation and sex trafficking against both male and female victims (under age 18), these crimes are discussed in this report as acts of abuse and violence against children and adolescents (see the committee’s guiding principles below). This frame is not meant to diminish the important role that gender may play in commercial sexual exploitation and sex trafficking, both domestically and internationally. In addition, this report includes discussion of gender-specific research (focused primarily on girls and women) and the role of sexualization of children and adolescents (particularly girls). Finally, this committee was not charged with estimating the prevalence of commercial sexual exploitation and sex trafficking of minors in the United States. Chapter 2 of this report describes a number of data collection efforts and reviews the difficulties, in general, of measuring crimes of a hid- den nature to address the question of what is known about the “scope” of these problems. However, readers should note that the focus of this study with respect to victim identification relates to service provision and preven- tion as opposed to census. Guiding Principles To guide its deliberations, the committee began with three fundamental principles: 1. Commercial sexual exploitation and sex trafficking of minors should be understood as acts of abuse and violence against children and adolescents.

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26 Commercial Sexual Exploitation and Sex Trafficking of Minors BOX 1-2 Mandatory Reporting Mandatory reporting is an important tool for responding to acts of violence and abuse. A report to police (in the case of domestic violence) or to child welfare (in the event of intrafamilial child abuse or neglect) can activate responses to both victims and offenders. Ideally, a report will interrupt violence and protect the safety and well-being of the victim. Yet while mandatory reporting facilitates appropriate interventions in many instances, unfortunately that is not always the case. While an examination of mandatory reporting was not part of the committee’s official charge, the issue was an important consideration for the committee for several reasons. First, the committee recognizes that the commercial sexual ex- ploitation and sex trafficking of minors are forms of child abuse. If treated as such, they would trigger a legal requirement to make a report to either child welfare or law enforcement; indeed, some states are amending reporting requirements to include these cases. The current response to such a report, however, is uncertain and potentially ineffective or even harmful. In many states, a report of commercial sexual exploitation or sex trafficking of a minor to child protective services would be considered outside the purview of child protective services if the abuse were extrafamilial in nature. A report to law enforcement, on the other hand, might lead to a victim’s arrest or some form of detention. As this report demonstrates, the systems charged with protecting and serving children and adolescents (e.g., juvenile justice and child welfare) are not designed to support and assist victims and survivors of commercial sexual exploitation and sex trafficking effectively. Under these circumstances, mandatory reporting may do more harm than good to victims and survivors (Flaherty et al., 2006). Reporting of suspected child abuse and neglect, domestic violence, and dat- ing violence is riddled with legal, ethical, and practical complexities. For example, current reporting of suspected child abuse and neglect—even among mandated reporters—is inconsistent. Significant percentages of primary care clinicians either fail to recognize child abuse and neglect or do not make reports in some cases even when they do recognize or suspect that a child is abused or neglected (Flaherty et al., 2008; Sedlak et al., 2010). Reasons for not reporting include anticipation or experience of negative consequences—such as lack of effective intervention, lack of benefit, or actual harm—for children or their families when a report is made (Flaherty et al., 2006; Jones et al., 2008). Also, mandatory report- ing by health care providers could compromise the patient-provider relationship and patients’ perception of health care professionals as supportive, trustworthy caregivers (Gielen et al., 2000; Rodriguez et al., 1999). 2. Minors who are commercially sexually exploited or trafficked for sexual purposes should not be considered criminals. 3. Identification of victims and survivors and any intervention, above all, should do no further harm to any child or adolescent.

