Key PointsQuestion
What risk factors are associated with sexual exploitation in children?
Findings
A systematic review and meta-analysis of 37 unique studies with 67 453 unique participants found 52 factors were associated with child sexual exploitation and available for meta-analysis. Results showed significant factors associated with exposure to sexual exploitation for children and youth are engagement in sexual risk behaviors, increased number of sex partners, posttraumatic stress disorder, exposure to child pornography, and a history of childhood sexual abuse.
Meaning
Findings of this study suggest sexual risk behaviors, trauma, and exposure to sexual violence are key factors associated with sexual exploitation in children; results should inform future policy reform and prevention and intervention efforts.
Importance
Although research has examined factors associated with child sexual exploitation (CSE), consensus is lacking in regard to which factors should be prioritized, thereby hindering policy reform, prevention efforts, and development of early detection and intervention.
Objective
To provide a meta-analytic synthesis of studies examining factors associated with CSE and to quantify their relative importance.
Data Sources
Electronic databases searched to June 2019 included Medline, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Informit, yielding 396 nonduplicative records. Literature search was performed in July 2019.
Study Selection
Inclusion criteria were quantitative investigations of sexual exploitation and mean sample age of 18 years or younger.
Data Extraction and Synthesis
Literature review and data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Thirty-seven studies met final inclusion criteria. Two independent reviewers extracted all relevant data. Random-effects meta-analyses were used to derive odds ratios (ORs) for each factor. Data were analyzed from September 1 to October 28, 2019, and prediction intervals calculated in June 2020.
Main Outcomes and Measures
Child sexual exploitation, defined as coerced sexual acts between a child or a young person (aged ≤18 years) and an individual or a group in exchange for money, gifts, substances, or other commodities and associated factors.
Results
Thirty-seven unique studies were included with a total of 67 453 unique participants (mean [SD] age of 16.2 [2.5] years; 49.9% female). Fifty-two factors associated with CSE were included in the meta-analysis. The strongest factors significantly associated with exposure to sexual exploitation were engagement in sexual risk behaviors (OR, 6.31 [95% CI, 3.12-12.76]; P < .001), having more than 5 sexual partners (OR, 5.96 [95% CI, 1.63-21.87]; P = .007), a diagnosis of posttraumatic stress disorder (OR, 5.29 [95% CI, 3.40-8.22]; P < .001), historical exposure to child pornography (OR, 5.50 [95% CI, 0.99-30.53]; P = .049), and a history of childhood sexual abuse (OR, 3.80 [95% CI, 3.19-4.52]; P < .001). A number of other potentially modifiable factors had moderate to strong associations.
Conclusions and Relevance
In this systematic review and meta-analysis, children and adolescents affected by sexual exploitation showed high levels of sexual risk taking, multiple sexual partners, posttraumatic stress disorder, exposure to child pornography, and childhood trauma. Accurate detection of CSE may prevent this type of sexual violence occurring to adolescents and/or provide opportunities for intervention and recovery. Therefore, prevention and intervention efforts will likely benefit from integrating these factors into screening, assessment, and treatment.
Sexual exploitation is the second most lucrative crime in the world,1-4 estimated to affect up to 5% of the general child and youth population worldwide,5,6 with increasing numbers detected globally during the past decade.7-9 Although no unified global definition of child sexual exploitation (CSE) exists, it is considered a subtype of human trafficking.1 Definitions commonly include the actual or attempted abuse of a position of vulnerability, differential power, or trust over adolescents and children for sexual activity (online and/or offline) in exchange for something of value (eg, gifts, money, substances, or developmental needs, including shelter, food, and protection).1,2 Power imbalance between a perpetrator and young person is often characterized by age differences; however, age cutoffs vary greatly, making CSE difficult to clearly define and identify.10,11 Furthermore, CSE can occur between perpetrators and those exposed to sexual exploitation of the same age, and samples of young people can include emerging adults. Therefore, sexual exploitation vulnerability factors are likely more clinically relevant than singular age cutoffs in detecting and intervening for individuals affected by CSE. Nevertheless, to classify studies unequivocally, the present study focuses on CSE occurring in people 18 years or younger.
