Adapting a family intervention to reduce risk factors for sexual exploitation

The key to preventing commercial sexual exploitation (CSE) in at risk youth may lie in bolstering family relationships and/or strengthening other supportive relationships. The Trafficking Victims Protection Act defines sex trafficking as sexual activity induced by force, fraud, or coercion or when a minor is induced to perform any sexual act regardless of the presence of force, fraud or coercion [1]. The Institute of Medicine/National Research Council (IOM/NRC) expanded on this definition by identifying commercial sexual exploitation and sex trafficking as a “range of crimes of a sexual nature committed against children and adolescents” that includes exploitation via prostitution, survival sex, pornography, sex tourism, early marriage, or performance in sexual venues (e.g. strip clubs).” [2]. Despite the existence of multiple definitions of CSE and sex trafficking in the literature, youth, particularly youth with socially complex needs are at risk. Youth with socially complex needs are youth who experience overlapping adversities such as the presence of Adverse Childhood Experiences (ACES), homelessness, and/or involvement in the child welfare or juvenile justice system.

In order to better understand CSE in the context of the lives of at risk youth, we used Bronfenbrenner’s Ecological model to map out the complex circumstances that may lead to CSE. Bronfenbrenner’s Ecological Model describes the social and cultural subsystems of the human–environment and the ways they interact and influence one another [6]. The ecological model presented by the IOM/NRC [2] poses four levels of risk factors (individual, relationship, community, and societal) that parallel Bronfenbrenner’s subsystems: microsystem, mesosystem, exosystem, and macrosystem. These four levels describe the circumstances and external conditions that may interact to make youth more susceptible to commercial sexual exploitation and trafficking.

Intersectionality is a theoretical framework that situates multiple microlevel experiences within macrolevel systems of privilege and oppression [18]. A limitation of most research and policy is the lack of acknowledgement that intersectionality exists in the lives of participants as well as our own lives [18]. Intersectionality acknowledges the complexity of inequity by considering the junctures of multiple social locations (e.g. race, gender, sexuality), power relations, and experiences [19]. Some intersecting vulnerabilities of youth in the current study include being a youth of color and/or LGBTQ+ and experiences such as homelessness, gender based violence, or having a history of trauma. The original STRIVE intervention will be adapted, through focus group methodology, for use in an urban Midwestern setting to reduce risk factors that predispose youth to sexual exploitation. We intentionally consider the unique needs of homeless/runaway, African American, and LGBTQ+ youth given the cumulative risk identified above for sexual exploitation. Taking an intersectional approach [20, 21] is a logical next step as we propose to take a proven intervention with homeless youth and refine the content and approach to take into account the layered risks associated with their age, race/ethnicity, sexual exploitation history, sexual/gender identity, and family functioning.

The first author leveraged existing relationships in the community to recruit experts to participate in an expert focus group. Youth were recruited from the same community organizations as the content experts. The two initial focus groups were conducted with experts versed in youth homelessness, working with minority youth, and/or sexual exploitation in order to examine the STRIVE intervention for potential adaptations (n = 4; n = 7; Table 1). The experts included social service providers, social workers, counselors, and advanced practice nurses. Experts came from a variety of organizations including those that work with homeless and sexually exploited youth from settings such as drop-in centers, shelters, and school-based and community centers. The majority of the experts were female (n = 9) and from an ethnic/racial minority background (n = 6). Expert focus groups were conducted via video conference (WebEx). All experts were recruited through email and informed consent was signed electronically via REDCap. Experts were incentivized with ten dollar electronic gift cards. Next, youth focus group participants were recruited from youth-serving organizations (homeless shelters, school-based health centers, and community centers). Our content expert partners organized the focus group meetings and invited youth to participate in the study. Once the research team arrived, informed consent was completed prior to youth participation. Due to the sensitive nature of the discussion, demographic data were not collected from the youth. In order to protect student confidentiality, the only documents with youth names were the signed informed consent documents. Youth were also encouraged to refrain from using names in the focus group meetings. Four focus groups were held with youth (n = 29) whose ages ranged from 15 to 23 years old. One youth was White and the remaining 28 youth were African American. In order to maintain a safe environment, youth were not explicitly queried about sexual orientation and gender identity. Youth focus groups were held at four sites in the community. One group was held at a high school serving underserved youth during lunch time. A youth-serving community agency held a group for at-risk boys during their afterschool program. Groups were also held at one short-term and one long-term homeless shelter. Youth were incentivized with five dollar gift cards and provided with pizza and pop during the meeting. During the youth focus groups the STRIVE intervention was discussed for potential refinement.

