3


Risk Factors for and Consequences
of Commercial Sexual Exploitation
and Sex Trafficking of Minors

Identifying risk factors for commercial sexual exploitation and sex trafficking of minors is necessary to understand the etiology of these problems and to inform interventions for preventing and addressing them. Understanding the various short- and long-term consequences of commercial sexual exploitation and sex trafficking of minors also is necessary to guide future prevention and intervention strategies. This chapter describes what is known about individual, family, peer, neighborhood, and systems-level risk factors associated with victims and offenders of commercial sexual exploitation and sex trafficking of minors. In addition, to clarify the impact of these crimes, the chapter describes what is known about their physical, emotional, and behavioral health consequences, as well as their developmental, social, health, and legal implications. Because the existing evidence base for these subjects is extremely limited, the discussion draws heavily on related research literatures (e.g., on child maltreatment, sexual assault/rape, and trauma), as well as evidence from secondary source materials (e.g., the committee’s workshops and site visits). Finally, this chapter aims to connect the dots between these sources of evidence to provide guidance for future research efforts on commercial sexual exploitation and sex trafficking of minors in the United States.

RISK FACTORS

Commercial sexual exploitation and sex trafficking of minors are multiply determined with causes at several levels, ranging from individual characteristics to family, peer, and neighborhood factors. Community and



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3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors Identifying risk factors for commercial sexual exploitation and sex traf- ficking of minors is necessary to understand the etiology of these problems and to inform interventions for preventing and addressing them. Under- standing the various short- and long-term consequences of commercial sexual exploitation and sex trafficking of minors also is necessary to guide future prevention and intervention strategies. This chapter describes what is known about individual, family, peer, neighborhood, and systems-level risk factors associated with victims and offenders of commercial sexual exploitation and sex trafficking of minors. In addition, to clarify the impact of these crimes, the chapter describes what is known about their physical, emotional, and behavioral health consequences, as well as their develop- mental, social, health, and legal implications. Because the existing evidence base for these subjects is extremely limited, the discussion draws heavily on related research literatures (e.g., on child maltreatment, sexual assault/rape, and trauma), as well as evidence from secondary source materials (e.g., the committee’s workshops and site visits). Finally, this chapter aims to connect the dots between these sources of evidence to provide guidance for future research efforts on commercial sexual exploitation and sex trafficking of minors in the United States. Risk Factors Commercial sexual exploitation and sex trafficking of minors are mul- tiply determined with causes at several levels, ranging from individual characteristics to family, peer, and neighborhood factors. Community and 77

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78 Commercial Sexual Exploitation and Sex Trafficking of Minors societal norms and expectations about sexual behavior and coercion, as well as societal and cultural standards and expectations regarding minors, gender, sexual orientation, race/ethnicity, and power, also contribute to commercial sexual exploitation and sex trafficking of minors. Adding to this complexity, each of these factors interacts within and across levels to increase risk or protection. Because of the multiple forces involved, preven- tion and intervention efforts targeting only single risks may have limited utility. Moreover, a comprehensive understanding of risk factors for com- mercial sexual exploitation and sex trafficking of minors requires awareness that the processes associated with these problems, from beginning to end, are dynamic (see Figure 3-1). The ecological model depicted in Figure 3-1 highlights the complex and interconnected forces that contribute to initial and continued commercial sexual exploitation and sex trafficking of minors. It should be noted, how- ever, that the factors included in this schematic are likely only a subset of the risk factors for these problems. Moreover, some of those factors may be necessary but not sufficient contributors to the commercial sexual exploita- tion and sex trafficking of minors. For example, the presence of risk factors would not result in the commercial sexual exploitation and sex trafficking of minors without the presence of an exploiter or trafficker. Of note, the contributing and maintaining factors depicted in Figure 3-1 may function independently or in combination. In addition, risk factors in one sphere may trigger a cascade of effects or initiate pathways into or out of com- mercial sexual exploitation and sex trafficking. Because many of the factors in Figure 3-1 also may be risks for other types of adverse youth outcomes, readers are cautioned not to assume that the presence of any single risk factor necessarily signals commercial sexual exploitation and sex trafficking of minors. Instead, the presence of one or more of these factors should be considered as part of a more comprehensive assessment to determine youth at risk of or involved in commercial sexual exploitation and sex trafficking. Each domain included in Figure 3-1 is detailed in the following sections. Risk Factors for Victims Individual-Level Factors At the individual level, a number of factors may increase boys’ and girls’ vulnerability to commercial sexual exploitation and sex trafficking. These include sexual abuse, physical abuse, and other forms of maltreat- ment; disruptions in normative development; the experience of running away or being homeless or thrown away; being placed in foster care or otherwise systems involved; being lesbian, gay, bisexual, or transgender (LGBT); substance use/abuse; psychogenic factors and impaired cognitive

