Human Trafficking and Exploitation of Children and Adolescents: Policy Statement Free

Children and adolescents experiencing trafficking in human beings and exploitation (THB/E) for labor and/or sex routinely are deprived of their rights to basic needs, including health, dignity, respect, and safety from violence and exploitation, as outlined in the United Nations Convention on the Rights of the Child.¹ In this policy statement, the term “children and adolescents” is used to describe individuals younger than 18 years, although many national and international terms refer to this age group as “child/children”) (eg, “child trafficking”). Although laws and conventions^2,3 may restrict the definition of “child” to those younger than 18 years, many issues and recommendations outlined in this statement also apply to young adults.

Child labor exploitation occurs when a child is treated unfairly in the context of work⁴; labor trafficking occurs when a person uses force, fraud, or coercion to compel the minor to work.³ Child labor THB/E in the United States (US) occurs in various industries,^5,6 including domestic servitude, construction, forced peddling settings (eg, door-to-door magazine sales), illicit activities, agriculture, health and beauty services, and hotel and restaurant businesses.^7–15 Common settings outside the US include begging, fishing, domestic work, manufacturing, and armed conflict.^16–19 

According to US federal law, child sex trafficking involves commercial sex acts (sexual activity for which there is an exchange of something of value) with individuals younger than 18 years.^3,20 Demonstration of force, fraud, or coercion is unnecessary, as is the movement of trafficked persons across borders. The commercial sexual exploitation of children (CSEC) is closely related, involving “crimes of a sexual nature committed against juvenile victims for financial or other economic reasons.…”²¹ CSEC may occur online/offline, may involve transactional sex, may include monetary enticement, and may occur in the context of business travel and tourism. It also includes cases of mail-order-bride trade/early forced marriage, production of child sexual abuse material (CSAM, formerly called “child pornography”), live-stream sexual acts (wherein an online buyer directs the child to engage in sexual activities in real time, in front of a webcam), and performing in sexual venues.²¹ Image-based sexual abuse and exploitation of children (IBSEAC)²² includes production of sexual images by adults, peers, and victims with nonconsensual or consensual (but illegal) distribution. It includes “sextortion” (inducing an individual to send sexual images/videos, then blackmailing them for money or other items of value).²³ 

Major methodologic challenges hinder child THB/E prevalence estimates, as do the relative scarcity of robust antitrafficking ecosystems that can identify impacted individuals, and the paucity of validated screening tools for special populations.^7,21,24,25 The International Labour Organization estimated that more than 3.3 million children and adolescents were involved in forced labor globally in 2021 (including 1.9 million in CSEC).¹⁷ Accurate statistics on the US prevalence of child THB/E are similarly challenging.²⁶ Four recent studies of runaway and homeless youth suggest that rates of sex trafficking range from 6.5% to 25.8%, whereas labor trafficking ranges from 4.6% to 54.2%.^27–30 In 2021, the National Human Trafficking Resource Center (NHTRC) hotline received reports of 10 360 unique cases (incidents) of potential THB/E, including 136 possible child labor trafficking cases and 2078 possible sex trafficking cases.³¹ This likely represents a small portion of US THB/E. In a nationally representative sample of young adults (18–28 years), prevalence rates of online commercial sexual exploitation and sextortion were 1.7% and 3.5%, respectively.³² Girls, transgender and gender-fluid youth had higher rates than cisgender males; 13- to 17-year-olds were at highest risk.