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Introduction 27 As with mandatory reporting of child abuse and neglect generally, profes- sionals who suspect that a child or adolescent is a victim of commercial sexual exploitation or sex trafficking may choose not to make a report if they anticipate negative consequences to the child or adolescent. During its site visits and public workshops, the committee heard testimony that mandatory reporting of commercial sexual exploitation and sex trafficking of minors can have serious, harmful unintended consequences for victims and survivors (Sherman, 2012; Westmacott, 2012). Thus, laws and policies will need to be clear about how professionals should proceed when they identify a victim of commercial sexual exploitation or sex traf- ficking and what will happen when a case is reported. Laws and policies will also need to ensure that appropriate services are in place to address the needs of victims and survivors who are identified and reported. In addition, professionals will need to be reassured that reporting commercial sexual exploitation or sex traf- ficking of a minor will do no further harm to any child or adolescent. This reassur- ance can be realized only through clear and thoughtful planning and strengthening of services for victims and survivors. In sum, as of this writing, and in the absence of laws, policies, systems, and services designed and equipped to meet the needs of victims and survivors of commercial sexual exploitation and sex trafficking, the committee found that it lacked the information needed to make definitive statements or recommenda- tions regarding mandatory reporting of commercial sexual exploitation and sex trafficking of minors. The committee recognizes that reporting of child abuse is required by law, and does not condone nonadherence when current legal man- dates encompass cases of commercial sexual exploitation and sex trafficking. At the same time, the committee believes that the evidence that reporting often fails to benefit and can harm victims of commercial sexual exploitation and sex traf- ficking of minors undermines the ethical foundation of mandatory reporting. As part of its responsibility to identify challenges on the horizon for individuals and entities working to address the commercial sexual exploitation and sex trafficking of minors, the committee underscores the complex issues related to mandatory reporting in the relevant sections of this report (e.g., as applied to laws, see Chapter 4; as applied to specific sectors, see Chapters 6-9). It is the committee’s strong desire that individuals and entities working to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States will take these issues into consideration as they plan and implement laws, policies, systems, and services. Finally, the committee strongly urges that any developments related to mandatory reporting of commercial sexual exploitation and sex trafficking of minors in the United States be based on the principle: “Do no further harm.” These guiding principles were shaped by the expert judgment of the committee (i.e., based on its members’ collective legal, ethical, and practice- based knowledge), by expert testimony to the committee, and with the sup- port of the study sponsor. These principles provide an important foundation

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28 Commercial Sexual Exploitation and Sex Trafficking of Minors for understanding commercial sexual exploitation and sex trafficking of minors in the United States. Study Approach The study committee was comprised of 13 members with expertise in women’s, adolescent, and pediatric health; criminal and juvenile justice; law; child welfare; human services and victim services; statistics and mea- surement; psychology; sociology; nursing; social work; public health; health disparities; and technology. (See Appendix E for biographical sketches of the committee members.) Since 2000, scholarly interest in commercial sexual exploitation and sex trafficking of minors has increased dramatically. An emerging, albeit immature, evidence base reflects a need to advance knowledge and under- standing of these problems. Research in a variety of disciplines and fields, such as social work, nursing, child and adolescent health, law, and criminol- ogy, is described in this report. Despite the increase in scholarly interest, numerous challenges to con- ducting research on commercial sexual exploitation and sex trafficking of minors exist. These challenges include, among others, considerable ethical issues (e.g., the assignment of subjects to experimental and control groups), legal issues (e.g., privacy, confidentiality, autonomy), and practical issues (e.g., failure to identify victims, misidentification of victims, reluctance of victims to seek assistance, incomplete or inconsistent data collection and reporting). As a result, research on commercial sexual exploitation and sex trafficking of minors in the United States is underdeveloped. Recognizing the challenges presented by the paucity of research on commercial sexual exploitation and sex trafficking of minors, the commit- tee developed a plan for conducting its review of the literature. The focus of the review was primarily research published in the peer-reviewed scientific literature and law reviews. The committee found considerable variation in the quality of such studies but, given the early stage of development of this field of research, determined that even studies of limited strength could provide some useful information. This report includes appropriate qualifi- cations when such research is cited. In addition, the committee made every effort to include the most up-to-date research. However, strong evidence sometimes was found in older studies, which, not having been replicated in recent years, were the only available sources of data on certain topics. In other cases, large-scale studies are lacking, and so the committee relied on available data from smaller-scale studies. Finally, the committee looked to related fields of research for insights into this emerging field. Ultimately, the committee included in this study what it judged to be the best empirical evidence available.