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Societal Community Relationship Individual Risk Factors Risk Factors Risk Factors Risk Factors • Lack of awareness • Peer pressure • Family conflict, • History of child abuse, neglect, or of commercial • Social norms disruption, or maltreatment sexual exploitation • Social isolation dysfunction • Homeless, runaway, or “thrown-away” and sex trafficking • Gang involvement • LGBT • Sexualization of • Underresourced • History of being systems-involved children schools, (e.g., juvenile justice, criminal justice, • Lack of resources neighborhoods, foster care) and communities • Stigma and discrimination FIGURE 3-1  Ecological model adapted to illustrate the possible risk factors for commercial sexual exploitation and sex trafficking of minors. 79 NOTE: LGBT = lesbian, gay, bisexual, or transgender. Figure 3-1

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80 Commercial Sexual Exploitation and Sex Trafficking of Minors function; having a disability; earlier pubertal maturation; and the experi- ence of early adversity. Child maltreatment  Child neglect, physical abuse, and sexual abuse are commonly thought to be risk factors for commercial sexual exploitation and sex trafficking of minors (Dalla et al., 2003; Williams and Fedderick, 2009). Support for this perspective originates in studies reporting that youth identify the sexual abuse they experienced as a child as a major influence on their becoming involved in commercial sexual exploitation. For example, 70 percent of the subjects in a U.S. study conducted by Silbert and Pines (1981) and 73 percent of those in a Canadian study conducted by Bagley and Young (1987) reported that childhood sexual abuse affected their path to involvement in commercial sex work. Silbert and Pines (1981) found that 78 percent of the 200 San Francisco prostitutes in their sample were prostituted as juveniles. In that study, the majority of those interviewed were under age 21, and one subject was only 10 years old. Sixty percent of the sample reported that they had been or were being sexually exploited; 67 percent reported sexual abuse during their childhood by a father figure (33 percent by their biological father), 28 percent by a brother, and 31 percent by friends of the family. In 82 percent of the episodes of abuse, some sort of force was used. Because the results of these studies are based on retrospec- tive data, however, one cannot conclude that child maltreatment played a causal role in the youth’s commercial sexual exploitation. In one of the few prospective studies on this subject, Widom and Kuhns (1996) examined the relationship between childhood maltreatment and promiscuity, prostitution, and teen pregnancy. The study used a prospective cohort design in which victims of child maltreatment were matched with nonabused children and followed into adulthood. Child neglect and sexual abuse were found to be associated with later prostitution among females. Although male victims of child abuse and/or neglect had a higher prevalence of being prostituted (12.54 percent) than females (8.93 percent), the study did not find an association with later prostitution for males. In another prospective study, Wilson and Widom (2010, p. 18) found that victims of maltreatment were more than twice as likely as nonvictims to report involvement in prostitution as adolescents or adults, as assessed through participants’ positive response to a question about whether they had “ever been paid for having sex with someone.” Stoltz and colleagues (2007) found a significant association between child maltreatment (sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada. On the other hand, Nadon and colleagues (1998) compared a sample of 45 female adolescents involved in prostitution and recruited from service organizations in areas known for prostitution

