Category Archives: Health

Is Foster Care Really the Supply Chain for Domestic Sex Trafficking?

On Tuesday, April 8, the Center for American Progress sponsored a forum: “Combating Sex Trafficking of Minors in the U.S.” The panel included Senator Amy Klobuchar, (D-MN); Malika Saada Saar, Executive Director, Human Rights Project for Girls; and John Temple, Attorney-in-Charge, New York County District Attorney’s Office Human Trafficking Program.

Much of the discussion was by Senator Amy Klobuchar (D-MN) regarding legislation she is sponsoring, S.1733, “The Stop Exploitation Through Trafficking Act.” The legislation would encourage changes by law enforcement in the way they address domestic sex trafficking and sexual exploitation, specifically as it impacts minors. Key provisions of the legislation require states to treat minors who engage in a commercial sex act as a victim. It discourages the prosecution of victims for the crime of prostitution by creating “safe harbor” laws that would apply to minors. In addition it encourages the diversion of victims to child protection services and directs the U.S. Justice Department to develop a national strategy.

The discussion after the Senator’s remarks returned to a familiar theme heard many times in Washington, D.C. in the past two years. That discussion focused on the child welfare system with foster care receiving the primary blame for domestic sexual exploitation (a large part of trafficking involves international victims). At one point panelist Malika Sada Saar indicated that 80 to 90 percent of the children who are victims of sexual trafficking come from foster care and that “foster care is the supply chain for sexual trafficking victims.” Claims similar to this have been retold countless times in numerous briefings and discussions in Washington, D.C. The narrative portrays a child welfare system that takes children into care and turns them into victims of sexual trafficking. But is this really an actuate portrayal?


So, what do we know?

First, the statistics often cited in support of the child welfare-only explanation:

  • Of 88 child victims of sex trafficking in the state of Connecticut, 86 were “child welfare involved.”
  • In 2012, 56 of 72 commercially sexually exploited girls in an Los Angeles-based court program were “child-welfare involved.” Fifty-eight percent of these 72 kids were in foster care.
  • In 2007, New York City identified 2,250 child victims of trafficking. Seventy-five percent of those experienced “some contact with the child welfare system,” mostly in the context of abuse and neglect proceedings.
  • In Alameda County, CA, 41 percent of 267 victims in 2011-2012 were kids in foster care.

But there is additional information and research that paints a broader picture of this complex problem—a problem that started to get more national attention only as recently as 2000 with the passage of the Trafficking Victims Protection Act (TVPA, P.L. 106-386). The emphasis of the child welfare-only explanation ignores the population of homeless and runaway youth who are not necessarily the same children in foster care—currently the foster care population is just under 400,000 children with 254,000 entering foster care and 241,000 exiting care in 2012. According to HHS data,

  • Every day, approximately 1.3 million runaway, throwaway, and homeless youth live on the streets of America.
  • Children, both boys and girls, are solicited for sex, on average, within 72 hours of being on the street.
  • Approximately 55 percent of street girls engage in formal prostitution; 75 percent of those work for a pimp. About one in five of these children becomes entangled in nationally organized crime networks and is forced to travel far from home and isolated from friends and family.
  • A girl will first become a victim of prostitution between the ages of 12 and 14, on average.

The child welfare-only explanation also ignores other factors that influence victimization, especially children who have been victims of sexual abuse. A 1994 National Institute of Justice report states that, “minors who were sexually abused were 28 times more likely to be arrested for prostitution at some point in their lives than minors who were not sexually abused.” It is often assumed that all children who are victims of sexual abuse are part of the child welfare system, but they are not. Typically less than ten percent of the approximate 700,000 children substantiated for child maltreatment annually are substantiated for reasons of sexual abuse (as opposed to physical abuse or neglect).

The Urban Institute recently released a U.S. Justice Department funded report, “Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities.” The report looked at both the perpetrators (pimps) and the victims.

  • Seventy-eight percent of victims were woman, nearly 20 percent were transgender, and nearly 3 percent were male.
  • In some instances a person may have begun their lives in sexual exploitation as young as 11 and as old as 39. Seventy-eight percent started between the ages of 15 through 27 and 11 percent began before the age of 15.
  • The report indicates that, “Sex workers first started trading sex on the street for a wide variety of reasons, including economic need; homelessness; the encouragement of family members, friends, and acquaintances; a desire for social and emotional acceptance; as a natural continuation of other forms of commercial sex work, such as stripping and dancing and to support substance use. For many, a combination of these reasons served as the impetus to begin trading sex.”

