Abstract

Little is known about the prevalence of neurodevelopmental, mental, or behavioral disorders among CSEC survivors, and the experiences of CSEC survivors with these disorders with health care. We conducted a self-report survey study with N = 269 youths between the ages of 13 and 24 years old who disclosed that they had experienced CSEC prior to age 18 in the United States. The vast majority, 82%, reported that they had ever been diagnosed with a neurodevelopmental disorder or neurological impairment (i.e. ADHD, autism, intellectual disability, or learning disorder), a serious mental illness (i.e. schizophrenia, schizoaffective disorder, or bipolar disorder), a mood disorder (i.e. PTSD, depression, or anxiety), or a behavioral disorder (substance use, eating, or conduct disorder). Approximately 26% reported seeking healthcare while being exploited. Those with Serious mental illness (SMI) or behavioral disorder were more likely than other subsets of CSEC survivors to report poor mental and physical health, and negative experiences in the healthcare setting. Our findings have direct implications for efforts that align with the UN's Sustainable Development Goal of “promoting just, peaceful and inclusive societies,” in that they provide support for the idea that health care providers will benefit from training in supporting human trafficking survivors with neurodevelopmental, mental, and behavioral disorders.

Keywords: Disability; disorder; Autism; SMI; Human trafficking; Commercial sexual exploitation; Health; Health care

Citation: Rothman, E., Cusano, J., Wagner, A., Lockwood, S., Cuevas, C., and Farrell, A. (2024). Prevalence of neurodevelopmental, mental, and behavioral disorders in a sample of U.S. commercially sexually exploited youth, and associations with health and health care access. Journal of Human Trafficking. https://doi.org/10.1080/23322705.2024.2426943

Background

The trafficking of minors for commercial sex (i.e., the commercial sexual exploitation of children, or CSEC) is an urgent public health and public safety problem. Although precise estimates of the number of CSEC survivors are not available because of the complexity of identifying victims, in 2023, of the 22,442 children reported missing from the care of child welfare to the U.S. National Center for Missing and Exploited Children, 19% were suspected by child welfare professionals to be commercially sexually exploited  (National Center for Missing and Exploited Children, 2024). CSEC is associated with serious psychological and physical health consequences, including post-traumatic stress disorder, depression, anxiety (Hossain et al., 2010), sexually transmitted infections (Edinburgh et al., 2015), unwanted pregnancy (Greenbaum et al., 2018), and substance use disorders (Lederer & Wetzel, 2014), among other physical health consequences (Barnert et al., 2017). In the aftermath of CSEC, survivors also can experience problems obtaining medical and mental health care (Mumey et al., 2021; Powell et al., 2018), all of which undermine their physical and psychological health.

Pre-existing psychological and physical health problems may exacerbate the risk for CSEC  (Franchino-Olsen, 2021). Emerging research suggests that disabled individuals may be disproportionately likely to experience human trafficking and CSEC victimization, although research on the intersection between disability and human trafficking remains in a nascent stage (Jagoe et al., 2022).1 Disabled individuals are often marginalized, and many experience compound disadvantage because they are further disempowered due to their race/ethnicity, living in poverty, immigration status, experiencing childhood abuse, trauma or neglect, being female, or being transgender, non-binary, gay, lesbian, bisexual, pansexual, or queer (LGBTQ+) (Diaz et al., 2014; Franchino-Olsen et al., 2020). The fact that disabled people are more likely to experience childhood abuse, and that childhood abuse exacerbates the risk for CSEC, is a primary reason that disabled young people are considered at higher risk for CSEC victimization (Franchino-Olsen et al., 2020). Many survivors of CSEC may also acquire disorders and disabilities, including psychiatric disorders such as depression, anxiety, and post traumatic stress disorder, because of their CSEC experience (Office for Victims of Crime, 2023). As such, the importance of providing accessible human trafficking support services and building organizational capacity for engaging with disabled human trafficking survivors in communities has been highlighted by the U.S. Department of Health and Human Services (U.S. Department of Health and Human Services, 2022).