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Risk Factors for and Consequences of Commercial Sexual Exploitation 81 with a sample of 37 female adolescents not involved in prostitution and recruited from the same service organizations. Surprisingly, the adolescents involved and not involved in prostitution did not differ in terms of child sexual abuse: rates of child sexual abuse were similar in the two groups, as were the circumstances surrounding the abuse, including the relationships between perpetrators and victims. Notably, the commercially sexually ex- ploited youth had significantly higher rates of running away from home (see the discussion of this factor below); this finding suggests that it may not be the child sexual abuse alone but its consequences that heighten the risk for commercial sexual exploitation and sex trafficking of minors. In fact, Jesson (1993) and Nadon and colleagues (1998) argue that early maltreatment, family dysfunction, and running away are so closely linked that it may well be the running away that puts youth directly at risk. Thus the literature suggests that there are multiple possible indirect pathways to commercial sexual exploitation and sex trafficking of minors. A number of researchers have offered explanations for why child mal- treatment may create vulnerability to commercial sexual exploitation and sex trafficking of minors. Stoltz and colleagues (2007, p. 5) suggest that some “children who are sexually victimized develop psychologically and emotionally in ways that make them vulnerable to continuing sexual preda- tion.” For example, survivors of child sexual abuse may display sexualized behaviors (Putnam, 2003). In addition, according to Stoltz and colleagues (2007), victims of child sexual abuse may have the tendency to engage in risk-taking behaviors (i.e., drug and alcohol abuse, running away from home) that may lead to circumstances in which they perceive survival sex as one of the few remaining resources available to them. While suggesting that child sexual abuse creates a susceptibility to becoming involved in trading sex, the authors emphasize that the abuse does not cause commercial sexual exploitation and sex trafficking. Rather, they posit that the abuse is one component of a generally traumatic negative developmental experience that may weaken resiliency. Similarly, Steel and Herlitz (2005) suggest a possible pathway from child sexual abuse to sexual risk behavior, with psychological symptoms such as depressive mood, poor self-esteem, lack of assertiveness, poor self-worth, and posttraumatic stress disorder (PTSD) leading to future risk behavior (Stein et al., 2002; Swanston et al., 2003). Noll and colleagues (2003) suggest that stigma associated with child sexual abuse may make it difficult for victims to experience nonsexual or emotional rewards from re- lationships, thereby making victims more likely to engage in risk behaviors and more vulnerable to sexual exploitation (Lalor and McElvaney, 2010; Stoltz et al., 2007). According to several researchers, victims of child sexual abuse may experience poor affect regulation (i.e., how an individual con- trols his/her experience and/or expression of emotion), experience difficulty in forming relationships, and possess poor coping abilities (Arata, 2002;

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82 Commercial Sexual Exploitation and Sex Trafficking of Minors Cloitre et al., 1996, 2001; Gold et al., 1999; Lalor and McElvaney, 2010; Polusny and Follette, 1995). These outcomes can result in a number of negative consequences for victims of such abuse later in life. For example, victims may engage in emotional avoidance behaviors such as self-harm and substance abuse (Lalor and McElvaney, 2010). These behaviors, in turn, may increase a victim’s risk of future victimization (Gold et al., 1999). Taken together, these propositions highlight emotional and behavioral con- sequences of child sexual abuse that are associated with commercial sexual exploitation and sex trafficking of minors, suggesting mechanisms that may link child abuse to these crimes. In support of the above propositions regarding the indirect pathways through which child maltreatment increases the risk for commercial sexual exploitation and sex trafficking of minors, ample evidence documents as- sociations between child sexual abuse and outcomes that have been linked with these crimes. For example, victims of child sexual abuse may begin to engage in sexual activity at earlier ages than nonvictims (Fergusson et al., 1997; Lodico and Diclemente, 1994; Noll et al., 2003; Springs and Friedrich, 1992; Wilson and Widom, 2010). Earlier onset of consensual sexual activity is in turn associated with increased risk for truancy, drop- ping out of school, and running away, as well as for gang membership (Unger et al., 1998), each of which has been associated with commercial sexual exploitation and sex trafficking of minors. Several studies have found that sexually abused adolescents are likely to have higher levels of alcohol and drug abuse, risky sexual behaviors, depression, trauma, anxi- ety, and suicidality, as well as poorer sense of self (Negrao et al., 2005; Noll et al., 2006; Sickel et al., 2002). Children and adolescents who expe- rience abuse and/or neglect may use drugs to cope with a negative home environment (Harrison et al., 1989), to enhance self-esteem (Cavaiola and Schiff, 1998), or to relieve symptoms of depression (Allen and Tarnowski, 1989). In older adolescents, child abuse has been found to be associated with heightened sexual risk taking and heightened risks for other adverse behavioral outcomes (Fergusson et al., 1997; Noll et al., 2009). According to Kelley and colleagues (1997), adolescents with a history of child mal- treatment were at least 25 percent more likely to experience problems with juvenile delinquency, teen pregnancy, low academic achievement, drug use, and symptoms of poor mental health than those without such a history, which together could increase the risk for commercial sexual exploitation and sex trafficking of minors. Few studies have examined indirect pathways between child maltreat- ment, hypothesized mechanisms, and commercial sexual exploitation and sex trafficking in prospective studies. One exception is the work of Wilson and Widom (2010), who explored whether behavioral sequelae of child maltreatment (i.e., early sexual initiation, running away, juvenile crime,

