Thematic Outline

Crisis: The Journal of Crisis Intervention and Suicide Prevention Suicidal Ideation and Behavior Among Youth Victims of Sex Trafficking in Kentuckiana Laura M. Frey, Jennifer Middleton, Maurice N. Gattis, and Anthony Fulginiti Online First Publication, October 30, 2018. http://dx.doi.org/10.1027/0227-5910/a000557

CITATION Frey, L. M., Middleton, J., Gattis, M. N., & Fulginiti, A. (2018, October 30). Suicidal Ideation and Behavior Among Youth Victims of Sex Trafficking in Kentuckiana. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication. http://dx.doi.org/10.1027/0227-5910/a000557

© 2018 Hogrefe Publishing Crisis 2018 https://doi.org/10.1027/0227-5910/a000557

Research Trends

Suicidal Ideation and Behavior Among Youth Victims of Sex Trafficking in Kentuckiana Laura M. Frey1, Jennifer Middleton1, Maurice N. Gattis1, and Anthony Fulginiti2

1Kent School of Social Work, University of Louisville, KY, USA 2Graduate School of Social Work, University of Denver, CO, USA

Abstract. Background: Youth experiencing homelessness are at risk for sex trafficking and mental health concerns. Aims: More information is needed to elucidate the prevalence and characteristics of suicidal ideation and behavior among youth experiencing sex trafficking. Method: The present study examined suicidal ideation and behavior in a convenience sample of 128 youths experiencing homelessness aged 12–25 years in metropolitan Louisville, Kentucky, and southern Indiana. Participants were asked seven questions regarding suicidal ideation and attempts as part of an enhanced version of the 60-item Youth Experiences Survey (YES). Results: Approximately 53% of the sample reported experienc- ing suicidal ideation at some point in their lifetime and the odds of a youth experiencing homelessness who had experienced sex trafficking reporting suicidal ideation was 3.87 times higher than the odds of a youth experiencing homelessness who had not experienced sex trafficking. Additionally, of those who reported experiencing suicidal ideation, the majority (84.4%) reported they had attempted suicide in their lifetime. Limitations: This study relied on a convenience sample of youth receiving services in the Kentuckiana region and brief, self-report measures yielding categorical data. Conclusion: Programs servicing youth experiencing homelessness should require additional training and resources regarding the identification, screening, and assessment of youth who are at risk of or who have experienced sex trafficking in order to more quickly connect youth with much-needed, trauma-informed services.

Keywords: homelessness, human trafficking, sex trafficking, suicidal disclosure, suicide, youth

Recent reports suggest there are more than two million un- accompanied youth and young adults experiencing home- lessness in the United States (Covenant House, 2017). Homelessness may be due to a variety of factors, such as running away from home, being kicked out of the house, poverty, a lack of affordable housing, or maturing out of foster care. These individuals are at high risk for a variety of mental health problems: depressive symptoms and sub- stance use (Gattis, 2013; Whitbeck, Hoyt, & Bao, 2000), self-cutting (Hawton, Roham, Evans, & Weatherall, 2002; Hintikka et al., 2009), and suicidality (Esposito & Clum, 2003; Gattis & Larson, 2016; Yoder, Longley, Whitbeck, & Hoyt, 2008). Additionally, homeless and runaway youth are more likely to experience additional trauma and abuse (Barr, Fulginiti, Rhoades, & Rice, 2017). For example, these individuals are more likely to experience sex traf- ficking in which they are forced or coerced into sexual be- havior in exchange for food or shelter (Hudson & Nandy, 2012; World Health Organization, 2012).

Sex trafficking victimization has been documented in all 50 states in the United States, and the sex trafficking of a person is a criminal act in every state, according to state, federal, and international law (President’s Interagency Taskforce to Monitor and Combat Trafficking in Persons,

2014). According to federal antitrafficking laws, sex traf- ficking is defined as the recruitment, harboring, transpor- tation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coer- cion (22 USC § 71020). Notably, force, fraud, or coercion is not a required element for persons trafficked under 18 years of age (US Department of State, Office to Monitor and Combat Trafficking in Persons, 2013). Despite these laws and growing awareness of this issue in the United States, reports of sex trafficking are on the rise. In fact, the Inter- national Labour Organization (2014) recognizes sex traf- ficking as the fastest-growing business of organized crime and the third-largest criminal enterprise in the world.