This study was approved by the institution’s IRB. Each focus group followed the same procedure: introductions, informed consent process, and description of the STRIVE intervention, open-ended questions about considerations working with minority (ethnic/racial and/or sexual/gender) and/or marginalized youth (African Americans, homeless youth, sexually exploited youth, and/or LGBTQ+ youth). After allowing time to have an open discussion on population specific dynamics, we then proceeded to the interview guide which was primarily focused on the STRIVE intervention. The interview guide included the following questions: (1) what is missing from the described intervention, (2) what is the best way to recruit youth and parents/guardian/primary caregivers into the study, (3) how do we best talk to youth and their parents/guardian/primary caregivers about sensitive issues like sex risk-taking behavior, sexual exploitation, sexual/gender identity, (4) what adaptations need to be made to the language/terminology used in the intervention, and (5) what language/terminology should be used in the recruitment material?

The first author moderated the focus group discussion. Additional team members were present to take notes during the discussion, and attend to technical aspects of the research such as collecting signatures on consent forms and passing out incentives at the conclusion of the focus group. Every session was followed by a debriefing amongst the research team. The WebEx focus groups with content experts were video recorded; the groups lasted for 92 and 99 min respectively. Abridged transcripts were created from the videos and then uploaded into Dedoose Cross Platform Application [22] for analysis. Each youth focus group was digitally recorded. Youth groups lasted from 30 to 67 min. Digital recordings from the youth focus groups were transcribed verbatim, and uploaded into Dedoose for content analysis.

Content analysis was used to analyze the data from each focus group session by using systematic coding to identify trends, patterns, and discourses of communication [23, 24]. All focus group transcripts (content experts and youth) were independently coded by three different coders. Open coding was used, and each coder developed their coding frame as described in content analysis [24]. After independently coding all of the transcripts, the three coders met jointly over a series of 4 weeks to discuss similarities and differences in codes and to confirm emergent themes. Krefting asserts that trustworthiness in qualitative research is established by credibility, transferability, dependability, and confirmability [25]. Credibility was established by examining all transcripts and written notes, using the participants’ own words in quotes, and utilizing memoing during the coding process. Transferability was established by comparing narrative content across the various risk-related groups. Dependability and confirmability was ensured by adhering to consistent detailed analytical methods, building a unified coding frame, and using three independent coders.

Setting the stage refers to the initial phase of the relationship where building rapport and acknowledging experiences of structural violence are essential. Setting the stage is not a static concept, but rather an ongoing educational process that continues throughout the relationship in an effort to reduce stigma, express empathy, and manage misconceptions. The concept of building upon educational content as a means of establishing rapport, addressing misconceptions surrounding behavioral health, and validating experiences fits well within the existing structure of STRIVE as a psychoeducational intervention.

Being relatable was emphasized by both experts and youth across settings. One youth articulated:

You gotta relate to what people are goin’ through. You gotta be able to, I guess, like if you’re not from the hood you gotta be able to put on the shoes of somebody that is. You gotta try to see it from somebody else point of view regardless of what you’re comin’ from.

Similarly, Nina from the expert panel highlighted that trusted adults may be reticent to participate in the intervention because of concerns about maintaining privacy, “Black people don’t want people coming in and getting into their business.”