A 2009 U.S. Department of Health and Human Services (HHS) funded literature review, “Human Trafficking into and within the United States: A Review of the Literature,” found the key factors that influence victimization include, age, poverty, sexual abuse, family substance/physical abuse, individual substance abuse, learning disabilities, loss of parent/caregiver, runaway/throwaway, and sexual identity issues. The National Institute of Justice also points to the role of substance abuse, “Multiple studies suggest that girls involved in prostitution are more likely to come from homes where addiction was present. For example, one study of 222 women in Chicago involved in prostitution found 83 percent had grown up in a home where one or both parents were involved in substance abuse. Further, prostituted girls are more likely to have witnessed domestic violence in their home; specifically, girls are likely to have seen their mother beaten by an intimate partner.” Substantive studies also highlight methods of recruitment that include solicitation by boyfriends, friends, and  family members across a range of locations that include the street, juvenile justice facilities, shopping malls, schools, shelters, group homes, and the internet.

One point does seem to be clear from the recent Washington debate, there are few treatment options for victims and there are on-going debates on what that treatment should be, including residential, lock-down, and home-based. During last week’s panel discussion, John Temple from New York City discussed that city’s efforts to address trafficking of girls and boys. He indicated that within New York City, a city of 8.3 million people, there are only “about 20 to 25 beds that were available for treatment” for children victimized by sexual traffickers. There are differences in the number of beds available, but a national survey last year by an Illinois-based group funded by the U.S. Justice Department found 33 residential programs totaling 682 beds. The treatment needed is complex and has to address factors such as trauma bond, underlying issues like substance abuse, trauma from previous sexual abuse and other trauma such as exposure to violence. Ironically the call for more treatment via child welfare comes up against a backdrop of current child welfare reform debates and discussions that are increasing calling for caps, restrictions and limitations on the use of residential care.

The HHS review of literature determined that when it comes to treatment key needs include,

  • Emergency Services:  safety, housing, and food/clothing and
  • Short-term and Long-term Services: legal assistance, intensive case management, medical care, alcohol and substance abuse counseling/treatment, mental health counseling, life skills training, education, job training/employment, and family reunification.

The problem with the current debate.

The problem regarding much of the recent debate that focuses solely on child welfare is that it ignores all of the other sources of sexual exploitation. It suggests a solution can be carried out by simply amending child welfare law and that child welfare can address the problem without any additional funding.

Recent proposals ignore the need to address the front end whereby child maltreatment, including sexual abuse, may plant the seeds for future victimization. These proposals also discount the need to address all youth in care so that none transition to the streets. Proposals that would simply mandate new directives without the resources create a “zero-sum game.” The same child welfare agencies will have to use the same dollars to expand care (and under some proposals expand child welfare services up to age 25). Advocates within the child welfare community know we are not doing enough to serve infants and toddlers, that far too many youth (over 24,000 in 2012) leave foster care not because we found them a family but because they grew too old to stay in care, and that we have over 100,000 children and youth officially listed as waiting to be adopted.

In regard to sexual trafficking the Administration has started to recognize the need for greater effort regarding the domestic side of sexual and human trafficking but from a more comprehensive approach. The proposed FY 2015 budget includes an increase of $8 million to $10 million to expand services for domestic victims of human trafficking. The January FY 2014 appropriations created a small $2 million initiative that will provide competitive grants to pilot projects by state, local, and tribal governments, or non-profit organizations that can work with trafficking victims or work with at-risk populations including runaway or homeless youth or those who have experienced intimate partner violence, sexual abuse, or other forms of maltreatment. The proposed focus will include intensive case management services to facilitate follow-up care, such as access to mental and behavioral health services, and information and referral to public benefits and other services. Grantees will be expected to coordinate services between entities that encounter trafficking victims including police, hospitals, culturally specific community based organizations, sexual violence organizations, community mental health agencies, and immigrant service providers. Demonstrations will target areas with high rates of domestic trafficking.

The Urban Institute study discussed strategies: “Cities and counties should address sex trafficking as a complex problem that requires a system wide response, and schools, law enforcement, and social service agencies must work collaboratively to combat sex trafficking in their communities. Prevention campaigns must ensure that both boys and girls are educated about the role of force, fraud, coercion, and exploitation in sex trafficking. Public schools should implement awareness campaigns. Local law enforcement should present in schools and share stories related to real cases, as well as encourage student outreach and reporting to law enforcement officials. Increasing the awareness of school officials will also help them identify at-risk or involved youth. Cross-training of local school officials and teachers and awareness raising within the schools will encourage the active involvement of school authorities in detecting possible cases of sex trafficking.”