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Risk Factors for and Consequences of Commercial Sexual Exploitation 83 school problems, and early drug use) were precursors of commercial sex- ual exploitation of minors. Each type of child maltreatment (i.e., neglect, physical abuse, sexual abuse) was significantly associated with early sexual initiation, running away, juvenile crime, and school problems; these prob- lems, in turn, were linked with prostitution by adulthood. Initiation of sexual behavior before age 15 emerged as the strongest link between child maltreatment and later prostitution. Other possible mediating factors (e.g., parental conflict, parental psychopathology) that may link child maltreat- ment with high-risk behavior and/or victimization by commercial sexual exploitation and sex trafficking are discussed below. While the above studies suggest that child maltreatment, particularly child sexual abuse, may be associated with commercial sexual exploitation and sex trafficking of minors, it should be noted that findings of the few prospective studies available suggest that only an extremely small propor- tion of children who are sexually abused subsequently become involved in trading sex for money or something of value (Lalor and McElvaney, 2010; Lamont, 2010). For example, while Flowers (2001, p. 82) notes that “nearly all girl prostitutes have been sexually molested, assaulted, or physically abused before entering the profession,” the reverse does not hold. In a study of 2,810 Swedish citizens, Steel and Herlitz (2005) found that very few of the individuals who were victims of child sexual abuse (n = 268) reported having engaged in “sex work” (n = 1). This finding does not suggest a strong predisposition to involvement in prostitution among victims of child maltreatment. Moreover, while child maltreatment, and child sexual abuse in particular, appears to increase the risk for later high- risk behaviors and revictimization for some children and adolescents, this is not the case for all victims of child maltreatment. For example, Widom’s previously described longitudinal studies (Widom and Kuhns, 1996; Wilson and Widom, 2010) found no differences in teen pregnancy or promiscuity between individuals who experienced childhood maltreatment and those who did not. Reasons for such resilience after experiencing child maltreat- ment are unknown, as studies indicating what may make some victims of child abuse more or less resilient are lacking. In addition to a limited understanding of factors associated with resil- ience in victims of child sexual abuse, several factors limit understanding of the overall impact of child maltreatment on the risk for commercial sexual exploitation and sex trafficking of minors. In many studies, the timing of involvement in prostitution is unclear, nor is it possible to distinguish be- tween prostitution and commercial sexual exploitation and sex trafficking of minors. Moreover, studies have examined associations between child sexual abuse and later engagement in high-risk sexual behavior, including having multiple sexual partners, engaging in commercial sex work, and being sexually promiscuous; however, methodological issues—such as sam-

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84 Commercial Sexual Exploitation and Sex Trafficking of Minors pling women and girls already involved in commercial sex work, relying on retrospective reports of maltreatment, and using instruments that have not been psychometrically tested—limit the conclusions that can be drawn from this research. Other methodological problems include failure of most studies to distinguish among different types of maltreatment, as well as vast differences in definitions of abuse, differences in methodologies for identifying abuse, and the fact that most studies fail to measure the inten- sity and duration of the abuse or the relationship between perpetrator(s) and victim (Briere, 1992; Hastings and Kelley, 1997; Hulme, 2004; Kelley et al., 1997). These types of problems limit the ability to make comparisons across studies with regard to type of abuse, prevalence, and sequelae, in turn making it difficult to determine the risks associated with each form of abuse. Furthermore, Lalor and McElvaney (2010) report that nonresponse rates of 30 percent are common in surveys on abuse, calling into question the generalizability of the responses of the 70 percent of people who typi- cally agree to participate. In attempting to establish associations between child sexual abuse and commercial sexual exploitation and sex trafficking of minors, moreover, it is important to recognize that, like other forms of abuse, child sexual abuse is an extremely complex phenomenon (Hulme, 2004). The individual experiences of victims, including the number of in- cidents, the age at onset, the frequency and duration of the abuse, and the relationship between perpetrator(s) and victim, vary greatly (Hulme, 2004, 2007). In some cases, the boundaries between child abuse and commercial sexual exploitation are blurred, as when a parent or other family member coaches a child to be sexually involved in return for money (Saphira, 2001). Despite these methodological concerns, because commercial sexual ex- ploitation and sex trafficking of minors are extreme forms of child sexual abuse, it is widely assumed that their victims will exhibit behaviors similar to those of victims of child sexual abuse. However, additional prospective, longitudinal research is needed to demonstrate more explicitly whether causal links exist between child sexual abuse and commercial sexual ex- ploitation and sex trafficking of minors. Disruptions in normative development  The terms disrupted development and disrupted transitions have been used to describe precocious transi- tions to adulthood, or the “rush to adulthood” perspective developed by Wickrama and other researchers (Wickrama and Baltimore, 2010; Wickrama et al., 2003, p. 63, 2005a,b). Disrupted transitions can be de- fined as life events that either interrupt normative developmental pat- terns or occur prematurely. For example, Wickrama’s work demonstrates links between precocious transitions, such as early sexual activity, teenage pregnancy, early cohabitation, and early marriage, and negative long-term emotional, behavioral, and physical health outcomes. Similarly, earlier oc-

