Victimization, Symptomology and Emotion Dysregulation in A Sample of Commercially Sexually Exploited Minors who Abuse Substances

The Victims of Crime Act (VOCA) was enacted with the recognition that victims often require significant support to obtain evidence, prosecute and recover from their experiences [1]. The literature has demonstrated that a history of significant victimization and/or exposure to Adverse Childhood Experiences (ACEs) is associated with engaging in maladaptive and deleterious behaviors (e.g., substance misuse/abuse), the development of significant health issues, and early death [2]. As part of this legislation, the Crime Victim Fund was established to assist with funding. According to recent reports, VOCA provided over 67 million dollars toward mental health services for victims, with the average victim receiving more than 3 separate services related to mental health needs [3]. VOCA was later modified to explicitly include assistance for minors who have experienced Commercial Sexual Exploitation (CSE), or “the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age” [4]. Since the establishment of these definitions, terms such as sex trafficking, Commercial Sexual Exploitation Of Children (CSE or CSEC), and Domestic Minor Sex Trafficking (DMST) have been used largely interchangeably, though there may be some differences. Some additional categories receiving VOCA funding include but are not limited to kidnapping, physical abuse, child sexual abuse and sexual assault, homelessness and exposure to domestic violence, all of which can be associated with CSE. 

Those who have experienced CSE evidence high rates of problematic alcohol and substance use and endorse traumatic, depressive, and anxious symptomology [5-7]. Substance use is a prevalent issue in those who have experienced CSE. For some, early substance use contributed to entrance into the life, while others were introduced to substances in an attempt to keep them in the life. Of course continued and escalating use may also represent maladaptive attempts to regulate the trauma and other dysregulation stemming from histories of victimization [8-10]. 

The current study sought to examine relationships between various categories of victimization tracked by VOCA with self-reported emotional dysregulation, anxiety and depression in a sample of youth who experienced commercial sexual exploitation or trafficking. For the purpose of this study, VOCA categories of physical abuse, child sexual abuse, exposure to domestic violence, homelessness and violation of a court order were explored. While initially comparisons were to be made between those who abused substances and those who did not, over 90% of the original sample evidenced problematic substance use. Thus, the current study focuses solely on this subset. It was expected that the current sample of youth who experienced CSE and engage in substance abuse will have high rates of suicidal behaviors and self-harm, psychiatric hospitalization and self-report significant symptomology and emotional dysregulation.

• Sample 

The current sample was comprised of 85 youth, ages 13-21, referred between late 2017 and 2023 to a nonprofit organization in an urban county in the southwestern US. The organization seeks to break the cycle of revictimization and system involvement for youth, helping them reclaim their narratives and persisting forward through comprehensive support (e.g., on-site school, trauma therapy center, art therapy, and paid internships). Inclusionary criteria included a history of commercial sexual exploitation or sexual abuse, and a majority of referrals came from the juvenile justice system. During intake, youth complete various assessments and participate in a clinical interview. Among general demographic and other information, self-reported histories (often corroborated through the record) of psychiatric hospitalization, suicidal behaviors or self-harm, and substance use are collected. Youth are also administered the ACE-Q Teen Self-Report [11], the Beck Depression Inventory [12], the Beck Anxiety Inventory [13], and the Difficulties in Emotion Regulation Scale [14] upon intake. 

• ACE-Q teen self-report (Adverse Childhood Experiences Questionnaire) 

The Center for Youth Wellness ACE-Q Teen Self-Report [11] is an expanded version of the original ACE Questionnaire. This measure expands upon the previous ACE list, adding nine other areas of concern (e.g., placement in foster care, the impact of parent incarceration, community violence, etc.). 

• Beck Depression Inventory-II (BDI-II) 

The Beck Depression Inventory-II is a self-report measure comprised of 21 items that measure the severity of depression in individuals aged 13-80 [12]. It is the most commonly used diagnostic tool in clinical and research settings for assessing depression, speaking to its reliability and validity. While the total score provides a general indication of the severity of the experience of depressive symptoms, clinical cutoffs have been supplied with category descriptors for a qualitative understanding of distress (Minimal [0-13], Mild [14-19], Moderate [20-28], Severe [29-63]). 

• Beck Anxiety Inventory (BAI) 

The Beck Anxiety Inventory [12] is a 21-item self-report instrument developed to assess the severity of anxiety. Similar to the BDI-II, the BAI’s scores can be described based on clinical severity (Minimal [0-7], Mild [8-15], Moderate [16-25], Severe [26-63]). 

• Difficulties in Emotion Regulation Scale (DERS) 

The DERS is a 36-item self-report measure assessing six aspects of emotion regulation (ER): nonacceptance of emotional responses, difficulty engaging in goal-directed behaviors, impulsivity, lack of emotional awareness, limited access to strategies for emotional regulation, and a lack of emotional clarity and understanding [14]. Respondents rate each prompt on a Likert scale ranging from 1 (meaning almost never, 0-10%) to 5 (almost always, 91-100%). Total scores provide a global understanding of ER, while subscale scores provide more specific information pertaining to ER deficits. 

• Analyses 

Basic demographics were collected and cross-tabulated to examine associations between variables. Analyses were conducted using SPSS (IBM® SPSS® Statistics Premium 28, Armonk, NY, USA).