What is needed in dealing with sexual exploitation is a comprehensive strategy whereby child welfare plays a role. What is needed in child welfare are improvements and resources that make sure all victims of abuse are treated, all children find permanent families, and no young person ages out without a family and a future. Child welfare has to be a part of any comprehensive solution to domestic sex trafficking, but the suggestion that it is the solution (and the blame) is at best off the mark. At worse, it is potentially harmful to children and youth who are in care as the last best hope when other systems—public, private and familial—have failed.

“Doc Fix” Includes Home Visiting & Demo’s On Therapeutic Foster Care

On Monday, March 31 the Senate followed up House action from the week before and approved the Medicare “doc-fix.” As a result they also gave approval to extend the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program into 2015. The Senate vote on the measure (H.R. 4302) was 64 to 35 and it became P.L. 113-93 when the President signed it on Tuesday. It extends the home visiting program for half the fiscal year through the end of next March but provides a full year of $400 million in mandatory dollars. After passage, the House held a hearing on Home Visiting that is reported below.

The “doc fix” extension legislation also includes the bipartisan “Excellence in Mental Health Act,” which authorizes the creation of a 2-year pilot program to be awarded to 8 states that compete to create federally certified Community Behavioral Health Centers. The provision designates $900 million in the expansion of services to various populations in need of mental health services and establishes new standards for providers. One of those provider groups identified in the legislation are agencies licensed by the state to deliver therapeutic (or treatment) foster care (TFC). For the first time ever, TFC is defined under Medicaid (Social Security Act, Sec. 1905) as a reimbursable service provided by state licensed child placing agencies which are accredited by nationally recognized accrediting bodies.

The Foster Family-based Treatment Association (FFTA) has been working hard to strengthen the definition and the use of treatment foster care within Medicaid for several years. Traditional foster care and treatment foster care are distinct program models intended to serve different child populations. Children are referred to TFC programs to address serious levels of emotional, behavioral and medical problems. Treatment foster care is active and structured, and occurs in the foster family home. What people view as “traditional” foster care provides nurturing, safe, and custodial care for children who require placement outside of their family. The primary reason for placement in traditional foster care is the need for care and protection. The role of the foster parent is that of caregiver and nurturer. Treatment, if any, occurs outside of the foster home. Therapeutic care combines the treatment technologies typically associated with more restrictive settings and the nurturing, individualized family environment with foster parents who receive special training.


A day after the “doc fix” extension became law, the House Ways and Means Subcommittee on Human Resources held a hearing on MIECHV. The Chair of the Subcommittee, Congressman Dave Reichert (R-WA) opened the hearing with a statement that said in part, “Our purpose today is to review what we know about the effects of this program, so we can begin thinking about next steps…we need to review whether the actual outcomes of this program are living up to its promise in terms of producing better outcomes for children and families. We also need to think about whether the program’s mix of supporting proven and promising approaches continues to makes sense. And we should consider whether this program should continue to have 100 percent federal funding, especially since some of the positive outcomes we hope to see will benefit our state partners.”

Witnesses included Crystal Towne, Nurse-Family Partnership; Sherene Sucilla, Former Nurse Family Partnership (NFP) program participant; Darcy Lowell, Child First; Jon Baron, Coalition for Evidence-Based Policy; and Rebecca Kilburn, RAND Corporation.

Crystal Towne described the NFP model explaining that it has served over 190,000 families and currently has over 28,000 first-time families enrolled in 43 states. She said that for every 100,000 families served research demonstrates that,

  • 14,000 fewer children will be hospitalized for injuries in their first two years of life;
  • 300 fewer infants will die in their first year of life;
  • 11,000 fewer children will develop language delays by age two;
  • 23,000 fewer children will suffer child abuse and neglect in their first 15 years of life; and
  • 22,000 fewer children will be arrested and enter the criminal justice system through their first 15 years of life.

Jon Barton offered a strong endorsement for reauthorization summarizing:

  • “MIECHV represents an important, bipartisan departure from the usual approach to social spending: it uses scientific evidence of effectiveness as a main factor in determining which activities to fund.
  • This evidence-based design is important because there is great variation in the effectiveness of different home visiting program activities (“models”). Rigorous studies have identified several models that produce major improvements in the lives of children and mothers – such as 20-50% reductions in child maltreatment – as well as a larger number of models that produce no meaningful effects.
  • MIECHV’s evidence-based design has succeeded, in part, in focusing funds on the subset of effective models; and, with a few modest revisions, it could do even better.”

To read all the testimony, go the Human Resources website. Organizations can still submit testimony for the record to the subcommittee by April 16. Directions for public submissions for the record can be found here.