The United States is a “destination” country for THB/E, and statistics from 2021 indicate that the leading “origin” countries for federally identified victims (all ages, all types of trafficking) were the United States, Mexico, and Honduras.³³ The production of CSAM is a vast global phenomenon: the internet Watch Foundation identified 255 588 URLs (webpages) containing CSAM or links to images in 2022, originating from countries worldwide.³⁴ 

Factors at the individual, community, and societal levels contribute to THB/E vulnerability globally¹⁷ (see Table 1). Children in the custody of government child welfare agencies, notably in the United States, are at increased risk, which may be partially related to co-existence of other risk factors such as a history of sexual abuse, and family dysfunction.^9,53 Attitudes and practices that marginalize populations (eg, systemic racism, colonialization, and xenophobia) limit economic and social opportunities, restrict health care access, condone persecution, and increase the risk of THB/E.^{17,33,35,36,54–61} 

Massive population displacement often involves children and adolescents, including unaccompanied minors (UMs).^59,60,62 Individuals and families may flee war, community or familial violence, persecution, poverty, natural disasters, or other major crises. UMs are at significant risk for THB/E,^17,61,63 given their age, absence of adult supervision, lack of knowledge pertaining to host language/culture, need to repay debt or support family, and precarious legal status.^6,15,64 

Global pandemics, as observed during the COVID-19 pandemic of 2020, increase the risk for THB/E, especially involving those already at risk for exploitation.^{37,38,65–68} Increases in unemployment, poverty, homelessness, and illness or death of caregivers contribute to THB/E vulnerability.^{33,64,69–75} 

Access to the internet continues to expand. As of 2019, 95% of US children 3 to 18 years old had home internet access.⁷⁶ COVID-19 led to increased use in response to social isolation requirements.⁷⁷ Concurrently, exploiters use the internet to recruit, groom, sexually abuse^78–80 and extort,^81,82 produce/distribute CSAM,⁷² manage THB/E financial transactions, ³³ and arrange live-stream sex acts for global buyers.⁸³ Resources on internet safety, including legal protections, are widely available (AAP’s Center of Excellence on Social Media and Youth Mental Health),^84,85 although outcome/impact studies are needed.^84,85 

Global climate change may increase THB/E vulnerability.^{39,40,86–88} Drought, sudden storms, flooding, and slow-onset coastline erosion may drive agriculturally dependent families to migrate, exposing children and adolescents to the risk of THB/E as described earlier.^17,60 In 2020, weather events displaced 30 million individuals.⁴⁰ Massive individual losses and demand for cheap labor accompany severe weather events and lay a foundation for THB/E.^40,89,90 

Although evidence suggests that legal residents experiencing sex THB/E in the United States are likely to seek medical attention during their period of exploitation,^91,92 those without legal documentation and individuals trafficked in foreign countries around the world (US citizens and others) may have limited access to health care.^93,94 It is important for pediatric clinicians in any country to appropriately recognize and respond to THB/E (see AAP clinical report on labor and sex trafficking).⁴¹ 

Increasingly, THB/E is being viewed through a public health lens focusing on, raising public awareness,⁹⁵ prevention, identification of risk and protective factors, resilience and recovery, rigorous scientific research, and development of a multidisciplinary response.^{54,75,96–104} Pediatric clinicians play a critical role in advocating for public health efforts to combat and prevent THB/E.¹⁰⁵ 

In the United States, THB/E involves the criminal justice and child protective systems at federal and state levels. The Trafficking Victims Protection Act (TVPA) of 2000,³ recognizes THB/E as a federal crime and offers protection; multiple reauthorizations have expanded its scope.^106–108 In the 2008 William Wilberforce Trafficking Victims Protection Reauthorization Act (TVPRA),¹⁰⁶ special provisions were added to protect unaccompanied minor migrant children. These include mandatory screening for possible THB/E and persecution in the home country. To date, all 50 states and the District of Columbia have passed legislation making THB/E a felony offense. Information on these and related laws is available from the AAP Committee on State Government Affairs as well as Shared Hope International.

Foreign national children and adolescents in the United States who are identified as having experienced THB/E may be eligible for various special visas that allow them to remain temporarily in the United States and receive federal assistance. Health professionals may refer patients who they suspect have experienced THB/E to the Office of Trafficking in Persons (https://www.acf.hhs.gov/otip/victim-assistance/child-eligibility-letters/request-assistance). Referrals to pro-bono immigration attorneys or organizations providing immigration legal assistance are also helpful.