CSEC survivors often utilize health care while being exploited, and thus health care providers are considered well-positioned to identify young people at risk for exploitation and provide trauma informed responses (Chang et al., 2022; Chisolm-Straker et al., 2018; Smirnoff et al., 2022). In recent years, health care providers have begun to develop screening tools to increase the identification of individuals who experience CSEC across a variety of health settings (Baldwin et al., 2011; Greenbaum et al., 2015; Mostajabian et al., 2019). However, there is a lack of guidance on how to identify, refer, treat, and serve human trafficking survivors who have neurodevelopmental, mental, and behavioral disorders or disabilities. In general, individuals with such disorders often either require, or benefit from, accommodations that address sensory needs, executive function challenges, and communication differences. For example, helpful accommodations include creating physical environments that are sensory-friendly, providing health information in plain language or photosymbols with large font, including supportive carers during appointments, addressing patient fear and anxiety, and managing negative patient expectations (Bisset et al., 2023; Bradshaw et al., 2019; Doherty et al., 2023; Shady et al., 2024).

While not all individuals who are medically diagnosed with disorders have substantial functional limitations or impairment, and therefore may not legally qualify for disability rights, disability benefit programs, or identify as “disabled,” assessing the health care use and needs of commercially sexually exploited adolescents and young adults with diagnosed disorders nevertheless contributes to the discourse on disability because many disorders do result in disability. Mental disorders, for example, are one of the largest causes of disability worldwide (Arias et al., 2022), and approximately 70% of individuals with mental disorders who apply for disability benefits receive them (Bilder & Mechanic, 2003). To some extent, the nomenclature (“disorder” vs. “disability”) reflects current debates about the physical and social definitions of disability and impairment (Berghs & Graham, 2016)—which is beyond the scope of this paper. Here we focus on youth ages 13-24 years old who experience neurodevelopmental, mental, and behavioral disorders.

From a pragmatic standpoint, developing CSEC-specific health information accessible to people with neurodevelopmental, mental or behavioral disorders (abbreviated as NMBD herein), or trainings for health care providers on how to meet the needs of potential CSEC survivors with disabilities resulting from these disorders, seems worthwhile—but to date there has been little empirical research that would substantiate that this is a pressing need. Research on the health consequences for CSEC survivors is generally plagued by small and geographically limited samples, and generally has not examined the relationship between NMBD  and psychological and physical health. While guidance is emerging on best practices for responding to the health needs of survivors of exploitation (Peck et al., 2021), it is crucial that these practices be better informed by high quality empirical research.

To address this gap, the aims were to answer the following four research questions: 

1. What is the prevalence of self-reported neurodevelopmental, mental, and behavioral disorders in a convenience sample of U.S. CSEC survivors ages 13-24 years old?

2. Is there variation in use of health care by CSEC survivors with neurodevelopmental, mental, and behavioral disorders?

3. How does the self-reported health of CSEC survivors with neurodevelopmental, mental, and behavioral disorders compare to the self-reported health of CSEC survivors in general?

4. Are CSEC survivors with neurodevelopmental, mental, and behavioral disorders more likely to report experiences of health care discrimination than CSEC survivors in general?

Methods

This was a cross-sectional research study using a sample of youth ages 13-24 years old who experienced commercial sexual exploitation as children (CSEC). The study received IRB approval from the last author’s institution.

Participants and setting

Recruitment was conducted through two primary methods: (1) partnering with advocacy organizations that serve youth experiencing commercial sexual exploitation in New York, Texas, Oregon, Florida, Connecticut and Massachusetts, and (2) advertising on social media, including Facebook and Instagram. We recruited a total of N=534 youth who were screened in for experiencing CSEC, with 266 youth recruited from advocacy organizations, and 268 youth recruited from social media.

Eligible participants were individuals who met the following criteria: (a) were referred to the research study either by an advocacy organization because they had exchanged, or were at high risk for exchanging, sex for money or something else of value in the past five years in the U.S., or were recruited through social media advertisements and screened positive for CSEC victimization (b) were between the ages of 13 and 24 years old; and (c) reported that they were able to speak, read, and write in English or Spanish. CSEC was assessed through seven self-report survey items (described below). For the present analysis, we restricted the sample to those who self-disclosed CSEC experiences on the survey through these seven items (n=269), and did not include the n=265 youth who did not endorse any of the CSEC items. The 265 youth who did not endorse any of the CSEC items were invited to complete the survey by advocacy organization staff that served them because of their “at-risk” status.