Young people make up a majority of all reported sex traf- ficking cases. A report from the Human Trafficking Data Collection and Reporting Center found that 70% of all sex trafficking victims were under the age of 24 and 30% were under the age of 18 (Farrell, McDevitt, & Fahy, 2008). In general, at-risk youth – both those experiencing homeless- ness and youth who have run away from home – are more likely to fall victim to sex trafficking and are often forced or coerced to trade sex for their basic needs such as food or shelter (Bigelsen & Vuotto, 2013; Hudson & Nandy,

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2012). Many of the youth engaging in this type of “sur- vival sex” meet criteria established by the 2000 Victims of Trafficking and Violence Protection Act (US Depart- ment of State, Office to Monitor and Combat Trafficking in Persons, 2000). This growing awareness about what was traditionally considered acts of desperation now being included in the definition of sex trafficking victimization has prompted researchers, service providers, and policy makers to reframe the context within which we conceptu- alize how at-risk youth experience survival sex and com- mercial sexual exploitation, including a significant shift in language (e.g., from child prostitution to child sexual assault or child sex trafficking and from survival sex to commercial sexual exploitation; Bigelsen & Vuotto, 2013).

Sex Trafficking and Risk for Suicide

These exploitive and often coercive experiences put youth at additional risk for posttraumatic stress disorder and oth- er mental-health-related concerns (Walker, 2013). It can be difficult to isolate the various causes of outcomes from sex trafficking: Survivors often experience myriad symp- toms that can have compounding effects, such as sleep deprivation, drug and alcohol abuse, difficulty remember- ing, physical health problems (e.g., stomach or back pain, fatigue, headaches), and sexually transmitted diseases (West Coast Children’s Clinic, 2012; World Health Or- ganization, 2012; Zimmerman et al., 2006). In addition, suicide risk has commonly been reported among victims of sex trafficking. Raymond and Hughes (2001) linked su- icidality to the emotional toll that sex trafficking can have on an individual, along with depression, hopelessness, anger, and rage. Other researchers have described how sex trafficking can have a long-term effect on survivors, in which the “lasting mental and emotional as well as physi- cal toll” causes continued trauma even after survivors have escaped trafficking situations (Lederer & Wetzel, 2014, p. 70). Suicide-related theories can also be used to ex- plain the increased suicide risk. For example, Durkheim’s (1897/1951) concept of social integration – which repre- sents the ways in which people feel they are contributing to and accepted by society – or the components in the inter- personal theory of suicide (Joiner, 2005) of thwarted be- longingness and perceived burdensomeness can be used to explain what some survivors may feel when they have been exploited by those on whom they rely. These feelings coupled with hopelessness – or a feeling that the situation will not change or could happen again – may exacerbate one’s risk for suicide.

Experts commonly state that individuals who have ex- perienced sex trafficking are more at risk for suicide; yet, the research to support this claim has mostly focused on

adults. In a small sample (n = 25) of adult women who sur- vived sex trafficking, 64% of US women had experienced suicidal thoughts while 63% stated they had tried to hurt or kill themselves (Raymond & Hughes, 2001). Utilizing a larger sample (n = 106), another study found slightly low- er rates: Surveys of adult female sex-trafficking survivors indicated 46% had experienced suicidal ideation, with 42% attempting suicide during the trafficking experience and 21% attempting after trafficking occurred (Lederer & Wetzel, 2014). Minors who have experienced sex traf- ficking are also susceptible to suicide risk (Flowers, 2001a, 2001b); however, research to support this claim is limit- ed. Reports from directors and staff of residential facili- ties treating minor victims of sex trafficking indicated an increased risk of suicide ideation and behavior, although specific rates were not provided (Clawson & Goldblatt Grace, 2007).

Despite the expectation that minor and young adult victims of sex trafficking are at risk for suicide, previous studies have failed to provide rates of suicidal ideation or attempts based on a history of sex exploitation or traffick- ing for minors. There is limited information on the link be- tween sex trafficking and suicide risk and how it changes a youth’s odds of experiencing ideation or behavior. This in- formation could be an important component to urge pub- lic health approaches to combat sex trafficking and provide specialized training for clinicians to treat suicidal ideation and behavior within this population. Moreover, addition- al information about suicide-related disclosure and who has access to information about past suicidal behavior is needed to target prevention efforts to the appropriate populations. Therefore, this study aimed to determine the prevalence of suicidal ideation and behavior among youth victims of sex trafficking in Louisville, Kentucky, and southern Indiana, to determine the odds of youth victims of sex trafficking experiencing ideation and attempts, and to examine to whom in their social networks they commu- nicated this information.