The 2014 Preventing Sex Trafficking and Strengthening Families Act (Pub L No. 113–183) requires that state child welfare agencies develop procedures to identify and serve individuals under their care or supervision who may have experienced THB/E. The Justice for Victims of Trafficking Act of 2015²⁰ requires that states include sex THB/E in their definitions of child abuse, although not all states have laws requiring mandatory reporting when the alleged perpetrator of sex THB/E is not the parent/caregiver. Criminal sanctions were additionally expanded to include persons who patronize/solicit individuals younger than 18 years for commercial sex acts. The Act provides federal grant incentives for states to pass comprehensive Safe Harbor Laws to eliminate a punitive approach to individuals who engaged in illegal activity related to their exploitation, and to instead provide immunity, diversion, and/or mandatory referral for services.¹⁰⁹ 

The United Nations Convention on the Rights of the Child (UNCRC) safeguards children from violence, exploitation, and abuse. Although the United States signed the agreement in 1995, it is the only nation not to ratify it, endorsing the principles without legal commitment.¹ Opponents of ratification assert that the Convention conflicts with some US laws regarding privacy and family rights, that it is an ineffective mechanism for protecting child rights, and that it undermines US sovereignty.¹¹⁰ The AAP commits to advocate for policies that conform to the principles of the United Nations Convention on the Rights of the Child and supports US ratification.

Research continues to demonstrate the need for clinician training for recognition and care of patients who experience THB/E.^111–113 In a study of pediatric clinicians at an academic children’s hospital, 62.8% of participants reported they had never received education on THB/E. ¹¹⁴ Multiple training curricula are available^115–120 however, outcomes research is needed.^{118,121–123} 

An AAP clinical report on child THB/E provides detailed information on the trauma-informed health care response,⁴¹ and online training is available.¹²⁴ A set of core competencies for a THB/E response in health care/behavioral health systems provides further guidance to professionals, health care organizations, and training programs.¹²⁵ Of critical importance is the need to protect patient privacy and safety when documenting sensitive information in the medical record. Individuals who have experienced THB/E have valid concerns regarding potential access to the record by traffickers, caregivers and others who may harm the patient, and they may also fear staff bias and discrimination by those discovering stigmatizing data such as substance misuse, commercial sexual exploitation and undocumented immigration status. Strategies to protect patient privacy and promote safety include granular metadata and segmentation that is incorporated into all facets of the EHR, and clinician transparency with patients regarding information to be included in the record. A thorough discussion of the privacy and confidentiality issues associated with THB/E and guidance regarding documentation of sensitive patient information is available.^126–128 Comprehensive clinical guidelines on pediatric THB/E are critical^41,125 and resources exist to help clinicians and health administrators design tailored clinical protocols for their organizations.^129–131 

Pediatric THB/E screening tools specifically designed for health settings are limited, especially for young children, and lack validation for individuals with significant intellectual disabilities, migrant populations, or American Indian/Alaska Native/Indigenous (AI/AN/I) patients. Most do not screen for labor THB/E.^132–135 Universal education and resource strategies tend to focus on sexual and domestic violence.^136,137 The development of validated, brief, trauma-informed screening tools and universal education resources addressing all forms of THB/E are needed across diverse at-risk populations.

Prevention initiatives for THB/E can encompass various strategies including promoting healthy and safe relationships, child sexual abuse prevention, internet safety, and providing information on THB/E, labor rights, and risk reduction.^{103–105,137–140} The AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents includes anticipatory guidance recommendations for patients from newborn infants to 21 years of age.¹⁴¹ However, these recommendations do not provide specific guidance on THB/E. There is relatively limited evaluation of THB/E prevention efforts,¹⁴² and outcomes research is needed. Consideration should be given to integrating THB/E prevention into existing, evidence-based child sexual abuse prevention programs.¹³⁹ 

Evidence-based research on THB/E remains relatively limited¹⁴³ with an overall low level of rigor.¹⁴⁴ Large gaps exist, particularly regarding special subpopulations; the impact of cultural beliefs/practices; biases/systemic racism and colonialism as they impact individuals of color; exploitation of child migrants; and child labor trafficking. Evaluation studies of treatment models are also lacking.^101,144,145 

The vast majority of THB/E research is focused on cisgender female individuals and on people experiencing sex trafficking.¹⁴⁶ Many studies on THB/E publish aggregate results for adults and children/adolescents,^147–149 male and female individuals,¹⁵⁰ or individuals from multiple countries of origin.⁷¹ Some merge individuals victimized by various forms of THB/E.⁹¹ Aggregated data may preclude identification of findings specific to children and adolescents or subpopulations.