An additional group of experts expressed their perceptions about the potential challenges associated with engaging African American youth in the STRIVE intervention:

Veronica: I think you need therapists that are African American. I mean I think that would go over better with families. Again it decreases the stigma that they are working with someone who is African American and is in a healing profession. It would decrease some of the worries of being involved in a research study and distrust of researchers in general.

In particular several content experts expressed that families may be concerned about the potential for becoming involved in child protective services. Veronica went on to say, “Some families are going to be scared that DCFS is going to get involved.” Both youth and content experts stressed the importance of considering the historical contexts of research in the African American community which is magnified when the focus is on the topic of mental health and wellbeing. Recommendations for working with sensitive topics such as mental and sexual health require a cultural lens that reflects an understanding of the population being served.

A second emergent consideration during the setting the stage phase was the high prevalence of misconceptions and alternative perspectives surrounding sexual exploitation. This is aligned with existing data that suggests that many victims of sexual exploitation do not identify as victims, nor do they label their relationships as exploitative [8]. Content experts in the current study emphasized these misconceptions. Veronica noted the following: “you don’t want to marginalize them or turn them off to the study by initially declaring them exploited cause that’s not how they see themselves necessarily. Some will– some won’t.” Amy, a content expert colleague concurred by voicing the following perspective, “Some people will never identify as experiencing exploitation. And so changing that language would be helpful to get people engaged.”

Finally with regard to the importance of addressing misperceptions around the concept of sexual exploitation, another content expert, Jasmine voiced the following perspective:

I would like to add a piece of psychoeducation in there. In regards to sexual exploitation—what does exploitation look like? Because sometimes I find that they use different language for what it is so that it becomes acceptable for them to actually live in that kind of environment and not feel like, you know, they’re being judged or as if they’ve made a bad choice…not assuming that they recognize that this relationship is defined as something that is exploiting them sexually.

In accord with this line of thinking from the experts, youth often did not perceive trading sex or engaging in unwanted sexual behavior as unsafe or exploitative, even though they may have been homeless and trading sex for survival. Content expert, Michael stressed the need to discuss how to get basic needs met in a healthy way with youth because:

Whatever they might be doing to get their needs met in some way might be unhealthy. Right…Just being able to have a discussion about getting those basic needs in a healthy way… Half the time they’re not aware that getting those needs don’t have costs to it.

The following perspective from a youth focus group participant emphasized the need for education on the concepts of sexual exploitation and healthy relationships:

I never once had anybody take advantage of me. I’m not gonna let you do something I don’t want you to do. I’m not gonna let you. As far as in a sexual matter. I ain’t gonna lie. People just don’t care [crosstalk] People just gonna do what they wanna do. It’s like you can bring a horse to water, can’t make ‘em drink you know what I mean. You can’t take a person out of a situation. My momma still on drugs. I can’t send her to rehab if she don’t wanna do it.

Another concern voiced by experts was the lack of support these youth currently have for a variety of reasons that can be seen in the following dialogue:

Veronica: There is a whole population of kids that don’t have anybody right…they don’t know many adults you know and I feel they don’t trust adults for good reason.

Nina: You’re going to really have to incentivize the hell out of this thing because it’s going to take an act of God to get these trusted adults to invest in this process… unfortunately the majority of young people that I work with just don’t seem to have adults in their lives who are invested in them like this.

Advocating for youth during potentially malfunctioning family dynamics is a child-centered approach that has the potential to build youth self-worth and model alternative pathways to resolve familial disagreement. It can reinforce the adult role as protector while simultaneously validating their perspective and feelings. This approach has the potential to build empathy amongst family members as well as model alternative strategies to resolve conflict that defuses the anger and resentment that can contribute to youth tendencies to run away… This group of content experts highlighted the challenges inherent with working with marginalized youth and their families:

Sam: It seems like the original assumption is that the family or the adults in the family, the parents, want to reunite with the child. And what I’ve seen is while that’s certainly valid I have seen families where either the mother was so distracted by other things happening in her life or her current partner/boyfriend that she just never had any real time to deal with the child. So the child leaving the household was almost welcomed by the mother. Because she no longer had to deal with that responsibility; she was really pursuing her own life rather than acting more as a parent.