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Introduction 29 Given the limitations of the published evidence base, the committee used a variety of sources to supplement its review of the literature. The committee met face to face six times and held two public workshops to ob- tain from a broad range of relevant stakeholders vital input that could not be derived from the published literature. (See Appendix D for the workshop agendas.) In addition, small groups of committee members and study staff participated in a series of regional site visits to learn about the efforts of a range of organizations and individuals working on issues related to com- mercial sexual exploitation and sex trafficking of minors in different parts of the country with broad range of populations. These site visits included in-depth discussions of local challenges and noteworthy practices. (See Ap- pendix C for the site visits’ methodology and summaries.) The committee readily acknowledges that this report cannot include all noteworthy activi- ties currently under way to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States. However, the committee made every attempt to learn about and document a broad array of strategies, programs, policies, and laws for this study. Any omissions should not be viewed as intentional, but as a function of the time and resources of the committee and the visibility of various activities across the nation. It is important to note that there are precedents at the National Acad- emies for studying topics on which the amount of published research in peer-reviewed journals is limited (see, for example, The Health of Lesbian, Gay, Bisexual, and Transgender People [IOM, 2011] and Understanding Child Abuse and Neglect [NRC, 1993]). Studies of this nature—challeng- ing as they may be—can make a significant contribution by shining a light on critical and understudied topics and by outlining future research and policy agendas. The committee intends this report to represent a significant step forward in advancing research, policy, and practice on underexamined and overlooked issues related to commercial sexual exploitation and sex trafficking of minors in the United States. In the chapters that follow, the committee evaluates the available relevant data, identifies gaps in the litera- ture, and in its recommendations addresses the need for additional research. Definitions of Key Terms The language used to describe aspects of commercial sexual exploita- tion and sex trafficking crimes and their victims and survivors—a collection of terms derived from the range of agencies, sectors, and individuals work- ing to prevent and address these problems—varies considerably. Some terms are diagnostic and scientific (e.g., screening and medical forensic exam). Others are legal terms (e.g., trafficking, offender, perpetrator). Some terms are used frequently in popular culture (e.g., pimp, john, child prostitute).

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30 Commercial Sexual Exploitation and Sex Trafficking of Minors Still others are focused on the experiences of exploited children (e.g., vic- tim, survivor, modern-day slavery). The result is the absence of a shared language regarding commercial sexual exploitation and sex trafficking of minors. The implications of this absence of a common language can be signifi- cant. Chapter 2, for example, notes that the lack of agreement on clear and reasonable definitions directly contributes to the difficulty of estimating the nature and extent of commercial sexual exploitation and sex trafficking of minors in the United States. Chapters 4 through 10 note how inconsistent terminology can introduce challenges to successful investigation, prosecu- tion, and provision of assistance to victims and survivors. For example, a child or adolescent victim identified as a prostitute may have access to significantly fewer resources than a child or adolescent identified as a sex trafficking victim, although services and support for the latter are scarce; the former child or adolescent may be treated as a criminal and detained as opposed to being referred for a range of health and protective services to which he/she is legally entitled. In addition, inconsistent terminology can be a source of confusion. For example, although the term sex trafficking may sound as though the crime involves movement of some kind (e.g., the crossing of an international border or the transportation of a victim from one location to another), the federal definition of the term does not require movement. The language used to describe commercial sexual exploitation and sex trafficking of minors also can influence how individuals, behaviors, and events are perceived. For example, whether perpetrators of commercial sexual exploitation and sex trafficking of minors are called pimps, johns, exploiters, or offenders may affect how society views them. Likewise, vic- tims of commercial sexual exploitation or sex trafficking are referred to as victims, slaves, survivors, or prostitutes, terms that may carry different connotations for different audiences. Finally, Chapter 10 describes how the lack of a common language can inhibit collaboration among sectors or create tension between natural and necessary partners. In sum, clarity on the language used to describe the commercial sexual exploitation and sex trafficking of minors is important because it can influence comprehension of the problem and have an impact on engagement and action. In the sections that follow, the committee explains how some of the more common terms used to describe the commercial sexual exploitation and sex trafficking of minors in the United States are defined in this report. In addition, given the importance of terminology and the range of perspec- tives that influence how terms are defined and used, the report includes an in-depth discussion of definitions and their sources (e.g., advocacy organi- zations, laws, government agencies) in Appendix A.