The limited^42,151–154 research on male individuals experiencing THB/E may indirectly reinforce societal beliefs that boys cannot be victimized, exacerbate the under recognition of exploitation and restricted services for this population,¹⁵⁵ and fuel the tendency to treat males as offenders rather than as individuals needing services.¹⁵⁶ 

Research remains limited regarding the THB/E experiences of individuals identifying as 2SLGBTQIA+, although their increased risk of abuse, violence, homelessness, and exploitation has been documented.^{28,67,157,158} Research exploring similarities and differences in the experiences and health needs of specific populations of 2SLGBTQIA+ individuals is needed.

Our knowledge of the prevalence of THB/E, risk factors, experiences and related needs of affected AI/AN/I children and adolescents is minimal.^35,159,160 Sexual exploitation is associated with oil rigging sites, uranium mines and with casinos on AI/AN/I tribal territory.^159,161,162 A national inquiry into missing and murdered Indigenous women and girls in Canada emphasizes the need to focus on vulnerabilities and needs of AI/AN/I children and adolescents as well as protective factors that are critical in designing culturally relevant prevention and intervention efforts.¹⁶³ 

Labor THB/E has not received the same public attention as sex THB/E¹⁶⁴ and there is a dearth of research in the United States.^6,10 Researching child employment, child labor, hazardous child labor, forced child labor, and trafficking is challenging due to subtleties of identifying and differentiating between these phenomena.¹⁶⁵ 

Systemic racism, deeply held implicit biases, the effects of colonialism, and widespread social and health inequities increase risk for THB/E in BIPOC populations and hinder access to assistance for those experiencing THB/E.^35,54,166 Research is needed to elucidate conditions that condone and promote continued discrimination and to facilitate positive cultural change.

Burgeoning research of online child sexual exploitation includes studies on risk, prevalence, offender characteristics, and prevention.^{22,32,81,167,168} Studies published by nongovernmental organizations (eg, “gray literature”) supplement research published in peer-reviewed journals.^158,169,170 

Multidisciplinary collaboration in the investigation and treatment of child abuse has become the standard in the United States,^171–173 and similar collaborations are evolving globally.^174,175 These collaborations involve work with other health professionals as well as professionals from legal, child welfare, education, law enforcement, immigration, and victim/survivor services. However, pediatric clinicians seeking to report cases and obtain services for patients often lack knowledge of available community partners or The National Human Trafficking Resource Center (1–888–373–7888),^112,176,177 and education is needed.¹⁷⁸ 

Major issues exist regarding public policy, medical education, research, and collaboration in the areas of child THB/E. There are needs for victim/survivor advocacy; increased victim/survivor services; training for health professionals; and research on THB/E.

The following recommendations apply to AAP chapters and to all individual health care professionals serving children and adolescents, including but not limited to physicians, nurses, advanced practice clinicians, dentists, behavioral health professionals, social workers, and trainees in these fields.

1. The AAP advocates for prevention of THB/E and respect for fundamental children’s rights.

2. Support relevant state, federal, and global anti-trafficking policies that address the following

• ○ Increase equitable access to direct services for all children and adolescents impacted by THB/E (online and offline), regardless of immigration status, race/ethnicity, abilities, gender identity, etc.

• ○ Increase interagency collaboration.

• ○ Improve THB/E screening and universal education in health care settings.