Method

Sample Characteristics and Sampling Plan

Respondents for this study were recruited from eight agencies providing services for youth experiencing home- lessness within the Kentuckiana region, which consists of eight counties in Kentucky and five counties in Southern Indiana. Youth experiencing homelessness were asked to complete a survey about their life experiences with specific questions targeting whether they had experienced sex traf- ficking in their lifetime. The survey took approximately 15

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min to complete, and youth received monetary compen- sation for their time. Respondents remained anonymous by depositing completed paper surveys into a locked box located at each site. The appropriate Institutional Review Board approved this study. These procedures resulted in 140 completed surveys. Ten were omitted owing to the participants’ age (> 25), and two were omitted because of missing data on all suicide-related questions.

The final sample included 128 respondents with ages ranging from 12 to 25 years (M = 19.62, SD = 3.70). A full list of respondent demographic information is provid- ed in Table 1. The sample was evenly split between female (49.2%) and male (47.7%) respondents, with 2.3% re- porting another gender (e.g., transgender, nonconform- ing, or two-spirit). The sample was primarily heterosexual (72.8%) and of a racial or ethnic minority (69.1%). In all, 25% (n = 32) of the sample identified as a gender or sexual minority. Respondents’ age at first experience of home- lessness ranged from 3 to 25 years (M = 16.58, SD = 4.07), and number of times respondents had experienced home- lessness ranged from 1 to 22 (M = 4.02, SD = 4.32). Near- ly 41% (40.6%) reported that they had been victims of sex trafficking at some point in their lifetime.

Measures

Data were collected via the Youth Experiences Survey (YES), which is a 60-item survey developed by Arizona State University’s Office of Sex Trafficking Intervention Research. The survey has been administered yearly from 2014 to 2016 with homeless young runaway adults ages 18–24 in Arizona (Roe-Sepowitz, Brockie, Bracy, & Ho- gan, 2016). It was administered with youth experiencing homelessness for the first time in 2016 in Kentucky. The YES asks questions about demographics, living situation, drug and alcohol use, mental and physical health and treat- ment, family experiences, and negative life experiences. A section of the survey addresses life experiences related to sex trafficking, including three questions that assess whether respondents had ever experienced sex trafficking (i.e., “Have you ever been compelled, forced, or coerced to perform a sexual act, including sexual intercourse, oral or anal contact for money, food, clothing, drugs, protec- tion, or a place to stay?”; “Do you currently have a person who encourages/pressures/forces you to exchange sexual acts for money, drugs, food, a place to stay, clothing, or protection?”; and “In the past, has anyone encouraged/ pressured/forced you to exchange sexual acts for money, drugs, food, place to stay, clothing, or protection?”). Re- spondents who reported a personal experience with sex trafficking were asked follow-up questions to determine characteristics of their sex-trafficking experience (e.g., age at first exposure, whether technology was used as a recruit- ment tool for sex trafficking).

To assess the prevalence and context of suicide risk among youth experiencing homelessness in Kentuckiana, seven questions related to personal history with suicidal ideation and behavior were added to the YES. First, partici- pants were asked: “Have you ever wanted to die or thought about killing yourself ?” Those who responded yes were asked to indicate whether they felt that way within the last week, month, 6 months, year, or over 1 year. Next, partici- pants were asked whether they disclosed their ideation to anyone, and if so, whether it was to a family member, friend, professional, or other. Then, the same series of questions were asked about experiencing a suicide attempt, with one additional question regarding whether the participant sought medical attention.

Data Analysis

Chi-square tests for independence were performed using IBM SPSS Statistics to assess whether ideation, suicide at- tempts, and related disclosure were different based on a history of sex trafficking, and the phi coefficient was used as a measure of association. Then, bivariate correlations

Table 1. Respondent demographic information (n = 128)