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Risk Factors for and Consequences of Commercial Sexual Exploitation 85 currence of physical maturation (e.g., puberty) has been associated with greater health risks occurring in adolescence (Fergusson et al., 1997; Noll et al., 2003). Explanations for this association include the greater stress experienced by early maturers, the short-circuiting of certain developmental tasks of early adolescence, and the greater social pressure to which early developers may be exposed (Tschann et al., 1994). Wickrama and Baltimore (2010, p. 3) summarize the impact of these early transitions as follows: Certain early life events may create “damages” that may multiply and continue into the young adult years. For example, youths who engage in early sexual activities get a “head start” and are more likely to engage in other unhealthy behaviors (Browning et al., 2008; Steinberg, 2005; Tubman et al., 1996). Research has not yet focused on early transitions as predictive of commercial sexual exploitation and sex trafficking of minors. However, a number of studies have identified adolescent life experiences that may be potential precursors to commercial sexual exploitation and sex traffick- ing of children and adolescents. Regardless of race or class, for example, those who become involved in the commercial sex trade (both juveniles and adults) are more likely to have a history of parental abuse and neglect, incest, rape, interrupted school activity (including early dropout), running away, and early sexual experiences (including early first intercourse) (Adlaf and Zdanowicz, 1999; Bracey, 1982; Chesney-Lind and Shelden, 1992; Gibson-Ainyette et al., 1988; Hernandez et al., 1993; Kidd and Kral, 2002; Macvicar and Dillon, 1980; Newman et al., 1982; Raj et al., 2000; Schaffer and Deblassie, 1984; Silbert and Pines, 1981; Vigil et al., 2005). It should be noted, however, that most studies of victims of commercial sexual exploitation and sex trafficking are based on retrospective reports, which are subject to errors of memory and are not verifiable; the result may be underreporting or overreporting of experiences such as sexual abuse and other maltreatment (Hulme and Agrawal, 2004). Additionally, associations between childhood experiences and commercial sexual exploitation and sex trafficking of minors do not necessarily indicate a causal link; other factors may account for the commercial sexual exploitation and sex trafficking of minors. Thus, care must be taken in concluding which, if any, of these fac- tors may be predictive of involvement in these crimes. Runaway, thrown-away, and homeless youth  Of the many factors that may increase vulnerability to commercial sexual exploitation and sex traf- ficking of minors, especially among adolescents, homelessness is widely considered the most direct contributor (Estes and Weiner, 2001). Homeless youth may include runaways (i.e., children who leave home without per- mission) and so-called thrown-away children (i.e., children and adolescents