• ○ Provide continuous financial coverage for physical and mental health expenses for individuals impacted by THB/E regardless of immigration status.¹⁷⁹ 

• ○ Increase availability of pediatric examiners trained in THB/E and trauma-informed care, especially in rural areas.

• ○ Ensure access to family planning and reproductive health services irrespective of immigration status, promoting harm reduction strategies for those experiencing THB/E.

• ○ Advocate for 2SLGBTQIA+ children, adolescents, and adults who experience THB/E, ensuring access to physical and psychosocial health services to all.

• ○ Increase protection and assistance to migrant children and adolescents during^164,180 and after migration; increase access to free/low-cost medical homes; expand post-release services for unaccompanied minors (UMs), facilitate screening, and improve access to immigration legal services.¹⁸¹ 

• ○ Combat child labor THB/E globally.¹⁷ This includes legislation, international treaties, memoranda of understanding, and other agreements to:

  • protect children and adolescents in all occupational sectors;

  • ensure monitoring and enforcement of child labor laws;

  • train labor inspectors to detect and respond to labor violations that may represent THB/E;

  • promote fair and ethical recruitment of adults and children for employment;

  • ensure respect for the rights of all migrants regardless of immigration status;

  • incorporate THB/E prevention, recognition, and response measures into all levels of humanitarian crisis responses and disaster risk reduction strategies¹⁸²;

  • require industries to take appropriate measures to ensure that all workers are protected from adverse health and safety consequences;

  • improve data collection regarding national and global child labor THB/E.

• ○ Support efforts to address social drivers of health and economic factors linked to vulnerability factors for THB/E.

• ○ Support legislation addressing systemic racism and bias/discrimination against populations.³⁶ 

• ○ Address climate change and its impact on children’s vulnerability to THB/E.

• ○ Facilitate primary prevention of child THB/E through education of children and adolescents, caregivers, child welfare professionals, and clinicians. These efforts should be informed by rigorous research incorporating the views of young people.^183,184 Include school programs and extend efforts to reach nonattenders. Explore opportunities to integrate internet safety and THB/E prevention into evidence-based programs on healthy relationships.^32,139 

• ○ Protect individuals <18 years who have experienced any type of THB/E from prosecution for related offenses, emphasizing treatment and services.

• ○ Prevent detention of migrant children and adolescents and separation from their families, as this increases the vulnerability to THB/E.

• ○ Increase legal access to cross-border migration so UMs and families do not need to rely on smugglers.

• 3. Facilitate a public health approach to THB/E¹⁰² that embraces culturally responsive, rights-based, trauma-informed, and child-centered care.⁴¹ 

1. Advocate for:

   • Standardized pediatric clinician training on THB/E, including:

     • ○ Prevention, recognition, assessment, treatment, follow-up and referral for community services.¹²⁵ 

     • ○ A trauma-informed, culturally responsive, and rights-based approach⁴¹;

     • ○ Awareness of THB/E involving caregivers, young adults, and specific high-risk populations.

     • ○ Guidance on identifying referral pathways to immigration attorneys and organizations that assist foreign-born patients with obtaining visas and benefits.

     • ○ Use of strategies to address social drivers of health and connecting patients to community resources.

     • ○ Advocate for patient-informed and appropriate documentation of sensitive health information and use of THB/E ICD-10 codes in the health record in ways that protect the safety and privacy of patients.^126,127,185 This includes granular metadata and segmentation that is incorporated into all facets of the record, and age-appropriate transparency with patients regarding who may have access to sensitive information. Patients should be empowered to make decisions regarding data documentation, while ensuring safe and appropriate ongoing care, and adherence to existing laws and policies.¹²⁸ 

     • ○ Education mitigating implicit/explicit bias and discrimination at individual and systemic levels.^186,187 

   • Provide timely medical education on THB/E at the trainee level.

   • Promote financial support, development, and global dissemination of culturally appropriate, trauma-informed curricula and clinical management guidance for pediatric clinicians addressing THB/E.