Recruitment and consent

Participants recruited through CSEC advocacy organizations were informed about the option to participate in the study through flyers, business cards, text messages, and in-person messages distributed by organization staff members. Interested youth were provided with a link to the research survey screening website. Similarly, youth recruited through social media saw recruitment advertisements and clicked on a link to complete the screening. We employed fraud detection protocols that our team had used on prior research studies that involved social media recruitment to reduce the risk that participants were completing the survey multiple times, or faking CSEC survivor status in order to get the research compensation (Bonett et al., 2024; Mitchell et al., 2021). For example, we checked if participants were signing in from multiple IP addresses, ensured that the IP address was from inside the U.S., and utilized built-in Qualtrics fraud protections such as RelevantID, bot protection, and multiple submission protection. The web-based screening questionnaire was available in both English and Spanish.

Eligible participants were directed to a website that provided informed consent/assent-related information. Participants under the age of 18 assented to the survey, and those 18 or older provided consent. Our team received a waiver of parental consent for youth younger than age 18 because of the possible risk to youth whose parents did not know they were commercially sexually exploited. After assent or consent was provided, enrolled participants were redirected to the self-report survey instrument, which was also available in both English and Spanish. Survey data were collected anonymously. Participants received a $30 gift card as compensation for their time spent participating. All participants were provided with national help-line phone numbers, including the National Youth Crisis Hotline (1-800-662-HELP), the Substance Abuse and Mental Health Services Administration, and the Crisis Text Line (https://www.crisistextline.org/). Additionally, participants who reported that they were distressed by the study, had concerns about suicidality, or experiences of maltreatment or neglect were asked if they would like a follow-up call from the research team to assist them in connecting to appropriate services. 

Data collection

Measures

Demographic measures. Participants self-reported information about their age, gender, sexual orientation, ethnicity and race, measures of socioeconomic status, residential location, health insurance, and education.

Self-Reported Commercial Sexual Exploitation of Children (CSEC).  A five-item self-report measure was used to assess CSEC victimization. The measure has been used in prior surveys with CSEC survivors (Rothman et al., 2020). Sample items include “Have you ever exchanged sex or sexual acts for money, food, a place to stay, drugs, gifts, transportation or favors?” and “Have you ever been in videos or photos that are sexually explicit (i.e. pornography) for money, or because someone forced or coerced you to do it?” The endorsement of one or more items was classified as self-reported CSEC victimization. Please see Appendix for a list of all five items.

Disorder diagnosis. Participants were asked: “Have you ever been diagnosed by a doctor, therapist, or another professional with any of the following?” and prompted to respond yes or no for each: (1) Post-traumatic stress disorder (PTSD), (2) attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD), (3) oppositional defiance disorder or conduct disorder (ODD or CD), (4) autism or autism spectrum disorder, (5) intellectual disability, (6) learning disorders including dyslexia, reading, math, or other learning problems, (7) depression, (8) eating disorder, (9) bipolar disorder, (10) Schizophrenia or schizoaffective disorder, (11) anxiety disorder or (12) substance use or alcohol use disorder. The original source of this set of survey items was the National Survey of Children’s Exposure to Violence III (NatSCEV III) (Finkelhor & Turner, 2016). Due to small subsamples reporting individual conditions, dummy variables were created to represent the presence or absence of the following groups of conceptually similar disorders: neurodevelopmental/neurological impairment (i.e., ADD or ADHD, autism or autism spectrum disorder, intellectual disability, and learning disability), serious mental illness (SMI) (i.e., schizophrenia/schizoaffective disorder and bipolar disorder), mood disorder (i.e., PTSD, depression, and anxiety disorder), and behavior disorder (i.e., substance use or alcohol, eating disorder, and oppositional defiant disorder or conduct disorder).

Health care utilization. To assess emergency and primary care service utilization while experiencing CSEC, participants were asked five questions developed by researchers. Participants were asked whether they have ever gone to or participated in the following healthcare services while exchanging sex or sexual acts/during the course of exploitation: an emergency room or urgent care facility, a doctor in a setting other than an emergency room or urgent care setting, were admitted to an inpatient unit for mental health or psychiatric reasons, participated in individual, group, or family therapy, or received a prescription from a psychiatrist or a doctor. Participants could respond yes, no, or not applicable. Participants who responded not appliable were coded as no.

