Confronting Commercial Sexual Exploitation
and Sex Trafficking of Minors
in the United States

Committee on the Commercial Sexual Exploitation and Sex Trafficking of
Minors in the United States

Board on Children, Youth, and Families

Committee on Law and Justice

Ellen Wright Clayton, Richard D. Krugman, and Patti Simon, Editors

INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Committee on the Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States Board on Children, Youth, and Families Committee on Law and Justice Ellen Wright Clayton, Richard D. Krugman, and Patti Simon, Editors

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Grant No. 2011-MC-CX-0004 between the National Academy of Sciences and U.S. Department of Justice. Any opinions, findings, con- clusions, or recommendations expressed in this publication are those of the editors and do not necessarily reflect the views of the organizations or agencies that pro- vided support for the project. International Standard Book Number-13:  978-0-309-28655-8 International Standard Book Number-10:  0-309-28655-7 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2013. Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE COMMERCIAL SEXUAL EXPLOITATION AND SEX TRAFFICKING OF MINORS IN THE UNITED STATES Ellen Wright Clayton (Co-Chair), Craig-Weaver Professor of Pediatrics, Professor of Law, and Co-Founder, Center for Biomedical Ethics and Society, Vanderbilt University Richard D. Krugman (Co-Chair), Vice Chancellor for Health Affairs and Dean, University of Colorado School of Medicine Tonya Chaffee, Medical Director of Child and Adolescent Support, Advocacy and Resource Center, University of California, San Francisco Angela Diaz, Jean C. and James W. Crystal Professor of Pediatrics and Preventive Medicine, Mount Sinai School of Medicine Abigail English, Director, Center for Adolescent Health & the Law Barbara Guthrie, Associate Dean for Academic Affairs and Professor, Yale University School of Nursing Sharon Lambert, Associate Professor of Clinical/Community Psychology, The George Washington University Mark Latonero, Research Director, Annenberg Center on Communication Leadership & Policy, University of Southern California Natalie McClain, Assistant Professor, Boston College William F. Connell School of Nursing Callie Marie Rennison, Associate Professor, School of Public Affairs, University of Colorado Denver John A. Rich, Professor and Chair of Health Management and Policy, Drexel University School of Public Health Jonathan Todres, Associate Professor of Law, Georgia State University College of Law Patti Toth, Program Manager, Washington State Criminal Justice Training Commission Consultant ELENA O. NIGHTINGALE, Scholar-in-Residence, Institute of Medicine Study Staff Patti G. Simon, Study Director Meg F. Barry, Associate Program Officer1 1  hrough T November 2012. v

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Yeonwoo Lebovitz, Research Associate2 Alejandra MartÍn, Research Associate3 Tara Mainero, Research Associate4 Pamella Atayi, Administrative Assistant Kimber Bogard, Director, Board on Children, Youth, and Families Arlene F. lee, Board Director, Committee on Law and Justice5 Jane Ross, Senior Board Director, Committee on Law and Justice6 2  hrough T May 2012. 3  tarting S July 2012. 4  tarting November 2012. S 5  tarting January 2013. S 6  hrough September 2012. T vi

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Acknowledgments This report reflects contributions from numerous individuals and groups. The committee takes this opportunity to recognize those who so generously gave their time and expertise to inform its deliberations. To begin, the committee would like to thank the sponsor of this study. Support for the committee’s work was provided by the U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. We wish to thank Karen Bachar, Katherine Darke Schmitt, Brecht Donoghue, Jeffrey Gersh, Melodee Hanes, Christopher Holloway, Robert Listenbee, Catherine Pierce, and Jennifer Tyson for their guidance and support. The committee greatly benefited from the opportunity for discussion with individuals who made presentations at and attended the committee’s workshops and meetings (see Appendix D). The committee also was grate- ful for the opportunity to conduct a series of regional site visits to learn about the work of a range of organizations and individuals in different parts of the country addressing issues related to commercial sexual exploi- tation and sex trafficking of minors (see Appendix C). The committee is thankful for the useful contributions of these many individuals. The committee could not have done its work without the support and guidance provided by the National Research Council and Institute of Medicine (NRC/IOM) project staff: Patti Simon, study director; Alejandra Martín, research associate; Tara Mainero, research associate; and Pamella Atayi, administrative assistant. The committee gratefully acknowledges Kimber Bogard of the Board on Children, Youth, and Families and Arlene Lee and Jane Ross of the Committee on Law and Justice for their guidance on this study. vii

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viii Acknowledgments Many other staff within the NRC/IOM provided support to this proj- ect in various ways. The committee would like to thank Meg Barry, Kathy Blakeslee, Patrick Burke, Laura DeStefano, Chelsea Frakes, Faye Hillman, Nicole Joy, Yeonwoo Lebovitz, Tracy Lustig, Janice Mehler, Abbey Meltzer, and Lauren Tobias. Thanks are due as well to Elena Nightingale, who pro- vided invaluable advice throughout the project. Finally, Rona Briere and Alisa Decatur are to be credited for the superb editorial assistance they provided in preparing the final report.