Research has indicated that sexually exploited young people are often psychologically controlled and manipulated by perpetrators; experience forcible isolation, rape, and extreme physical violence12; incur sexually transmitted infections13,14; and experience psychopathology, suicidality,15-17 and substance addiction.18,19 These outcomes have substantial economic costs, including service provision by child protection and health departments and long-term effects across the lifetime on the health and well-being of the individual.20,21
Previous research has identified numerous vulnerability factors associated with CSE, including psychological distress,17 emotion dysregulation,22-24 psychiatric symptoms,15-17 childhood trauma,5,25 poverty,13,26 single-parent families,19,27,28 criminality,29-31 and age.19,32 However, although these studies make an important contribution through the identification of discrete factors, no systematic synthesis of findings has been conducted to identify and quantify which factors are most critical and should be prioritized in CSE screening and intervention programs,33 for example, to investigate whether running away is associated with risk for CSE,34,35 a protective factor,26 or even unrelated.11
Furthermore, policy analysts, researchers, and professionals have advocated for multidimensional CSE prevention and intervention programs, which necessitate collaboration across health care providers, schools, and social services to support the needs of the child.36 However, despite growing documentation of CSE factors, the present evidence base only identifies unilateral risk factors or consists of studies insufficient in quality to meaningfully guide prevention and intervention.33
Therefore, to contribute to the elimination of all forms of trafficking and sexual exploitation, as outlined in the 2030 Agenda for Sustainable Development adopted by the United Nations,37 and to inform the development of effective CSE prevention and intervention, this meta-analysis aimed to synthesize the current evidence base of risk and protective factors associated with CSE and their estimated effect sizes. To our knowledge, this is the first meta-analytic review to examine and quantify factors associated with CSE.
The review protocol was preregistered on PROSPERO (CRD42018100344). We followed the standards set by the Meta-analysis of Observational Studies in Epidemiology (MOOSE)38 and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines.39
Included studies met the following inclusion criteria: (1) investigated sexual exploitation; (2) examined factors associated with sexual exploitation; (3) included children and young people (with a mean age of ≤18 years); (4) reported quantitative data; and (5) available in the English language. Studies were excluded if they (1) targeted adults (defined as mean age of sample >18 years); (2) described data qualitatively only; or (3) investigated sexual exploitation offenses.
Key terms (see eTable 1 in the Supplement) were searched via electronic databases in July 2019. The search included Medline, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Informit to June 2019. Articles were limited to peer-reviewed content. In addition, references of all included studies and gray literature (eg, government reports and working papers) were hand searched. Two authors (J.J.L. and B.K.) independently screened all titles and abstracts to determine which would proceed to full-text review. When reviewers were uncertain of a study’s eligibility, the full report was obtained, and discrepancies were discussed to obtain consensus.
Data collected from eligible studies included variables associated with CSE. Sexual exploitation definitions, sample size, study design, and study location were also extracted. If studies reported multiple effect sizes for the same variable, the effects were collapsed to avoid violating the independence of study effects. For example, variables such as living in foster care and living in residential care were collapsed as child protection involvement (see eTable 2 in the Supplement for full variable extraction information). When the same study sample was present across multiple publications, the largest sample size and the most comprehensive data extraction information was used. Studies were double coded, and discrepancies were resolved via consensus to maximize reliability and accuracy.
To examine the quality of methods and findings from included studies, 2 independent authors (J.J.L. and E.C.) evaluated each article, scoring them separately using a 9-point critical appraisal assessment tool adapted from Madigan et al40 (2018), based on previous meta-analytic research.1-44 Articles were given a score of 0 (no) or 1 (yes) for each criterion and summed to provide a total score of a possible 9. Higher scores correspond with higher methodological quality and lower risk of bias. Studies were categorized as low (<2), moderate (3-5), or high (≥6) quality. Full-quality assessment coding criteria and results are provided in eTables 2 and 3 in the Supplement.
Data were analyzed from September 1 to October 28, 2019. Prediction intervals were calculated in June 2020. Data were extracted and analyzed in Comprehensive Meta-Analysis software, version 3.45 A series of meta-analyses were conducted for each sexual exploitation factor, presented as an odds ratio (OR) with associated 95% CIs around the estimate. Effect sizes were weighted by the inverse of their variance, giving greater weight to studies with larger sample sizes, and thus more precision around estimates. Random-effects models were selected to calculate effect sizes, because they assume a distribution of effects across studies.
The Q and I2 statistics were computed to assess for statistical heterogeneity of effect sizes.46,47 A significant Q statistic suggests that study variability in effect size estimates is greater than the sampling error. The I2 statistic (ranging from 0%-100%) indicates the proportion of variability across studies owing to heterogeneity rather than chance. An I2 statistic of greater than 50% is indicative of at least moderate amounts of heterogeneity, although the statistic should be interpreted cautiously where there are few studies. Owing to variability of effects across different settings, prediction intervals are reported to evaluate between-study heterogeneity. A 95% prediction interval estimates where the true effects are expected for 95% of similar studies that might be conducted in the future.48,49 Two-tailed P < .05 indicated significance.