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86 Commercial Sexual Exploitation and Sex Trafficking of Minors who are asked or told to leave home). According to the U.S. Interagency Council on Homelessness, approximately 5 to 7 percent percent of U.S. youth under age 18 (about 1.6 million) may experience an episode of homelessness each year (Ringwalt et al., 1998; USICH, 2010). The experi- ences of these youth vary widely, ranging from being in adult shelters to sleeping outdoors, in abandoned buildings, or with strangers (Gilmore, 2012; Greene et al., 1999; Holzman, 2012; Ringwalt et al., 1998). Causes of homelessness vary widely as well. For example, youth who have been in foster care are at particularly high risk for becoming homeless (NAEH, 2009). Approximately 40 to 60 percent of homeless youth have experienced physical abuse, and 17 to 35 percent have experienced sexual abuse. Once homeless, young people experience greater risk for violence, sexual assault (NAEH, 2009), and commercial sexual exploitation and sex trafficking (Barnardo’s, 2002, 2012; Estes and Weiner, 2001). The risk of commercial sexual exploitation and sex trafficking among homeless youth increases with a prior history of sexual abuse, as does greater sexual risk taking (e.g., having multiple partners, having unprotected sex) (Raj et al., 2000; Rotherham-Borus et al., 1996) (see also the section on child maltreatment above). Once homeless, young people are at significant risk of commercial sexual exploitation and sex trafficking for reasons ranging from a lack of resources for basic needs, such as food and shelter, to the need for social connection when separated from the family unit and other social supports. Not only are homeless youth victims of commercial sexual exploitation and sex trafficking, but older homeless male youth may recruit their peers into involvement in these crimes (Rotherham-Borus et al., 1992). In addition, homeless and thrown-away youth are at particularly high risk for substance abuse (Gleghorn et al., 1998), which has been linked with involvement in commercial sexual exploitation and sex trafficking. A number of studies have examined engagement in the commercial sex industry and transactional or survival sex among homeless youth (Curtis et al., 2008; Estes and Weiner, 2001; Greene et al., 1999; Gwadz et al., 2009; Miller et al., 2011). While estimates of such engagement vary greatly (between 2 percent and 46 percent), a cluster of studies suggest a figure of 15 to 30 percent (Adlaf and Zdanowicz, 1999; Greenblatt and Roberson 1993; Greene et al., 1999; Kipke et al., 1995, 1997; Milburn et al., 2006; NAEH, 2009; Rotherham-Borus et al., 1992; Unger et al., 1998; Wagner et al., 2001; Yates et al., 1991). In another example, a study in Seattle by Wagner and colleagues (2001) found that 41 percent of a sample of 272 Seattle homeless youth had been sexually exploited through survival sex and/or commercial sex work, and that 47 percent of females and 37 per- cent of males had been propositioned to sell sex. Estes and Weiner (2001) research found that homeless youth “are subject to an extraordinary range of risks of engaging in commercial sex that are not experienced by ‘at risk’

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Risk Factors for and Consequences of Commercial Sexual Exploitation 87 housed youth” (Estes and Weiner, 2001, p. 63). They suggest that homeless- ness puts young people at “special risk” for commercial sexual exploitation, not only because life on the streets puts them at greater risk from those who might prey on them, but also because homelessness among young people often is a result of other risk factors, such as family poverty, family dysfunc- tion, or serious mental illness (Estes and Weiner, 2001). The United Kingdom’s Barnardo’s, a social service organization with a long and deep involvement in working with homeless and thrown-away youth and victims of commercial sexual exploitation and sex trafficking, notes that commercial sexual exploitation and sex trafficking of minors oc- cur gradually and incrementally, not suddenly (Barnardo’s, 2012). Young people at risk become more vulnerable simply if they are spending a great deal of time away from home, from their care placement, or from school, even for short episodes (Barnardo’s, 2012). Similarly, Gwadz and colleagues (2009) found that initiation into the “street economy” is a gradual process and that many homeless youth reveal connections to both the conventional economy and the street economy, but that over time, the conventional econ- omy becomes viewed as foreign. It is important to note that not all homeless youth are involved in prostitution or engage in survival sex, however. Yates and colleagues (1991) found that among homeless youth, those involved in prostitution were more likely to live on the street, more likely to have dropped out of school, less likely to be involved in sports, more likely to have been sexually abused, and more likely to have engaged in survival sex. Greene and colleagues (1999) criticize many studies of survival sex among homeless and shelter youth because they are based on extremely small sample sizes. To address this gap, they conducted a nationally rep- resentative study of homeless and sheltered youth across both urban and nonurban settings, and found that 27.5 percent of street and homeless youth and 9.5 percent of youth in shelters engaged in survival sex. Research on adolescent survival sex remains difficult, however, given the constantly changing circumstances surrounding such activity, as shown by an extensive study conducted in New York City (Curtis et al., 2008). This study found constant variations in the neighborhoods in which survival sex occurred, as well as who “controlled” the market—for example, with increasing gang involvement in recent years. Frequent displacement of sexually exploited youth also was found in a study by Miller and colleagues (2011), which showed that young people involved in survival and exchange sex may move into and out of homelessness over time. Foster care placement and other systems involvement  During its San Francisco site visit, the committee heard that young people who are placed in foster care have backgrounds that include many of the factors thought to contribute to the risk for commercial sexual exploitation and sex traf-

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