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Lucy Berliner, University of Washington Howard Davidson, American Bar Association Karen Heimer, The University of Iowa Kathleen Kim, Loyola Law School, Los Angeles Coleen H. Kivlahan, Associations of American Medical Colleges David Kolko, University of Pittsburgh School of Medicine M. Allen Northrup, Northrup Consulting Group Alexandra Pierce, Othayonih Research Malika Saada Saar, Human Rights Project for Girls Francine Sherman, Boston College Law School Anne Teitelman, University of Pennsylvania School of Nursing Shannon Thyne, University of California, San Francisco ix

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x Reviewers Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the report’s conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Georges Benjamin, American Public Health Association, and Kristine Gebbie, Flinders University School of Nursing and Midwifery. Appointed by the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface It is important to understand that commercial sexual exploitation and sex trafficking of minors are manifestations of child abuse. By doing so, one can gather valuable insights from the nation’s work on child abuse and neglect over the past several decades and gain a better understanding of the challenges that must be overcome to confront these crimes. Children have been abused and neglected for millennia. Examples of abuse and neglect of children are explicitly described in Ancient Egyptian, Greek, and Roman writings (Lynch, 1985). Physical abuse of children leading to death was described in France in 1860 and in several articles in the U.S. pediatric literature between 1946 and 1960. These early articles elicited what Christopher Ounsted referred to in 1975 as “gaze aversion,” a collective indifference to child abuse that contributes to the failure to confront the problem directly and effectively (Ounsted, 1975). For cen- turies, and even now, many individuals and societies have turned away from recognizing and addressing the maltreatment of children because it is either too distressing or distasteful, because it is thought to be something that cannot be dealt with effectively or prevented, or because it is viewed as a family matter. There have been waves of public interest in the abuse and neglect of children in American history. In 1874, in response to the case of Mary Ellen McCormack in New York City, the first child protective agency— the New York Society for the Prevention of Cruelty to Children—was founded. Through the 1920s, such societies created shelters or orphanages for children who were being abused or neglected in their homes. Interest was reignited by C. Henry Kempe’s publication of “The Battered Child xi

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xii Preface Syndrome” in the Journal of the American Medical Association in 1962, in which he estimated that there might be as many as 749 battered children in the United States (Kempe et al., 1962). The media attention to this pa- per helped lead all 50 states to implement a policy of mandatory reporting of child abuse. By 1969, there were 60,000 reported cases nationwide; by 1979, there were 669,000 reported cases; and by 1990, there were more than 3 million reports to social service agencies and 1.2 million confirmed cases. Also in 1990, the U.S. Advisory Board on Child Abuse and Neglect declared that the failure to address the problem adequately had led to “a national emergency.” The field of child maltreatment has expanded over the years to encom- pass sexual abuse, emotional abuse, physical abuse, educational neglect, and inadequate medical care. Sexual abuse of children, while, like child abuse generally, in existence for millennia, emerged as a public issue in the United States coincident with and in part as a result of the women’s move- ment. Kempe described the sexual abuse of children as “the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate the social taboos of family roles” (Kempe, 1978, p. 382). Sexual abuse can occur within and outside the fam- ily and, depending on the developmental age of the child, will have different forms and consequences. Intrafamilial abuse (incest) was the initial focus of activity in the 1980s. Unlike the response to physical abuse of children (which was dealt with primarily by child welfare and juvenile [civil] court systems), the sexual abuse of children has been the purview primarily of law enforcement and the criminal justice system. Fifty years after Kempe’s landmark publication, the Institute of Medi- cine convened a committee to study the commercial sexual exploitation and sex trafficking of minors in the United States. At its core, commercial sexual exploitation and sex trafficking of children in the United States represent the organized sexual abuse of young children and adolescents, who, as this report demonstrates, often were previously victims of abuse and neglect in their home settings and escaped from that unsafe environment to an external environment on streets and in neighborhoods where they have been exploited. This report reveals that the complex needs of these young people are not being adequately met by either criminal justice or child protection systems. Further, mandatory reporting of suspected cases will not help these youth if the resources they need are unavailable. It is time to refocus the perspective on these problems and direct efforts toward preventing commercial sexual exploitation and sex trafficking of minors; identifying youth at risk and those who have become ensnared; and developing effec-

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Preface xiii tive, evidence- and trauma-informed approaches that can enable them to reclaim their lives. Ellen Wright Clayton and Richard D. Krugman Co-Chairs Committee on the Commercial Sexual Exploitation and Sex Traffick- ing of Minors in the United States Institute of Medicine and National Research Council References Kempe, C. H. 1978. Sexual abuse, another hidden pediatric problem: The 1977 C. Anderson Aldrich lecture. Pediatrics 62(3):382-389. Kempe, C. H., F. N. Silverman, B. F. Steele, W. Droegemueller, and H. K. Silver. 1962. The battered-child syndrome. Journal of the American Medical Association 181(1):17-24. Lynch, M. A. 1985. Child abuse before Kempe: An historical literature review. Child Abuse & Neglect 9(1):7-15. Ounstead, C. 1975. Gaze aversion and child abuse. World Medicine 12:27.

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Contents Summary 1 PART I: Understanding Commercial Sexual Exploitation and sex trafficking of minors in the united States 1 Introduction 19 2 The Nature and Extent of Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States 41 3 Risk Factors for and Consequences of Commercial Sexual Exploitation and Sex Trafficking of Minors 77 4  Legal Framework 143 PART II: Current and Emerging Strategies 5 The Legal System 197 6 Victim and Support Services 235 7 Health and Health Care 271 8 The Education Sector 297 xv

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xvi Contents 9 The Commercial Sector 323 10 Multisector and Interagency Collaboration 337 PART III: Recommendations 11  Overall Conclusions and Recommendations 371 Appendixes A Disentangling the Language of Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States 401 B Lessons Learned from International Efforts to Respond to Commercial Sexual Exploitation and Sex Trafficking of Minors 407 C Site Visit Methodology and Summaries 413 D Workshop and Site Visit Agendas 429 E Biosketches of Committee Members and Staff 439