Coalition Discusses ACF-Medicaid Budget Proposal

The National Foster Care Coalition (NFCC) spent most of its recent quarterly meeting on health care for children and youth in foster care, an important focus of CWLA’s upcoming Advocacy Summit. The discussion follows the President’s budget proposal to bring the state child welfare and Medicaid agencies together with Administration for Children and Families (ACF) competitive funding and incentive funds under Medicaid to better address the needs of children in child welfare. The proposal has the potential to address such challenges as the over use of some prescription medications as well as providing better services to children overall. Joo Yeung Chang, Associate Commissioner for the Children’s Bureau (CB), discussed the Administration proposal following two related issues.

Robert Hall of the American Academy of Pediatrics (AAP) shared his organization’s on-going effort to promote the use of medical homes. The medical home concept is to make sure that populations, such as children in foster care, have one central coordinated health care provider instead of moving from provider to provider over time. Inconsistent providers can result in uncoordinated and conflicting therapies, treatments and services. The medical home is described by the AAP as “an approach to providing primary care services …[and] team-based whole person, comprehensive, ongoing, and coordinated patient-centered care.”

A second part of the agenda was on the new state requirements under the Affordable Care Act (ACA, P.L. 111-148) to provide Medicaid coverage to young people up to age 26 if they exited foster care at age 18 (or later). Timothy Bell of FosterClub discussed the challenge they are having in their efforts to help these youth formerly in foster care to obtain this health coverage. States are supposed to provide Medicaid coverage to all young people to age 26 if they were in foster care, regardless of whether the state has taken up or rejected the expansion of Medicaid under the ACA. However, states can deny coverage to youth if they were in foster care in another state. States are a mixed bag in terms of implementing the coverage and seeking out these young people. Some states may have more barriers to qualifying, including requirements for eligibility determination, acknowledgement of providing coverage, and existing data and information on past cases of placement in foster care. First Focus has provided a brief on the topic of Medicaid to 26 for youth in Foster Care.

Commissioner Chang discussed the Administration’s proposal and the CB’s openness to greater feedback and input on the structure of the incentive fund under ACF. Fifty million dollars a year would flow from ACF in competitive grants while the matching Medicaid funding of $100 million would provide states incentives to hit certain targets or goals. The capacity building through ACF would include:

  • Enhancing the child welfare workforce;
  • Providing reliable screening and assessment tools;
  • Coordination between child welfare and Medicaid, especially Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT);
  • Training for foster parents, adoptive parents, guardians, and judges;
  • Implementing an evaluation and
  • Providing data.

Home Visiting Close to Passage For Year Extension

On Thursday, March 27, the House gave approval to a bill that will likely extend the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program into 2015. It came about when the House of Representatives passed another “patch” to the Medicare law that modifies the formula determining how doctors are reimbursed. The “doc-fix,” as it is called, has become an annual congressional ritual since it was included in a 1997 budget act. The coalition of home visiting programs and supporters had been working aggressively over the past several weeks to get any kind of home visiting extension attached to the Medicare bill under the belief it might be one of the only or the only “vehicle bill” that will be passed this year.

The MIECHV program, first included as part of the Affordable Care Act (ACA, P.L. 111-148), was authorized for five years with current funding set at $400 million a year in mandatory funds. The program sets new standards for the allocation of human service funding in that it requires states to spend 75 percent of its funding on evidenced-based and research-based models. The remaining 25 percent can be used for more experimental models but they too must undergo serious evaluation.

Although Congress has taken to passing the Medicare “doc-fix” (SGR, Sustainable Growth Rate) bill annually, this year’s effort took a few different turns and time was running out on the month and on how long Congress had to fix this year’s formula. While Finance Committee Chair, Senator Ron Wyden (D-OR) was crafting a permanent fix that would stretch out beyond ten years, Senate Majority Leader Harry Reid (D-NV) and House Speaker John Boehner (R-OH) were crafting a deal that would extend the patch through this year. That House-Senate deal included funding for the home visiting program. The deal had been reached on Wednesday but overnight the doctors groups started to sound the alarm about the shortness of the deal. At that point it looked like the House leadership might lose the needed two-thirds approval for the vote that had been taken up bypassing the rules committee. However, some behind the scenes discussions resulted in an agreement for a voice vote with neither side asking for a roll call, allowing members to not be on the formal voting record. Once the House moved the bill the Senate was scheduled to act, but that has been delayed until today.

In the Senate, a vote on Wyden’s ten year, permanent fix, is likely but not likely to pass because of opposition to using as savings the end of the war costs. When that vote fails, the Senate is expected to move the House bill. The deal allows the home visiting program to continue for one more year, requiring advocates to quickly refocus on the next round.