Jasmine: I would also like to add that sometimes the caregiver/parent has some real fears around the child being a presence in the home because there may be a connection to recurring violence or there may be some untreated symptoms… There is this fear factor with reuniting with the runaway child because they’re not sure that they’re not the cause of some of the trauma that’s coming in the home or the violence in the community that they’re surrounded by.

The following experts highlight the need to balance family needs. They felt the need to advocate for youth and simultaneously validate the parents’ concerns within the context of a family intervention that focuses on negotiation and problem solving. Balancing family needs by advocating for youth and validating the parents’ concerns within the context of a family intervention that focuses on negotiation and problem solving was highlighted in the following dialogue amongst experts:

Sam: Well I think one of things for a lot of youth that I see is they just need a consistent advocate in their lives. And what I mean by that is for a lot of kids that are living on the margins…things like advocacy things that we take for granted, they can’t… I’ve seen countless kids who they left their family of origin, their immediate nuclear family, but now that they’re homeless; they have no relatives that they can even go crash on the couch with. The family itself is sort of splintered and so things like going to sleep on your cousins couch for a couple of nights while things cool off in that house, that’s not really an option for them because their cousins or their aunts, their grandmothers, just don’t feel enough of a kinship to them to allow those sorts of things.

Jasmine: I would also like to suggest, or what has worked for us is to support the reality of the fears that the caregivers or that supportive participant has. The caregiver or whoever that youth has chosen as the person who’s willing to walk alongside them for the sessions. You know up front identifying and kind of affirming those are real fears but then also saying how can we make this environment better or how can we support the goal which is to kind of offer skills or coping mechanisms for this youth to be able to re-engage back in the family.

Later Sam emphasized the need for:

Family reconciliation services. If the youth may have done something that may have offended someone in the family or if the family did something that may have offended the youth. Sometimes there needs to be somebody that can get both parties back into the same room to sort of reconcile…sometimes it just needs to be, I don’t want to say refereed but sort of a moderator so that two people can reconcile and get the youth back into the household because at some level it’s just egos, competing egos that are preventing the family from reengaging.

The youth also reinforced how family conflict was central to their homelessness by expressing:

I don’t know, ‘cause a lot of people who run away, they just can’t go back home after they run away, ‘cause they feel like they might get in trouble.

The need to get to know youth and their personal experiences was coupled with the need to ensure safety. This theme was endorsed by both youth and content experts.

I think that a lot of people (need to) tell their stories first…You all know we homeless so that’s why we’re here, but you don’t know our stories…like let me tell you a story first. Then, after they tell their story, then you can say, all right, so this is how STRIVE can benefit you.

Experts echoed a similar concern since the STRIVE intervention is intended for youth who may leave home without permission or be asked to leave due to conflict. Lisa emphasized the following:

I would also say that some conversations around like harm reduction (are needed). If young people are already removed from their homes or have already runaway. What I think is important to do is some information gathering around what are the other safe places they identified or flee to. You know what we observe is (that) often the environment (they flee to) may be safer in one context…whatever was the factor that was so bad that the young person left, they’re not experiencing that in the new place that they’re at but there might be a whole other crop of risk factors that they’re exposed to in that new environment.

A content-related theme that emerged from both the experts and youth while walking the safety tightrope was related to the need for resources related to the youth’s survival (i.e. transportation, securing employment, or housing). Experts stressed the need to be prepared to navigate the multiplicity and complexity of needs inherent in working with vulnerable youth. Stephanie stressed the following:

Because of how intense this target population that you are looking to work with (is), are you considering other organizations that are working with this target population that can be that added support? Because, you know, I worry if you’re just a standalone in this, what is the likelihood of the commitment and the involvement students would have in participating in this study?.