Self-reported health. Self-reported physical and mental health in the past 30 days was assessed using items adapted from the Behavioral Risk Factor Surveillance System (BRFSS) (National Center for Chronic Disease Prevention and Health Promotion, 2019). Participants were asked to report, during the past 30 days, how often: (1) their physical health was not good, (2) their mental health was not good, (3) their poor physical or mental health kept them from doing their usual activities, (4) they felt sad, blue or depressed, (5) they felt worried, tense, or anxious, and (6) they did not get enough rest or sleep. Participants could respond 0 days, 1 day, 2-3 days, 4-7 days, 8-14 days or 15-29 days. Responses were dichotomized as less than one week versus more than one week. Additionally, participants were asked to respond using a Likert-type scale to one item about their self-rated physical health. Responses were dichotomized as poor or fair versus good, very good, or excellent. Last, participants were asked whether they were limited in any way in activities because of any impairment or health problem. Participants could respond yes or no.

Health care discrimination. Experiences of healthcare discrimination were measured with a modified version of the validated Everyday Discrimination Scale (EDS) (Krieger et al., 2005; Sternthal et al., 2011). The EDS has been previously used to study perceived discrimination in medical settings among participants with a range of clinical conditions (e.g., diabetes, HIV/AIDS, breast cancer) (Peek et al., 2011). Participants were asked to report on a five-point Likert-type scale, with response options of “never,” “rarely,” “sometimes,” “most of the time,” and “always,” how often: they are treated with less courtesy or respect than other people, they receive poorer service than other people, a doctor or nurse thinks they are not smart, a doctor or nurse acts as if they are afraid of them, a doctor or nurse acts as if he or she is better than them, and a doctor or nurse is not listening to what they are saying. A summary score for all seven items was calculated, and higher scores indicated more healthcare discrimination.

Data analysis

Our first step was to describe the participants by their socio-demographic characteristics (see Table 1). Next, we calculated the percentage of participants that used healthcare settings while being exploited, by disorder diagnosis status (see Table 2). We used chi-square tests to determine if there were statistically significant differences in healthcare utilization for participants with one of the disorder groups (i.e., neurodevelopmental or neurological impairment, SMI, mood disorder or behavior disorder) as compared to all participants, using a cutpoint of p<.05 for statistical significance. Because 82% of the sample had at least one disorder diagnosis, the subgroup of those with no disorder diagnosis was too small for meaningful comparisons. In cases where cell sizes were less than five, we used Fisher’s exact text. We used this same procedure to compare self-report health for those with the diagnoses of interest compared to all participants (see Table 3). Finally, we used t-tests to compare experiences of self-reported healthcare discrimination among participants with the diagnoses of interest compared to all participants (see Table 4).

Table 1. Demographics (N = 269).

Table 2. Health Care Use During CSEC Experience, by Disorder Status (N = 269).

*p < .05. **p < .01. ***p < .001, comparing the column of interest to the all participants column.

Table 3. Self-Rated Health in the Past 30 Days, by Disorder Status (N = 269).

*p < .05, comparing the column of interest to the all participants column.

Table 4. Experiences of Discrimination While Receiving Health Care Treatment, by Disorder Status (N = 269).

^†Healthcare discrimination was assessed using a five-point Likert-type scale, and higher scores indicate more discrimination.

*p < .05 **p < .01, comparing the column of interest to the all participants column.

Results

Of the N=269 youth in our sample who self-disclosed CSEC, approximately 71% identified as women/girls (Table 1). The mean age for the sample was 19.2 years (Range 13-24 years; SD = 2.9). A majority of participants (51%) identified as White, and more than one-third identified as Black (34%). Two-thirds of participants (69%) reported being enrolled in school, and 43% reported living with their parents, a family member, or a partner within the last six months of participating in the survey. Less than half of the participants had public health insurance (39%), nearly one-fifth reported that they had private insurance (19%), a small subset were not covered by insurance (11%), and the rest were unsure or did not have insurance  (Table 1). 

With regard to our first research question, about the prevalence of disorders in our sample, most participants in the sample (82%) had been diagnosed with a NMBD , and 73% reported having more than one diagnosis (Table 1). The prevalence of mood disorders in the sample was 76%, which included depression (73%), anxiety (63%), or PTSD (55%) (Table 1). Nearly half of participants (45%) had been diagnosed with a neurodevelopmental disorder or neurological impairment such as ADD or ADHD (36%), a learning disorder (20%), or autism (10%). One-quarter (25%) had been diagnosed with a serious mental illness (SMI)  such as schizophrenia (6%) or bipolar disorder (25%), and 41% had been diagnosed with a behavior disorder such as substance use (24%), eating disorder (24%), or oppositional defiant disorder or another conduct disorder (12%). There was considerable overlap between participants reporting a neurodevelopmental disorder and a mood disorder (41%, see Figure 1).  In this sample, 13% of participants reported having a diagnosis of all four disorders: mood disorder, SMI, behavior disorder, and neurodevelopmental disorder or neurological impairment (Figure 1). 