Characteristic %

Gender

Girl/woman 49.2

Boy/man 47.7

Other 2.3

Sexual orientation

Heterosexual 72.8

Bisexual 15.2

Gay 3.2

Asexual 3.2

Pansexual 3.2

Lesbian 0.8

Other 1.6

Race/ethnicity

Black/African American 45.1

White/Caucasian 32.0

Biracial/Multiracial 9.0

African/Caribbean 6.6

Hispanic/Latino/Latina 3.3

Native American/American Indian 2.5

Arab 1.6

Asian/Pacific Islander 0.0

Indian/South Asian 0.0

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were used to explore the associations between these su- icide-related variables and additional factors related to sex trafficking experience (i.e., age at first experience of sex-trafficking, whether they had experienced sex traffick- ing prior to age 18, how many individuals they knew who had experienced sex trafficking, whether they felt afraid to leave a sex trafficker, whether technology was used in the recruitment of sex trafficking, and whether a trafficker was currently present in their lives). Variables that elicited sta- tistically significant correlations were further tested using chi-square tests for independence to determine differenc- es in proportions. Throughout the study, values of p < .05 were used to determine statistical significance; sparingly, values of p < .10 were used when effect sizes (i.e., odds ra- tio, r) indicated a meaningful association within our sam- ple, suggesting analyses would have been able to detect a statistically significant effect if our sample size had gener- ated enough power to detect it. Effect sizes were consid- ered meaningful if they were medium to large, which was at least 2.5 for odds ratios in chi-square analyses and at least .3 for r in bivariate correlations (Cohen, 1988).

Results

Ideation-Related Variables

Descriptive information related to ideation variables is pre- sented in Table 2. Over half of the sample (53.9%) report- ed experiencing suicidal ideation at some point in the past. Roughly a third (34.4%) of respondents who reported ide- ation had experienced it over 1 year ago, 10.9% within the past year, 12.5% within the past 6 months, 20.3% within the past month, and 21.9% within the past week. Among those with a history of sex trafficking, 75.0% reported they had experienced ideation. Results from a chi-square test for independence (Table 3) indicated the odds of a youth experiencing homelessness who had experienced sex traf- ficking reporting ideation was 3.87 times higher than the odds of a youth experiencing homelessness who had not experienced sex trafficking.

Of the youth experiencing homelessness who reported ideation, there was no difference in the odds of disclosing ideation between those who had experienced sex trafficking compared with those who had not. However, after adopting a more generous p value of .10, there were observed differ- ences within our sample based on whether they told specific individuals. Youth were 2.57 and 2.77 times more likely to disclose ideation to a friend and professional, respectively, if they had experienced sex trafficking compared with those who had not. No differences were observed in telling a fam- ily member. Fewer individuals told a professional compared

Table 2. Frequencies of respondent reports of ideation-related varia- bles (n = 128)

Variable Yes No Missing Valid % yes

Ever experienced ideation 69 59 0 53.9

In past weeka 14 – 5 21.9

In past montha 13 – – 20.3

In past 6 monthsa 8 – – 12.5

In past yeara 7 – – 10.9

Over 1 year agoa 22 – – 34.4

Ever disclosed ideationa 44 21 4 67.7

To familyb 20 23 1 46.5

To friendb 19 24 1 44.2

To professionalb 16 27 1 37.2

To otherb 5 38 1 11.6

Note. aOut of those who reported ideation (n = 69). Respondents were in- structed to select only one option. bOut of those who disclosed ideation (n = 44). Respondents were able to select more than one individual.

Table 3. Number of respondents reporting suicide-related variable and chi-square results based on history of sex trafficking (n = 128)

Suicide variable

Sex trafficking

No Yes χ2 p φ OR

Ideation 28 39 11.48 .001 .32 3.87

(36) (13)

Ideation disclosure 17 26 0.17 .785 .05 –

(9) (11)

To family 8 11 0.24 .753 −.08 –

(8) (15)

To friend 5 14 2.04 .082 .22 2.57

(11) (12)

To professional 4 12 2.17 .082 .23 2.77

(12) (13)

Attempt 19 33 10.02 .002 .36 4.96

(20) (7)

Attempt disclosure 11 24 0.34 .746 .08 –

(6) (9)

To family 7 11 0.96 .471 −.17 –

(4) (13)

To friend 2 14 4.90 .035 .37 6.30

(9) (10)

To professional 2 9 1.31 .435 .19 –

(9) (15)

Note. Numbers in parentheses are the number of respondents who did not report the suicide-related variable based on whether they reported a history of sex trafficking.

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with family members or friends. The majority of respond- ents (71.4%) who reported both experiencing and disclos- ing ideation most commonly indicated telling only one of the people listed (M = 1.40, SD = 0.74), with the remain- ing 19.0% telling two confidants, 7.1% telling three confi- dants, and 2.4% telling four confidants.