Youth reinforced how we must be ready to assist in meeting their survival needs, as highlighted in the dialogue below:

Interviewer: Let’s talk a little bit about young people who had to trade sex to survive. You end up sleepin’ with somebody ‘cause you needed a place to stay, you needed somethin’ to eat, you needed a ride, whatever the case might be. Like I said, this could be somebody that you know that has experienced this. Could STRIVE help that person?

Youth 1: Could it? If I was trading sex for a ride, would you be able to give me a free ride? If the answer is yes, then sure. If the answer is no, then I doubt it.

In addition to being prepared to meet their needs, expert panelist, Lisa poignantly reminded us of the need for a non-judgmental approach by stating,

If we are not going to give them money then we need to be really careful about how we criticize the way they are getting money because it doesn’t mean they’re gonna stop getting money that way, it just means that they’re going to stop talking to us about it.

She also encouraged that we consider how service environments can also create tension for youth when she stated that:

With armed security or police there’s an adversarial relationship between many members of the African American community and the police. So what ways might we set up young people to already be tense or uncomfortable or feel criminalized as they’re coming into services for the intervention…Having an affirming or empowering environment as opposed to one where young people are initially criminalized and their behavior is being surveilled… (or) reacted to with force. I think removing that dynamic may also allow young people to feel more comfortable and express themselves.

In order to prevent sexual exploitation and disrupt the trajectory of runaway and homeless youth, intervention adaptation of existing efficacious interventions is warranted. As one of the youth focus group participants put it, “When you see something for so long, you gonna start doing that ‘cause you’re not gonna know another way.” Although it is difficult to meet all of the needs of vulnerable youth within the context of a research study, future efforts should explore the impact of embedding family reunification research into existing interventions within the community to ensure the availability of safety nets for youth. Additionally, relationships matter, and future research must also consider how these relationships—whether they include a family member, trusted adult, or provider—impact the trajectory of vulnerable homeless youth. Chisolm-Straker et al. along with other literature on at risk youth reinforces the need to focus on families [44]. In fact, one study found that the main difference between homeless youth who were trafficked and those who were not trafficked was the presence of a supportive adult. STRIVE’s primary focus is on improving family functioning via the development of communication and problem solving skills. Re-engaging youth with their family and/or a trusted adult is essential to their development [45]and also potentially protective against sex trafficking [44].

There are a few limitations that should be considered while interpreting our findings. First, we used co-ed groups for the majority of the focus groups. It is possible that some youth did not feel comfortable in this setting and therefore may not have freely expressed themselves; their responses may have been influenced by social desirability. We also did not hold focus groups that were explicitly comprised of lesbian, gay, bisexual or transgender specific groups. Given the stigma still associated with being a sexual and/or gender minority, this limitation may have influenced a comprehensive exploration of the needs of these specific youth. This might mean that we have not captured all of their needs, particularly with regard to family conflict and survival needs. Since 40% of homeless youth belong to the LGBTQ+ community [46], we will have to consider their needs on an individual level at intake into our program.

One of the youth focus groups was an all-male group, and in general, there were more boys than girls who participated in our youth focus groups. Given the fact that girls have historically been more impacted by CSE, this inequity may have impacted our findings. Lastly, we chose to focus on youth at risk for sexual exploitation rather than those who have previously been exploited. Because we did not ask, we do not know which members of the youth focus groups have a history of exploitation. It is very possible that the needs of youth at risk for CSE and those who have experienced CSE differ given the psychological trauma inherent in specific types of sexual exploitation, such as forced sex trafficking. Furthermore, the documented confusion in nomenclature in the field of sexual exploitation suggests that we cannot assume that there was universal understanding and/or agreement of the concept of CSE amongst the focus group participants. Despite these limitations and the tension between lack of youth voice and acknowledged agency of youth who trade sex, the findings from the focus groups remain relevant across several contexts.