To contextualize the prevalence rates in our sample, we compared them to the prevalence of disorder diagnoses in the general population of U.S. youth. For example, the prevalence of ADHD is 11.3% in children 5-17 years old as compared to 36% in our sample (National Center for Health Statistics, 2024; Statistics, 2024), the prevalence of autism is 2.7% (U.S. Centers for Disease Control and Prevention, 2024) as compared to 10% in our sample, the prevalence of intellectual disability is 1.9% compared to 6.4% in our sample (U.S. Centers for Disease Control and Prevention, 2024), the prevalence of learning disabilities is 8% as compared to 19.9% in our sample (Li et al., 2023), and the prevalence of schizophrenia/schizoaffective disorder is approximately 1% in the general U.S. population and it was 6% in our sample (Perälä et al., 2007). The prevalence of depression in our sample was approximately three times that of adolescent girls ages 12-17 in the U.S. in general (72% vs. 23%) (Daly, 2022), and the prevalence of PTSD was 55.4%, compared to 7.3% of adolescent females in a national U.S. sample (McLaughlin et al., 2013).

With regard to our second research question, about variation in health care use by CSEC survivors by diagnosed disorder status, approximately one-quarter (26%) of participants reported going to the emergency room or a doctor while being sexually exploited (Table 2). The percentage of youth who had visited an emergency room or doctor while being exploited was elevated for youth with an SMI diagnosis as compared to participants in general (38% vs. 26%, p < 0.05) (Table 2). Participants who reported having an SMI were also more likely to report having been admitted to an inpatient unit for mental health/psychiatric reasons while experiencing exploitation as compared to the general sample (49% vs. 24%, p<0.001, Table 2). Those with an SMI were also more likely to report they participated in therapy while being exploited (48% vs. 32%, p<.01, Table 2). Participants who reported having a behavior disorder diagnosis were also more likely to report healthcare use while being exploited, as compared to participants in general. Nearly one-third of participants who had a reported behavior disorder (31%) went to an emergency room while experiencing exploitation compared to 23% of the general sample (p<.05), and 39% were admitted to an inpatient unit for mental health/psychiatric reasons compared to 24% of the general sample (p<.001) (Table 2).

Our third research question pertained to possible differences in self-reported health by diagnosed disorder status. We observed no differences in physical health by disorder status, but participants who reported having a neurodevelopmental disorder/neurological impairment were more likely to have experienced poor mental health symptoms for more than seven days in the past month compared to the general sample (65% vs. 54%, p < 0.05, Table 3). Similarly, a greater percentage of participants who reported an SMI experienced poor mental health symptoms for over a week in the past month compared to the general sample (68% vs. 54%, p<.05, Table 3). Participants who reported an SMI or a behavior disorder were more likely to report that their poor physical or mental health kept them from doing their usual activities for more than seven days in the past month compared to the general sample (52% vs. 39%), Table 3, although the differences were not statistically significant at the p<.05 level.

To answer the fourth research question, participants were asked to report their experiences of healthcare discrimination (Table 4). Compared to all participants, participants with a behavior disorder were more likely to indicate that their doctor or nurse acted as if they were afraid of them (2.2 vs. 1.9, p<.05, Table 4), and that their doctor or nurse did not listen to them (3.3 vs. 3.0, p < 0.05, Table 4). Similarly, participants with an SMI were more likely than participants overall to report that their doctor or nurse acted as if they were afraid of them (2.3 vs. 1.9, p < 0.01, Table 4).