As shown in the PRISMA flow diagram (Figure), the electronic search yielded 396 nonduplicate records. A total of 112 articles were identified as potentially meeting inclusion criteria, with 37 full-text articles reviewed and included within the meta-analysis.
In total, 67 453 participants were included, with a mean (SD) age of 16.2 (2.5) years and near even distribution across sex (49.9% female and 50.1% male). The sample included 8.3% participants younger than 13 years; 2.3% aged 14 years, 34.3% aged 15 years, 44.8% aged 16 years, and 10.3% aged 17 to 18 years. Most studies were from the United States of America (n = 20), followed by Africa (n = 5), Sweden (n = 3), the United Kingdom (n = 2), and Canada (n = 3), with 1 study each from Taiwan, India, Norway, and the Philippines. All 37 articles5,6,14-19,22-26,28-32,34,35,38,50-57,59-66 were categorized in the high-quality range, with a mean (SD) study quality score of 8.4 (0.7) (see Table 1 and eTables 2 and 3 in the Supplement).
Factors Associated With CSE
A total of 52 factors associated with CSE were available for meta-analysis (see Table 2). These factors were collapsed across 6 domains, including demographic, trauma and exposure to abuse and/or violence, internalizing problems (ie, internally focused symptoms), externalizing problems (ie, externally focused behavioral symptoms), and psychosocial and protective domains.67
Thirteen studies5,14,17-19,28,30,32,50,54,55,57,60 were available to estimate the pooled effect size for the association between age and CSE (see Table 2), with mean participant ages ranging from 8 to 17 years. A random-effects analysis produced a significant combined effect size (OR) of 0.49 (95% CI, 0.35-0.69), indicating that for every year of age, the odds of being sexually exploited were 50% less (eg, an individual aged 16 years was half as likely to be sexually exploited compared with one aged 15 years). Female participants were twice as likely to experience CSE compared with male participants (OR, 2.25 [95% CI, 1.52-3.32]). Young people from culturally and linguistically diverse communities were more than twice as likely to experience CSE when compared with those who identified as White (OR, 2.57 [95% CI, 1.95-3.39]). Heterogeneity was high for age and sex and moderate for culturally and linguistically diverse variables (see Table 2).
Of the 10 factors within this domain, 9 adverse childhood experiences (potentially traumatic events that occur from 0 to 17 years of age) were associated with increased odds of experiencing CSE in adolescence (see Table 2). A history of childhood sexual abuse increased the odds by nearly 4 times (OR, 3.80 [95% CI, 3.19-4.52]). Neglect (OR, 2.15 [95% CI, 1.52-3.03]) and physical (OR, 1.61 [95% CI, 1.34-1.92]) and emotional (OR, 1.60 [95% CI, 1.04-2.46]) abuse doubled the odds. Numerous episodes of physical or sexual abuse before CSE increased the odds of exposure to CSE by 1.35 (95% CI, 1.12-1.64]). Evidence suggested that exposure to child pornography (OR, 5.50 [95% CI, 0.99-30.53]) or a history of posttraumatic stress disorder (PTSD) (OR, 5.29 [95% CI, 3.40-8.22]) were associated with experience of CSE in adolescents, increasing risk 5-fold. Exposure to violent or rape pornography (OR, 2.76 [95% CI, 1.08-7.04]), intimate partner violence (OR, 2.57 [95% CI, 1.47-4.47]), or a family member involved in sex work (OR, 1.84 [95% CI, 1.11-3.04]) increased the odds of experiencing CSE from 2 to 5 times. Family violence was not found to be associated with CSE (OR, 1.22 [95% CI, 0.83-1.79]). Heterogeneity was high for exposure to child or violent pornography and moderate for intimate partner violence, neglect, sexual/physical abuse, repeated episodes of violence and/or abuse, and family violence. No heterogeneity was reported across PTSD or emotional abuse.