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Introduction 31 Commercial Sexual Exploitation and Sex Trafficking of Minors Commercial sexual exploitation and sex trafficking of minors refer to a range of crimes of a sexual nature committed against children and ado- lescents, including • recruiting, enticing, harboring, transporting, providing, obtaining, and/or maintaining (acts that constitute trafficking) a minor for the purpose of sexual exploitation; • exploiting a minor through prostitution; • exploiting a minor through survival sex (exchanging sex/sexual acts for money or something of value, such as shelter, food, or drugs; • using a minor in pornography; • exploiting a minor through sex tourism, mail order bride trade, and early marriage; and • exploiting a minor by having her/him perform in sexual venues (e.g., peep shows or strip clubs). As noted above, the committee found that the terms describing these crimes and abuses often are used inconsistently in the law, by advocates, and in the scholarly literature on these issues. The committee understands that commercial sexual exploitation and sex trafficking of minors are over- lapping but distinct terms, and in this report identifies how these distinc- tions are important for law, for research, and in other contexts. Appendix A details the significance of these distinctions and how the two terms overlap. In its review, however, the committee found that disentangling commercial sexual exploitation from sex trafficking was impossible in many instances, given both the inconsistent use of terminology and, equally important, the fact that the two terms involve many of the same crimes. As established above in the discussion of the study scope, this report focuses on trafficking for purposes of prostitution, prostitution, and sur- vival sex, with less emphasis on pornography, sex tourism, mail order bride trade, stripping, and performing in sexual venues. Except when referring generally to commercial sexual exploitation of children as a range of crimes, then, commercial sexual exploitation and sex trafficking of minors are used in this report primarily to refer to trafficking for purposes of prostitution, prostitution, and survival sex. The report notes specific types of exploita- tion when appropriate and/or possible. The committee recognizes that including survival sex in its definition of commercial sexual exploitation and sex trafficking of minors may introduce additional challenges to de- signing programs, policies, and practices. For example, including survival sex in the definition of commercial sexual exploitation and sex trafficking means that a third party need not be involved for the exploitation to be

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32 Commercial Sexual Exploitation and Sex Trafficking of Minors considered “commercial” in nature (e.g., if sexual activity is exchanged for something of value). However, the needs of a child or adolescent exploited by a third party may be different from the needs of a child or adolescent engaging in survival sex. It follows that programs designed for victims and survivors will need to account for a range of experiences and needs among the individuals and populations the programs serve. It is the committee’s intent that by calling attention to the challenges that exist, this report will inform the development of the range of programs, policies, and practices required to respond adequately to these crimes. Finally, as noted in the earlier discussion of its guiding principles, the committee also emphasizes the importance of recognizing and understand- ing the issues addressed by this study as part of a broader pattern of child abuse (as illustrated by Figure 1-1). Child Abuse Commercial Sexual Exploitation and Sex Trafficking of Minors FIGURE 1-1  Commercial sexual exploitation and sex trafficking of minors are forms of child abuse. NOTE: This diagram is for illustrative purposes only; it does not indicate or imply percentages. Figure 1-1 and A-4

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Introduction 33 Individuals Involved in Commercial Sexual Exploitation and Sex Trafficking of Minors This section defines the terms used in this report for the various indi- viduals involved in commercial sexual exploitation and sex trafficking of minors. It also provides the committee’s rationale for using each of these terms. Minors The term minor is used to refer to individuals under age 18, the des- ignated focus of this study (see the discussion of the statement of task and study scope earlier in this chapter). Other age-related terms, such as child, adolescent, and youth, are used to refer to minors in this report as appro- priate (e.g., in discussing laws that use these terms); however, minor is the term used in the committee’s charge. It is important to note that this is an age-related term and does not convey lesser importance (e.g., “domestic minor sex trafficking” is not a negligible violation). Victims Versus Survivors The terms victim and survivor both are used to refer to minors who are commercially sexually exploited or trafficked for sexual purposes. The committee determined that both terms are important, and they need not be considered mutually exclusive. Rather, the terms could be applied to the same individuals at different points along a continuum. The term victim indicates that a crime has occurred and that assistance is needed. Being able to identify an individual as a victim, even temporarily, can help activate re- sponses—including direct services and legal protections—for an individual. The committee also recognizes that the term survivor has therapeutic value and that the label victim may be counterproductive at times. Therefore, this report uses both terms to refer to minors who have been commercially sexually exploited or trafficked for sexual purposes. Prostituted Child, Not Child Prostitute Some victims of commercial sexual exploitation and sex trafficking are referred to as child prostitutes, juvenile prostitutes, or adolescent prosti- tutes. Prostitution is illegal in nearly all jurisdictions in the United States, and individuals who engage in prostitution are considered criminals. There- fore, the terms child prostitute, juvenile prostitute, and adolescent prostitute suggest that prostituted children are criminals; that is, victims and survivors of commercial sexual exploitation and sex trafficking may be viewed as