• Demographics 

Cross-sectional data were collected from 85 youth, referred to a nonprofit organization that serves youth who have experienced CSE, referred in an urban county in the southwestern US. Referrals were received between late 2017 and 2023. The average age at the time of referral was 16 (SD=1.6), ranging from 13 to 21 years old. Race was self-reported by participants as non-Hispanic Black (hereafter, Black), Hispanic or Latino, and non-Hispanic White (hereafter, White). The sample included 4.7% White, 42.4% Black, 47.1% Latino, with 5.9% identifying as mixed. Of the 83 youth with relevant information available, only 5.9% did not experience juvenile justice and/or child protection services involvement. 

In this population of youth who experienced CSE and engaged in substance misuse, 67.9% (n=84) had histories of self-harming or suicidal behaviors, with 64.7% reporting previous psychiatric hospitalization. Given the nature of the sample, all but two youth reported sexual abuse. Just over 75% experienced physical abuse, 55.3% (n=84) endorsed exposure to domestic violence, 36% (n=82) were unhoused, and 56.5% had previously violated court orders. Youth in the current sample averaged experiencing almost 10 ACEs (9.72). The average BDI score for the sample was 16.33 (n=84, SD=10.719), with 34% endorsing moderate or severe depressive symptomology. Pertaining to anxious symptomology, the mean for the BAI was 19.81, with 43.5% (n=62) reporting moderate to severe symptoms. As related to emotion regulation, the average DERS score was 92.96, suggesting significant dysregulation in this sample, with 77.6% of the sample scoring higher than the mean from the original norming sample [14]. Approximately 74% of the current sample of substance abusing youth who experienced CSE have experienced 4 or more ACEs and demonstrate significant emotion dysregulation as evidenced by a DERS score over 80. Relatedly, 56% of the sample experienced 4 or more ACEs and endorsed clinically significant experiences of anxiety. In contrast, 33% of the sample endorsed moderate or severe depressive symptomology and experienced 4 or more ACEs.

Consistent with the extant literature, as sparse as it is, youth who experienced commercial sexual exploitation surveyed in the current study report far more system involvement, ACE exposure (and thus VOCA tracked statistics), significant psychological symptomology, dysregulation and behavioral correlates of distress (e.g., self-harm or suicidal behaviors) than the general population. Again, it is emphasized that while the original intent was to compare substance abusers in this population to those who did not use or abuse substances, very few of the referred youth did not have a problematic relationship with substances. While rates of psychiatric admission for adolescents is hard to estimate, Egorova et al., suggest that admission rates were 5.5. per 1000 youth in the US [15], compared to almost 65% in the current sample. That same study emphasized strong relationships between exposure to 4 or more ACEs and various types of substance use or abuse (ORs ranging from 2-7 related to problematic, moderate or severe alcohol or substance use), which has been echoed in the literature by other studies.

To our knowledge, this is the first study that examined the utility of the DERS in understanding the experiences of commercially sexually exploited and trafficked youth, in general, and more specifically within a population of those youth with substance abuse issues. Results served to support a link between emotion regulation deficits as measured by the DERS and behavioral dysregulation in various areas (e.g., high rates of justice involvement, self-harming and suicidal behaviors, substance use, psychiatric hospitalization). Also of note, there were relatively high rates of self-reported anxiety. These findings support the idea that significant exposure to ACEs contributes to experiences of anxiety and disruptions in emotion regulation. By extension, it is likely that distress and difficulties coping and managing emotions then contribute to the use of substances in a maladaptive attempt to regulate.

Some limitations must be noted in the current study, the first of which is of course the small sample size. By extension, the sample was derived from a cross-sectional convenience sample of youth referred largely from the juvenile justice system in a specific catchment in the southwestern US. Though some historical data was either corroborated or reported through official documentation, much of the data gathered relied upon self-report. As related to substance use specifically, no measures were administered to assess the extent of problematic substance use more objectively. By extension, measures administered did not include validity scales or measures of social desirability, though it is believed that youth would actually be motivated to under-report their experiences in this context. Additionally, the current study did not include a comparison or control group. Future studies would benefit from a larger, more diverse sample. 

Clearly, based on the above results, with the benefits of a larger, more diverse sample, and implementation of more standardized assessment of substance use, more nuanced relationships between victimization, emotion dysregulation and other symptomology and substance abuse can be explored. Despite the limitations of the current study, it is believed that there are important implications. It is reiterated that this is a highly impacted population that requires intensive and comprehensive services to recover. As such, especially as related to VOCA or other grant funded programming, this highlights the importance not only of thorough assessment upon intake, but also the development of comprehensive programs that include interventions that address trauma specifically, emotion dysregulation and other symptomology in general, and associated substance use that likely develops as a failed attempt to address distress.

This research received no external funding.

Specific consent for this project was waived as the current study was a retrospective study or previous information collected that was deidentified and aggregated.

Patient consent regarding the collection of information was provided during the intake process.

The data presented in this study are available on request from the corresponding author. The data are not publicly available as we are a small non-profit organization providing services for a highly vulnerable population.

POETIC would love to thank all the incredible young women who have participated in our program, our generous funders and the team at POETIC.

The author declares no conflicts of interest.

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