Discussion

This study of a convenience sample of U.S. youth ages 13 to 24 years old who had experienced commercial sexual exploitation (CSEC) prior to age 18 found that the overwhelming majority had been diagnosed with a neurodevelopmental disorder or neurological impairment, an SMI, mood disorder, or behavior disorder, and that 73% had more than one of these diagnoses. Youth in this sample were more likely than youth in the general population to have been diagnosed with these disorders. This was unsurprising, given prior research with adult survivors of sex trafficking that also found that the rates of depression, anxiety, bipolar disorder and PTSD were elevated (Lederer & Wetzel, 2014). However, the finding highlights the need for any advocate or entity that engaged with CSEC survivors—such as peer mentors, health care providers, child protection service workers, congregate care staff, or others—to become educated in the cognitive, executive function, sensory and other needs of disabled youth so that they can provide better CSEC survivor services by centering and attending to those needs when relevant.

This study also uncovered that youth with an SMI diagnosis, or a behavioral disorder diagnosis, were more likely than other youth experiencing commercial sexual exploitation to seek medical care during the time when they were being exploited. More than one-third (38%) of CSEC-experienced youth in this sample with an SMI diagnosis sought some type of medical care while being exploited, and more than half (52%) were prescribed psychiatric medication by a psychiatrist or doctor during their exploitation, and as many as 48% of youth with a behavior disorder participated in some time of individual, group or family therapy while being exploited. Although prior studies have found as much as 88% of adult victims of human trafficking interface with a healthcare provider at least once during their trafficking experience (Wilks et al., 2021), there are too many instances when health care professionals fail to identify trafficking victims (Gordon et al., 2018), and as a result, there have been calls for both expansion and standardization of human trafficking training content for healthcare professionals (Powell et al., 2017). Our results add to the mounting evidence that suggests that it is important to invest in the preparation of healthcare providers and healthcare settings to identify, support, and refer youth experiencing CSEC. However, there are now at least 15 different commercial sexual exploitation detection instruments in use in the U.S. Few of these have been established as reliable and valid assessments, and none have specifically been designed with the unique needs and experiences of youth with neurological, mental and behavioral disorders. Therefore the emphasis of future research should be on obtaining more rigorous psychometric evidence supporting the validity of assessments for different populations rather than developing new instruments (Benavente et al., 2023), and ensuring that efforts to refine existing assessments are informed by research on the access needs of individuals with neurological, mental or behavior disorders.

This study also found that a substantial subset of the CSEC survivors reported poor physical and mental health in the past month, that they were frequently kept from usual activities due to poor health, often worried, tense or anxious, and lacking sleep—and that this was more likely to be true for those with an SMI diagnosis than for other CSEC survivors. In addition, those with an SMI or behavior disorder diagnosis were more likely to report negative healthcare experiences—such as feeling like the healthcare provider was afraid of them or not listening to them. These findings highlight the importance of focusing healthcare provider human trafficking training on those most likely to encounter patients with neurological, mental or behavior disorders, including psychiatrists, psychiatric nurses, psychologists, social workers, and counselors. It also suggests that all healthcare providers may benefit from training in trauma-informed care, disability competency, and cultural competency for multiple reasons, but specifically in order to reduce negative healthcare experiences among CSEC survivors (LoboPrabhu et al., 2000).

Recommendations

The results of this study suggest that there is a pressing need to develop specific best practices guidelines for healthcare entities so that they will identify, serve, refer and support CSEC survivors with NMBDs effectively—with a particular emphasis on prioritizing the subset of CSEC survivors with SMI or behavioral disorders. In addition, the human trafficking service provider sector needs competency training related to serving those with NMBDs. Because such a large majority of CSEC survivors may be living with NMBDs , all printed materials, communications, and settings in which CSEC survivors interface with healthcare professionals should be designed for accommodation of differences that may include sensory processing differences, executive function support needs, communication-related differences (i.e., preferring to book appointments online instead of on the phone, avoiding eye contact, using assistive technology for speech), the need for trauma-informed interpersonal interactions, and ensuring that screening for CSEC victimization takes into account that human trafficking assessment questions may need to be modified to “plain language.” The development of CSEC screening materials that use photosymbols, or written or video explanatory “social stories” (Chen et al., 2015) for use in healthcare settings, would be beneficial. Novel and cost-effective ways of training human trafficking service providers to develop accommodation plans for CSEC survivors who are disabled, such as preparing pre-recorded but interactive e-learning modules, is recommended. Training for both healthcare and human trafficking service professionals about the high rates of neurological, mental and behavioral disorders among CSEC survivors is also warranted.