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34 Commercial Sexual Exploitation and Sex Trafficking of Minors willing participants in an illegal activity. As stated in its guiding principles, the committee firmly asserts that these young people should be recognized as victims, not criminals, and that commercial sexual exploitation and sex trafficking are forms of child abuse. Therefore, this report uses the terms prostituted child (juvenile, adolescent) and prostitution of children (juve- niles, adolescents) as opposed to child (juvenile, adolescent) prostitute to describe victims of commercial sexual exploitation and sex trafficking.1 This usage is consistent with the committee’s definition and understanding of commercial sexual exploitation and sex trafficking of minors. Offenders A variety of terms—including traffickers, exploiters, and pimps—are used to describe individuals who exploit children for financial or other gain. While the word pimp originally was used to describe an individual who sells prostitutes, its meaning and use have evolved. In slang, pimp often is used to describe something as positive or glamorous. Therefore, the com- mittee decided to use the terms trafficker and exploiter rather than pimp to describe individuals who sell children and adolescents for sex.2 It is also important to note that traffickers and exploiters come in many forms; they may be family members, intimate partners, or friends, as well as strangers. Solicitors and purchasers are individuals who pay for sex with minors and thus represent the demand for commercial sexual exploitation and sex trafficking of minors. These individuals may actively seek to purchase sex with underage individuals or may be unaware of or uninterested in their age. Solicitors and purchasers often are referred to as johns. Over the course of the study, the committee heard from experts and practitioners who consider the term john to be problematic. They argue that the term sounds innocuous and that its use contributes to the perception that the prostitution of minors is a victimless crime. Using a term with such con- notations is inconsistent with the committee’s other definitions. Therefore, this report uses the terms solicitors and purchasers, rather than johns, to describe individuals who buy sex with children.3 1  n certain instances, notably in the chapter on laws (Chapter 4), the committee uses terms I such as prostitute and pimp when they reflect the language of a statute. 2  gain, the language used, especially in Chapter 4, may vary from this usage to accord with A that of a statute. 3  gain, specific usage may reflect the language of a statute. A

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Introduction 35 Facilitators Facilitators are individuals or businesses that are complicit in or ben- efit from the commercial sexual exploitation and sex trafficking of minors. Examples of facilitators include limousine and taxi drivers, hotel and mo- tel operators, landlords, and advertisers, among others. While facilitators enable and support commercial sexual exploitation and sex trafficking of minors—actively or passively—they are not the purchasers or sellers of sex with minors. Therefore, the committee does not consider the term facilita- tor to be synonymous with traffickers, exploiters, solicitors, or purchasers. It should be noted that many of the same individuals and businesses that could act as facilitators are well situated to help prevent, identify, and re- spond to commercial sexual exploitation and sex trafficking of minors. This report includes a number of examples of such efforts in Chapter 9. Notable Past Work While this report is the first in-depth examination of commercial sex- ual exploitation and sex trafficking of minors conducted by the National Academies, the Institute of Medicine (IOM) and the National Research Council (NRC) have a long history of studying issues related to child abuse and neglect, the prevention of violence in families, and vulnerable youth. Earlier reports by the IOM and the NRC that informed the committee’s work include Understanding Child Abuse and Neglect (NRC, 1993); Un- derstanding Violence Against Women (NRC, 1996); Violence in Families: Assessing Prevention and Treatment Programs (NRC, 1998); Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (IOM, 2002); Youth, Pornography, and the Internet (NRC, 2002); Advancing the Federal Research Agenda on Violence Against Women (NRC, 2004); and the recently released New Directions in Child Abuse and Neglect Research (IOM/NRC, 2013). The NRC also has exam- ined issues related to crime data and research (Measurement Problems in Criminal Justice Research [NRC, 2003] and Strengthening the National Institute of Justice [NRC, 2010]) and issues related to juvenile justice (Ju- venile Crime, Juvenile Justice [NRC, 2001] and Reforming Juvenile Justice: A Developmental Approach [NRC, 2012]). In addition to this earlier work of the National Academies, the com- mittee drew important lessons from the collection of efforts and research aimed at addressing commercial sexual exploitation and sex trafficking of minors and related issues by a range of engaged stakeholders. This report reviews their work in the chapters that follow.