The strongest externalizing factors associated with CSE (Table 2) were sexual risk behaviors (ie, condomless sex, sex in public, or meeting strangers from an online chat for physical sex) (OR, 6.31 [95% CI, 3.12-12.76]) and reporting multiple sexual partners in a lifetime (OR, 5.96 [95% CI, 1.63-21.87]), increasing risk 6-fold. Externalizing problems, such as aggression and hostility toward others (OR, 3.50 [95% CI, 1.98-6.07]) and a lifetime history of committing a crime (OR, 3.10 [95% CI, 1.50-2.16]), sending a sext message (sexually explicit content via electronic device) (OR, 3.12 [95% CI, 1.92-5.10]), and being sexually active (OR, 2.98 [95% CI, 1.99-4.45]), were found to triple the odds of experiencing CSE. Alcohol and drug use (OR, 2.16 [95% CI, 1.67-2.79]), running away (OR, 2.28 [95% CI, 1.63-3.19]), interpersonal difficulties (OR, 2.29 [95% CI, 1.54-3.41]), or conflict at school (OR, 2.15 [95% CI, 1.57-2.94]) doubled the likelihood of experiencing CSE. Age of first sexual experience (OR, 1.35 [95% CI, 1.10-1.69]) and age at initial substance use (OR, 1.30 [95% CI, 0.74-2.29]) increased the odds of CSE by nearly 1.5 times. Interpersonal difficulties with caregivers was not statistically significant (OR, 1.25 [95% CI, 0.88-1.79]). Heterogeneity was moderate for sexting and marijuana use and high for all other externalizing factors.
Factors associated with CSE within the internalizing problems domain included anxiety symptoms (OR, 3.11 [95% CI, 2.13-4.50]), emotional dysregulation (OR, 2.91 [95% CI, 1.86-2.33]), psychological distress (OR, 2.76 [95% CI, 1.86-4.01]), and hopelessness and suicidality (OR, 2.64 [95% CI, 1.48-4.71]), all of which nearly tripled the odds of experiencing CSE (see Table 2). Depression (OR, 2.10 [95% CI, 1.27-3.46]), social isolation (OR, 1.62 [95% CI, 1.19-2.20]), and locus of control (OR, 2.15 [95% CI, 1.36-3.42]) doubled the odds of experiencing CSE. Self-esteem issues (OR, 0.80 [95% CI, 0.19-3.42]) and psychoticism (OR, 1.09 [95% CI, 0.46-2.62]) were not significant. Heterogeneity was moderate for locus of control and anxiety and high for remaining internalizing factors.
Psychosocial factors significantly associated with sexual exploitation include a history of having a sexually transmitted infection (OR, 2.90 [95% CI, 1.50-5.71]) or being part of a single-parent household (OR, 2.75 [95% CI, 1.48-5.11]), increasing the odds of experiencing CSE 3-fold. Adolescents who reported a history of homelessness (OR, 2.22 [95% CI, 1.75-2.81]), family income below the poverty line (OR, 1.80 [95% CI, 1.19-2.72]), or child protection involvement (OR, 1.64 [95% CI, 1.14-2.35]) had a 2-fold risk. Youths exposed to household antisocial behaviors (ie, criminality) were 1.5 times as likely to experience CSE (OR, 1.52 [95% CI, 1.19-1.94]). Stressful life events in general (OR, 1.15 [95% CI, 0.59-2.24]), household mental illness (OR, 0.65 [95% CI, 0.11-4.00]), exposure to heterosexual pornography (OR, 0.72 [95% CI, 0.40-1.30]), and early parenthood themselves (<18 years of age) (OR, 0.70 [95% CI, 0.16-3.01]) were not significantly associated with CSE exposure. Heterogeneity was little or none for family involved in sex work, household antisocial behaviors, and exposure to pornography; moderate for social isolation and homelessness; and high for the remaining psychosocial factors.
Social engagement, including school completion or employment (OR, 0.83 [95% CI, 0.65-1.05]) and protective relationships within the family (OR, 0.68 [95% CI, 0.41-1.15]) or outside of the family unit (OR, 1.14 [95% CI, 0.49-2.63]), was not significantly associated with CSE exposure.
Factors Associated With CSE Based on Longitudinal Study Design
A total of 19 factors were extrapolated from longitudinal data (Table 3). Similar to the complete sample of studies, young people and children who experienced sexual exploitation were significantly more likely to experience child sexual abuse (OR, 2.89 95% CI, 1.70-4.58]), running away (OR, 2.75 [95% CI, 1.75-4.31]), homelessness (OR, 2.22 [95% CI, 1.68-2.92]), emotional dysregulation (OR, 1.69 [95% CI, 1.18-2.41]), alcohol use (OR, 1.54 [95% CI, 1.24-1.93]), and/or externalizing problems (OR, 1.37 [95% CI, 1.08-1.73]) when compared with nonexploited youth. In contrast, there were no significant differences as a function of sex, physical abuse, marijuana use, age at first sexual experience, or depression. Age at initial substance use and social engagement with school or work remained nonsignificant for associations with CSE; however, protective relationships within the family significantly reduced the likelihood of experiencing CSE in adolescence (OR, 0.84 [95% CI, 0.71-0.99]).