1. Advocate for research addressing:

   • ○ THB/E prevalence;

   • ○ Protective and resilience factors;

   • ○ The intersection of THB/E with specific populations (eg, males, 2SLGBTQIA+ individuals, individuals with disabilities, those in the custody of the state, etc);

   • ○ Effective implementation of trauma-informed care into a busy health care setting¹⁸⁸;

   • ○ Effectiveness of telehealth encounters in identifying/screening for THB/E;

   • ○ Impact of:

     • telehealth resources on service provision;

     • prevention initiatives, screening tools and universal education resources, and harm reduction strategies;

     • integration/reintegration services.

2. Facilitate research using an equity lens, rigorous designs including implementation science, and community-based strategies informed by individuals with lived experience.^143,144 

3. Advocate for centralized surveillance and data collection on THB/E using clearly operationalized definitions.

1. Advocate for pediatric clinicians to join community multidisciplinary teams combating THB/E, educating team members about survivors’ health needs and facilitating services to enhance the well-being of trafficked persons.

2. Encourage pediatric clinicians to promote public awareness of THB/E and advocate for increased service provision. This may involve supporting education initiatives, advocating for anti-trafficking legislation, and working with the media to counteract inaccurate representations that sensationalize and stereotype human trafficking.

3. Advocate for pediatric clinicians to identify local service providers and establish “warm hand-off” referral mechanisms, aiding patients in contacting referral organizations before leaving the health facility. Pediatric clinicians in small practices may collaborate with local/state task forces, the National Human Trafficking Resource Center (1–888–3737–888), or nongovernmental organizations (eg, International Organization for Migration) in areas where there is an absence of community partnerships.

4. Advocate for trauma-informed, patient-centered, and culturally responsive health care to recognize and respond to suspected THB/E.

Jordan Greenbaum, MD

Dana Kaplan, MD, FAAP

Nia Bodrick, MD, MPH, FAAP

Antoinette Laskey, MD, MPH, MBA, FAAP, Chairperson

Suzanne Breen Haney, MD, MS, FAAP, Immediate Past Chairperson

Andrea Asnes, MD, MSW, FAAP

Verena Brown, MD, FAAP

Rebecca G. Girardet, MD, FAAP

Nancy Heavilin, MD, FAAP

Amanda Bird Hoffert Gilmartin, MD, FAAP

Natalie Kissoon, MD, FAAP

Bethany Anne Mohr, MD, FAAP

Patricia Morgan, MD, FAAP

Shalon Marie Nienow, MD, FAAP

Norell Rosado, MD, FAAP

Rachael Keefe, MD, MPH, FAAP – Council on Foster Care, Adoption, and Kinship Care

Anna Kerlak, MD, FAAP – American Academy of Child and Adolescent Psychiatry

Serena Wagoner, DO, FAAP – Section on Pediatric Trainees

Jeff Hudson, MA

Heather A. Haq, MD, MHS, FAAP, Chairperson

Keri A. Cohn, MD, FAAP

Erin McCann, MD, MPH, FAAP

Megan McHenry, MD, FAAP

Alcy R. Torres, MD, FAAP

Rachel Umoren, MD, FAAP

Talia Bailes – District V

Magi Dickinson, MD, FAAP – SOPT

Sandya Valli Vikram, MD – District VII

Naji Hattar, MHA

The authors would like to thank Hanni Stoklosa, MD, MPH, HEAL Trafficking, Harvard Medical School, for her input and review of the policy statement.

THB/E

trafficking in human beings and exploitation

CSAM

child sexual abuse materials

AAP

American Academy of Pediatrics

ACE

adverse childhood experience

BIPOC

Black, Indigenous, and other people of color

AI/AN/I

American Indian/Alaska Native/Indigenous

HEAL (Trafficking)

Health, Education, Advocacy & Linkage

IBCSAE

image-based child sexual abuse/exploitation

ICD

International Classification of Diseases

2SLGBTQIA+

two-spirit, lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, asexual, or other

PATH

Physicians Against the Trafficking of Humans

TVPA

Trafficking Victims Protection Act