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36 Commercial Sexual Exploitation and Sex Trafficking of Minors ORGANIZATION OF THE REPORT This report is organized into three parts and 11 chapters. Part I, which includes Chapters 1-4, provides a foundation for understanding the com- mercial sexual exploitation and sex trafficking of minors in the United States. Part II, which includes Chapters 5-10, examines current and emerg- ing strategies for preventing and identifying commercial sexual exploitation and sex trafficking of minors, for assisting and supporting victims and sur- vivors, and for addressing exploiters and traffickers. Part III offers a path forward through recommendations designed to increase awareness; advance understanding; and support efforts to prevent, identify, and respond to the commercial sexual exploitation and sex trafficking of minors in the United States. Each chapter is described briefly below. (See Box 1-3 for a note to readers on the organization of this report.) Chapter 2 provides an overview of the nature and extent of commercial sexual exploitation and sex trafficking of minors in the United States. The chapter examines current estimates of commercial sexual exploitation and sex trafficking of minors, reviews the major challenges to measuring crime in general and these two crimes in particular, identifies current sources of relevant data, and explains the implications of insufficient data collection and analysis. Chapter 3 focuses on the risk factors and consequences of commercial sexual exploitation and sex trafficking of minors across the life course. To convey the complexity of these risk and protective factors over time, the chapter describes the developmental, ecological, and transactional contexts and relationships in which these factors are relevant. The chapter also details the individual health, public health, legal, and social consequences BOX 1-3 A Note to Readers About the Organization of This Report This report is organized in a way that the committee hopes will be maximally useful to a wide array of readers from a variety of sectors. To that end, the report includes a number of sector-specific chapters. However, this organization is not meant to imply that any one sector can fully address the range of issues related to commercial sexual exploitation and sex trafficking of minors in the United States. Therefore, the committee strongly urges readers to consult not only the chapters specifically related to their own field of practice or research but also those related to other disciplines and domains. Reading the report in this way should increase understanding of the overall picture of current and emerging practices and reveal complementary efforts, similar challenges, and abundant opportunities.

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Introduction 37 of commercial sexual exploitation and sex trafficking of minors, includ- ing both long- and short-term consequences and possible prevention and intervention points. Chapter 4 reviews current and emerging laws that address the commer- cial sexual exploitation and sex trafficking of minors in the United States. The chapter includes a description of the historical legal context for such laws and a summary of current federal and state laws. It also provides a dis- cussion of the interpretation and use of the laws, as well as their strengths and limitations, and highlights specific challenges and opportunities. Chapter 5 examines current and emerging practices in the legal system to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States. It describes the strengths and limitations of efforts by police, prosecutors, defense attorneys, the juvenile justice system, and the judiciary to assist victims and survivors and to in- vestigate and prosecute exploiters and traffickers. Chapter 6 describes a broad range of actors and approaches at the federal, state, and local levels involved in providing supportive services to victims and survivors of commercial sexual exploitation and sex traf- ficking of minors. The chapter reviews current and emerging practices in child welfare and child protective services agencies, within the federal and state governments, and in nongovernmental organizations. It reviews the strengths and limitations of existing and emerging practices, including the state of current research and the challenges and opportunities for involve- ment of victim and support services. Chapter 7 describes how the health care sector can identify and assist individuals who are at risk of or are victims and survivors of commercial sexual exploitation and sex trafficking of minors. The chapter describes the current resources, persistent challenges, and opportunities for health care professionals seeking to prevent, identify, and respond to commercial sexual exploitation of and sex trafficking of minors. Chapter 8 examines how schools and the education sector can use their expertise, resources, and daily interaction with school-aged children to help prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors on their campuses and in their communities. The chapter describes a number of noteworthy practices, including the develop- ment of district-wide policies and partnerships, the leveraging of established school and community resources, and efforts to raise awareness among members of the education community. Chapter 9 describes how commercial-sector companies have the capac- ity both to facilitate commercial sexual exploitation and sex trafficking of minors and to be involved in solutions. The chapter describes roles for the commercial sector, including applying industry innovation to the problems