Additionally, health care providers who encounter individuals who have both experienced exploitation and have a neurological, mental or behavioral disorder may need to modify their practice making accommodations to address sensory needs, executive function challenges, and communication differences. This could include sensory-friendly care and exam practices, including supportive carers during appointments, and devoting additional time to address patient fear and anxiety, and to manage negative patient expectations. In short, the prevalence of neurological, mental and behavioral disorders among CSEC survivors will requires changes in training and procedure informed by both our understanding of disability accommodations and trauma informed care.

Strengths and Limitations

This study was limited by several factors. First, we did not investigate all types of disorders, nor did we investigate if those with diagnosed disorders had difficulty to do certain activities or if they experienced participation restriction. We collected self-report information about selected NMBDs, only. If we had collected data on physical disabilities, hearing or vision impairment, dissociative disorders, and other types of disabilities, or the extent to which disorders influenced activities and participation, we would have been able to provide even richer information about disability, CSEC, and healthcare experiences. Brief, self-report measures of disability, impairment, functional limitation, and diagnosed disorders would advance disability research in human trafficking. Second, youth may not have known if they had ever been diagnosed with some of the disorders we asked about, and as such, our estimates of the prevalence of these disorders in our sample could be an underestimate. However, confidence in our findings is strengthened by the fact that 82% of our sample reported one or more of the disorders we investigated, so even if diagnoses were underreported (or under-detected by our methods), it would likely not have influenced our results substantially. Third, we did not assess specific physical health concerns such as high blood pressure or presence of chronic disease. Fourth, this analysis only included youth who self-disclosed one or more instances of CSEC on our self-report survey. In other words, youth whom advocacy organization staff may have suspected were commercially sexually exploited and invited to take part in the study, but who did not self-disclose CSEC on our research survey, were excluded. As with child victims of sexual violence, there are numerous barriers to young people disclosing commercial sexual exploitation on a survey, including adolescent developmental processes, mistrust, fear and, rejection of victimization labels (Lavoie et al., 2019). Additional research highlighting the health care-related needs of high-risk youth in addition to those of youth who self-disclose exploitation is also needed, as are new and improved methods of determining CSEC victimization through survey research.  Fifth, our sample was too small to carry out meaningful subgroup analyses that compared subsets of participants stratified by gender, or by race/ethnicity. Sixth, we grouped conceptually similar disorders together to create larger subsamples. Although we selected to group PTSD with depression and anxiety, a reasonable alternate approach would be to treat PTSD as a separate trauma disorder. Similarly, grouping eating disorder, substance use disorder and conduct disorder together seemed logical to us because of how youth with these disorders might present similarly in a clinical healthcare context. However, ideally future research will include large enough samples that each disorder can be considered separately.

Future Research

Future research can build on the work presented here in a few ways. If cost effective methods for surveying population-based cohorts of CSEC-experienced youth are developed, the generalizability of results can be improved by using representative samples. In addition, our study used an original self-report measure related to health care use while experiencing CSEC. Psychometric testing of this measure would be useful to the field. We also recommend that this type of study, which investigates the health needs and experiences of child sex trafficking victims who experience neurodevelopmental and other disorders, be replicated with individuals who experience labor trafficking or adult sex trafficking victim population, as well. Larger studies that include sufficient diversity by gender and race/ethnicity would permit subgroup analyses to investigate whether experiences of healthcare discrimination among CSEC survivors with disorders vary by these variables. Finally, we assessed self-report of specific NMBDs. A more comprehensive, valid self-report measure of disability that also captures hearing loss, vision impairment, physical disability, dissociative disorders, and other conditions, and severity of activity limitation and participation restriction, would benefit the field. In addition, more research in medical settings, examining how medical professionals are trained on human trafficking and CSEC issues--particularly when first building understanding and rapport with the patient—would benefit the field.

Conclusion

The vast majority of CSEC survivors in this sample reported having been diagnosed with a NMBD. The majority also reported two or more of these diagnoses. This research provides support for the contention that people with disorders are vulnerable to human trafficking victimization, and that CSEC survivors with disorders and disabilities may be at particular risk for experiencing poor health and forms of healthcare-related discrimination in medical settings. CSEC survivors with SMI and behavioral disorders may be at particularly acute risk for poor mental and physical health and having negative experiences with healthcare providers. We recommend training for healthcare and human trafficking service providers about these disorders and related disabilities, and making the process of identification, service, and referral accommodating for CSEC youth with neurodevelopmental, mental or behavioral disorders.

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