Attempt-Related Variables

Table 4 displays descriptive information for attempt-related variables. Of those who reported experiencing suicidal ideation, the majority (84.4%) reported they had attempt-

ed suicide in their lifetime, and almost 80% of attempt survivors had received medical attention for an attempt. Over half (56.3%) of those who reported an attempt had attempted over 1 year ago, with the remaining 10.4% within the past 6 months, 10.4% within the past month, and 6.3% within the past week. Among those with a histo- ry of sex trafficking, 82.5% had attempted suicide. A chi- square test for independence indicated the odds of a youth experiencing homelessness with a history of sex trafficking attempting suicide was 4.96 times higher than the odds of a youth experiencing homelessness who had not experi- enced sex trafficking.

Among those who attempted suicide, there was no statis- tical difference between the odds of disclosing an attempt based on whether there was a history of sex trafficking. Yet, similar to ideation disclosure, there were differences based on the recipient of disclosure. Youth were 6.30 times more likely to disclose a suicide attempt to a friend if they had experienced sex trafficking compared with those who had not been a victim of sex trafficking. No statistically signifi- cant differences were observed in disclosing an attempt to a family member or professional. Over half of the sample told a family member, with fewer telling friends. Only a third of the sample had disclosed their attempt to a profes- sional. Respondents who reported attempting suicide and telling someone most commonly (68.6%) indicated telling only one of the people listed (M = 1.46, SD = 0.78), while 20% told two people, 8.6% told three people, and 2.9% told four people.

Exploratory Analyses With Common Correlates

Bivariate correlations were used to explore the relation- ships between ideation, attempt, and disclosure variables

Table 4. Frequencies of respondent reports of attempt-related varia- bles (n = 69)

Variable Yes No Missing Valid % yes

Ever attempted suicidea 54 10 5 84.4

In past weekb 3 – 6 6.3

In past monthb 5 – – 10.4

In past 6 monthsb 5 – – 10.4

In past yearb 8 – – 16.7

Over 1 year agob 27 – – 56.3

Received medical attentionb

41 10 3 75.9

Ever disclosed attemptb 36 16 2 69.2

To familyc 19 17 0 52.8

To friendc 17 19 0 47.2

To professionalc 12 24 0 33.3

To otherc 4 32 0 11.1

Note. aOut of those who reported ideation (n = 69). bOut of those who reported attempt (n = 54). Respondents were instructed to select only one option. cOut of those who disclosed attempt (n = 36). Respondents were able to select more than one individual.

Table 5. Bivariate correlations between suicide-related variables and common correlates (n = 52)

Variable 1 2 3 4 5 6 7 8 9

1. Ideation –

2. Ideation disclosure .47** –

3. Attempt .72*** .29 a –

4. Attempt disclosure .40* .69*** .43** –

5. Age at first ST experience −.01 .08 −.38a −.11 –

6. ST before age 18 −.07 −.32a .08 −.11 −.86*** –

7. ST exposure .03 −.60** −.26 −.40 −.16 .32 –

8. Fear of leaving .17 −.23 .24 −.14 −.46* .41* .16 –

9. Technology in ST .35* −.06 .16 −.02 −.07 .06 .24 .33* –

10. Trafficker currently present .09 −.10 .20 .22 −.47** .52** .15 .43** .12

Note. ST = sex trafficking. a p < .10. *p < .05. **p < .01. ***p < .001.

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and various experiences related to sex trafficking (see Ta- ble 5). Among those who reported they had experienced sex trafficking, ideation was positively linked to the use of technology in recruitment. Within our sample (p < .10), ex- periencing a suicide attempt was negatively linked to the age at which individuals first experienced being coerced to engage in sexual activity. Although no variables were sta- tistically correlated with attempt disclosure, ideation dis- closure was negatively linked to the number of individuals a youth knew who had also experienced sex trafficking. There was also a possible trend (p < .10) negatively linking ideation disclosure to being sex trafficked before the age of 18.

Based on the results from bivariate correlations, a chi- square test for independence was conducted to determine the proportions of those who reported suicidal ideation and the use of technology in the recruitment for sex traf- ficking compared with those who did not. The involvement of technology was associated with 7.25 higher odds of ex- periencing ideation, χ2(1, 43) = 5.21, p = .042, φ = .35. A binary logistic regression analysis was planned to test whether knowing more victims of sex trafficking predicted the odds of ideation disclosure, but the sample did not pro- vide enough power.