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38 Commercial Sexual Exploitation and Sex Trafficking of Minors of commercial sexual exploitation and sex trafficking of minors and adopt- ing policies that can reduce their occurrence. Chapter 10 describes the value of current interagency approaches, multisector responses, and collaborative efforts to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States. The chapter includes a discussion of different models of collaboration among sectors and points to both opportunities and the challenges that remain. The report culminates with the committee’s recommendations in Chap- ter 11. The chapter includes specific actions that various stakeholders can take to achieve a coordinated, multisector response to commercial sexual exploitation and sex trafficking of minors in the United States. It includes examples of victim- and survivor-centered legislation and other strategies for preventing these crimes, for assisting victims and survivors, for deterring and prosecuting offenders, for training professionals, for leveraging existing resources, for raising awareness among people who routinely interact with children and adolescents, and for engaging essential partners. The chapter also provides guidance for implementing, evaluating, and replicating efforts and identifies opportunities for additional research and evaluation. The report includes a number of appendixes. Appendix A offers an in-depth discussion of terminology related to commercial sexual exploita- tion and sex trafficking of minors. Appendix B provides selected examples of international efforts to address commercial sexual exploitation and sex trafficking of minors. Appendix C describes the methodology for and sum- marizes the committee’s site visits. Appendix D includes meeting agendas and lists of participants in the committee’s public workshops and site visits. Finally, Appendix E provides biographical sketches of the committee mem- bers and study staff. References Casey, B. J., S. Getz, and A. Galvan. 2008. The adolescent brain. Developmental Review 28(1):62-77. Flaherty, E. G., R. Sege, L. L. Price, K. K. Christoffel, D. P. Norton, and K. G. O’Connor. 2006. Pediatrician characteristics associated with child abuse identification and report- ing: Results from a national survey of pediatricians. Child Maltreatment 11(4):361-369. Flaherty, E. G., R. D. Sege, J. Griffith, L. L. Price, R. Wasserman, E. Slora, N. Dhepyasuwan, D. Harris, D. Norton, M. L. Angelilli, D. Abney, and H. J. Binns. 2008. From suspicion of physical child abuse to reporting: Primary care clinician decision-making. Pediatrics 122(3):611-619. Gielen, A. C., P. J. O’Campo, J. C. Campbell, J. Schollenberger, A. B. Woods, A. S. Jones, J. A. Dienemann, J. Kub, and E. C. Wynne. 2000. Women’s opinions about domestic violence screening and mandatory reporting. American Journal of Preventive Medicine 19(4):279-285.

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Introduction 39 Holman, L. 2012. Presentation to the Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States, February 29, 2012, Washington, DC. IOM (Institute of Medicine). 2002. Confronting chronic neglect: The education and training of health professionals on family violence. Washington, DC: National Academy Press. IOM. 2011. The health of lesbian, gay, bisexual, and transgender people: Building a founda- tion for better understanding. Washington, DC: The National Academies Press. IOM/NRC (National Research Council). 2013. New directions in child abuse and neglect research. Washington, DC: The National Academies Press. Jones, R., E. G. Flaherty, H. J. Binns, L. L. Price, E. Slora, D. Abney, D. L. Harris, K. K. Christoffel, and R. D. Sege. 2008. Clinicians’ description of factors influencing their re- porting of suspected child abuse: Report of the Child Abuse Reporting Experience Study Research Group. Pediatrics 122(2):259-266. NRC. 1993. Understanding child abuse and neglect. Washington, DC: National Academy Press. NRC. 1996. Understanding violence against women. Washington, DC: National Academy Press. NRC. 1998. Violence in families: Assessing prevention and treatment programs. Washington, DC: National Academy Press. NRC. 2001. Juvenile crime, juvenile justice. Washington, DC: National Academy Press. NRC. 2002. Youth, pornography, and the Internet. Washington, DC: National Academy Press. NRC. 2003. Measurement problems in criminal justice research. Washington, DC: The Na- tional Academies Press. NRC. 2004. Advancing the federal research agenda on violence against women. Washington, DC: The National Academies Press. NRC. 2010. Strengthening the National Institute of Justice. Washington, DC: The National Academies Press. NRC. 2012. Reforming juvenile justice: A developmental approach. Washington, DC: The National Academies Press. Rodriguez, M. A., E. McLoughlin, H. M. Bauer, V. Paredes, and K. Grumbach. 1999. Manda- tory reporting of intimate partner violence to police: Views of physicians in California. American Journal of Public Health 89(4):575-578. Sedlak, A. J., J. Mettenburg, M. Basena, I. Petta, K. McPherson, A. Greene, and S. Li. 2010. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Con- gress, executive summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families. Sherman, F. T. 2012. Presentation to the Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Testimony at Boston-area site visit, March 23, 2012, Boston, MA. Steinberg, L. 2008. A social neuroscience perspective on adolescent risk-taking. Developmental Review 28(1):78-106. Westmacott, J. 2012. Presentation to the Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Testimony at New York City site visit, September 12, 2012, New York.

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