Discussion

The present study surveyed youth experiencing homeless- ness in Kentuckiana to examine suicidal ideation and be- havior among youth victims of sex trafficking. Findings in- dicated high rates of suicidal ideation (75%) and attempts by those with ideation (84%) among youth who had expe- rienced sex trafficking. These individuals were over 3 and 4 times more likely to experience ideation and an attempt, respectively, compared with youth experiencing home- lessness who had not experienced sex trafficking. For both groups, ideation and attempt disclosure more frequently occurred with family members. However, victims of sex trafficking were more likely to disclose ideation to friends or professionals and to disclose an attempt to friends com- pared with those who had not experienced sex trafficking.

The high rates of ideation and attempts among youth who have experienced sex trafficking are alarming. These rates are higher than those reported in previous samples of adults (cf. Lederer & Wetzel, 2014; Raymond & Hughes, 2001). Moreover, our study indicated that experiencing sex trafficking increased the likelihood of reporting both ideation and attempts, which is especially concerning in comparison with research showing sex trafficking increas- es youth’s risk for adverse physical, psychological, and so- cial issues (Deshpande & Nour, 2013). What remains un-

clear is whether the ideation and attempts occurred before or after sex trafficking, as our data collection instruments did not allow us to delineate between that information. It is possible to hypothesize that experiencing previous ide- ation or an attempt could put someone at risk for experi- encing sex trafficking. Previous research has indicated that experiencing an attempt can lead to distress, shame, isolation, and stigmatization (Segal-Engelchin, Kfir-Lev- in, Neustaedter, & Mirsky, 2015; Wiklander, Samuelsson, & Åsberg, 2003), which might lead some youth to turn away from their families in a way that could, in turn, in- crease youth’s exposure to unsafe environments outside of the family. More likely, the experience of sex trafficking is a risk factor for developing suicidal ideation and behav- ior. Either way, the findings from this study highlight the need for suicide prevention and intervention approaches tailored to address the unique needs of sex-trafficking vic- tims and for increased efforts to deliver those services to populations of youth experiencing homelessness.

Another interesting finding from this study was that the targets of disclosure differed among the two groups. For ideation and attempts, more youth overall disclosed to family than to friends or professionals; however, youth with a history of sex trafficking were more likely to disclose to friends and professionals compared with youth without a sex trafficking history. These findings point to the need for interventions that provide suicide gatekeeper training to youth experiencing homelessness (Fulginiti, Rice, Hsu, Rhoades, & Winetrobe, 2016) as well as to the profession- als who provide services to them. Gatekeeper trainings are specifically targeted to people (e.g., teachers, par- ents, faith-based leaders) in a position to recognize signs of suicide risk and to direct at-risk individuals to trained professionals (US Department of Health and Human Ser- vices, Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012). These trainings do not require previous experience and are designed to teach lay people how to recognize risk and direct people toward appropriate resources. However, these trainings miss a large portion of the population: the youth who are on the front lines hearing stories of peers’ suicidal ideations or attempts. These individuals need the training that allows them to recognize suicidal crises and direct their peers to support services that are safe and nonstigmatizing. Al- though providing care to youth experiencing homeless- ness who do not access services can be difficult, homeless shelters and other agencies providing services could also offer information on responding to suicide to the youth they serve. This information could include both the signs of risk and information combatting negative myths about help-seeking.

Finally, exploratory analyses indicated that ideation was also higher among those whose sex trafficking experiences

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involved technology. The link between these two experi- ences is not clear. One explanation could be that individu- als who already feel isolated and alone rely on technology as a way to connect with other individuals outside of their direct family or peer networks who can provide support and empathy. If these individuals use technology (e.g., so- cial media) to feel connected, and technology then results in a traumatic experience such as sex trafficking, it could increase the feelings of hopelessness and isolation even further. In fact, thwarted belongingness – the feeling that occurs when one’s interpersonal need to belong is not met (Joiner, 2005) – has been linked to suicidal desire (Van Or- den, Witte, Gordon, Bender, & Joiner, 2008). An alterna- tive explanation could be that sex trafficking experiences that involve technology may be, by nature, more traumat- ic. For example, technology used to promote or market the young person could lead to an increased frequency of sex-trafficking experiences. Similarly, technology may al- low for increased permanence of the experience, such as when photos or videos are shared online and can be viewed repeatedly by others. Both of these experiences could elicit more trauma symptoms and shame, thus increasing one’s risk for developing suicidal ideation or behavior. More research is needed to determine if either of these expla- nations are valid, and future studies should include more complex measures of technology use to elucidate the com- plexity of sex trafficking, technology use, and suicide risk.

Implications for Practice

Young victims of sex trafficking often experience an in- creased risk for adverse physical, psychological, and social issues (Deshpande & Nour, 2013). In addition, young peo- ple experiencing homelessness are at greater risk for sex trafficking. This information coupled with results from the present study suggest that programs servicing youth expe- riencing homelessness should require additional training and resources regarding the identification, screening, and assessment of youth who are at-risk of or who have expe- rienced sex trafficking in order to more quickly connect these young people with much-needed, trauma-informed services. These sex-trafficking screening and assessment protocols should also include suicide assessment meas- ures. One option could be the Columbia Suicide Severity Rating Scale – Triage Version for Primary Care Settings (Columbia Lighthouse Project, 2016), which is a brief, 6-question assessment of past and current ideation and behavior with guidelines regarding how professionals can direct individuals to various levels of care based on their responses. In addition, the findings from this study high- light the need for suicide prevention and intervention ap- proaches tailored to address the needs of sex-trafficking

victims and for increased efforts to deliver those services to populations of youth experiencing homelessness.

Limitations

The findings from the present study should be considered along with their limitations. The study relied on a conven- ience sample of youth experiencing homelessness in the Kentuckiana region. Therefore, similar prevalence rates may not occur among samples from other regions of the United States. Similarly, recruitment methods targeted young people receiving services, and rates of risk and vic- timization may differ among young people who chose not to access or who cannot receive services. Data collection for this study also relied on brief, self-report measures that generated categorical data. This type of information lim- its the ability to conduct more sophisticated data analyses. The data also did not allow for mediation and moderation analyses. Given the increased risk for suicide among those with posttraumatic stress disorder (Krysinska & Lester, 2010), substance use issues (Pompili et al., 2012), and family distress or isolation (Frey & Cerel, 2015), it is like- ly that youth who have experienced sex trafficking have additional factors that increase their risk for suicidal ide- ation or behavior. Future research needs to examine the role of additional risk factors to understand the relation- ship between sex trafficking and suicide risk more clearly. The data collected in the survey were also dependent on the respondents’ willingness to be honest about their ex- periences. Therefore, there may be some experiences that were not captured by this study. Finally, some statistics were reported using a more generous p value (p < .10). This level was used to assess for meaningful effects within our sample; however, we cannot confidently generalize these findings to the larger population of youth experiencing homelessness and sex trafficking.

Acknowledgments Data for this study were collected with funding from the Kent School of Social Work at University of Louisville, in partnership with the Arizona State University Office of Sex Trafficking Intervention Research and The McCain Insti- tute for International Leadership.

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Received November 22, 2017 Revision received April 23, 2018 Accepted April 24, 2018 Published online October 30, 2018

Laura M. Frey, PhD, LMFT, is an assistant professor in the Couple & Family Therapy Program within the Kent School of Social Work at the University of Louisville, KY. Her work examines the role of suicide-relat- ed disclosure following one’s experience of suicidal ideation and dis- closure as well as the role of family relationships in treatment-seeking behavior.

Jennifer Middleton, PhD, MSW, is an assistant professor in the Kent School of Social Work at the University of Louisville, KY. She is also the director of the University of Louisville Human Trafficking Research Initiative. Her substantive area of research is trauma-informed child welfare and forensic social work, with special emphasis placed on or- ganizational health and transformational leadership as it relates to vicarious trauma and job retention.

Maurice N. Gattis, PhD, MSSW, is an assistant professor in the Kent School of Social Work at the University of Louisville, KY. He engages in research regarding: health disparities; gay, lesbian, bisexual, and transgender (GLBT) populations; and youth experiencing homeless- ness. Primarily, he focuses on the role of contextual factors – such as family, peers, school, discrimination, and stigma – on negative psycho- logical outcomes.

Anthony Fulginiti, PhD, MSW, is an assistant professor in the Graduate School of Social Work at the University of Denver, CO. His work seeks to understand and develop ways to leverage social connections to pre- vent and relieve the suffering associated with experiences of suicidal thinking and behavior among vulnerable populations.

Laura M. Frey Kent School of Social Work University of Louisville 136A Burhans Hall Shelby Campus Louisville, KY 40292 USA [email protected]