Child sexual exploitation remains a major global problem demanding an evidence-based response. Although a plethora of vulnerability factors for CSE have been examined, the present study is the first, to our knowledge, to systematically synthesize and quantify factors associated with children and adolescents (≤18 years) affected by sexual exploitation and to ascertain which factors are the most significant. Findings highlighted young people who commonly experience recurring trauma and violence before exploitation and consequently experience psychological symptoms associated with prior exposure to abuse and/or violence and trauma as the strongest factors associated with CSE.
The most impactful risk factors associated with CSE are clustered around early, risky, and abusive sexual behaviors. These include sexual risk-taking behaviors (eg, condomless sex, sexual intercourse in public, or meeting face-to-face with strangers from an online environment for sex), multiple sex partners (>5), and exposure to child pornography, which increases the likelihood of exposure to CSE by as much as 6-fold. These findings are consistent with research that suggests exposure to sexually exploitative material and experiences at a young age contribute to ongoing risk behaviors and increased likelihood of exploitation in adolescence.68,69 Similarly, adolescents who experienced sexual abuse or have engaged in electronic sexting behaviors are 3 to 4 times as likely to experience CSE.70 Research consistently reports sexual risk taking, online and offline, to be linked with adverse mental health outcomes and future exploitation.70,71 Online sexual violence research also suggests that pornography and sexting behaviors can function as extensions of offline forms of sexual coercion,72,73 which may explain our findings associating several online sexual risk behaviors with the physical experience of CSE. Furthermore, exposure to or exchanging sexually explicit content online can act as a potential vehicle for online grooming and can be a form of CSE itself.74
Consequent to exposure to abuse and/or violence, it is not surprising that symptoms associated with trauma, including a diagnosis of PTSD, aggression or hostility toward others (ie, externalizing problems), anxiety, emotional dysregulation, and psychological distress were associated with a 3- to 5-fold increase in the likelihood of CSE. Neurobiological evidence indicates that unresolved trauma interferes with functioning in daily life and the capacity to regulate arousal, emotions, and behavior.75,76 For example, atypical regulatory systems develop to cope with threat when trauma is experienced at a young age,75 and although these strategies are effective in the short term (eg, running away or substance use), they are risky and damaging in the long term.77
A cluster of psychosocial vulnerabilities and demographic factors were also found to be associated with CSE, including age and sex. Specifically, results indicate younger age and female sex are implicated in CSE vulnerability, mirroring research that reports young women are twice as likely to experience sexual violence before 15 years of age when compared with young men.78 Some research reports other factors, such as PTSD, may be a greater determinant of future sexually violent situations independently of sex.79 The present study supports the notion that PTSD is a significantly stronger factor than sex, but these factors may still interact. Furthermore, results affirm research that indicates children and young people affected by HIV, poverty, homelessness, and broken homes are vulnerable to CSE at higher rates than their peers.80
Three protective factors were available for meta-analysis, and although protective relationships (extrafamilial and intrafamilial) and social engagement were not significantly associated with CSE in the complete sample of studies, separate analysis of these factors based on longitudinal design alone found close family relationships may protect young people from CSE. However, data were largely based on studies using samples from child protection and criminal justice services, thus limiting generalizability in regard to relational protective factors.
Seven studies17-19,25,32,34,62 based on a longitudinal design reported significant variation across effect sizes. Although findings were largely heterogenous, sex and internalizing factors, including psychological distress and depression, were not associated with CSE. These results are preliminary owing to limited data availability, and further investigation is warranted. However, longitudinal data provided further evidence that trauma and early childhood events of exposure to abuse and/or violence remain closely associated with future experiences of CSE. Although these events cannot be undone, trauma symptoms can be tempered by evidence-based interventions that assist with emotion regulation and trauma processing, supporting a young person’s pathway into recovery.81,82
A final finding of this study lies in confirmed variability among factor effect sizes between studies. Although seeking clarity regarding which factors are important for CSE intervention and prevention initially drove the conduct of this study, heterogenous findings further highlight the inconsistency and dearth of research within the area of CSE. Practice, policy, and, most importantly, the adolescents and children reflected in this research require further exploration to more wholly understand pathways into and out of sexual exploitation. Consequently, without further research, the development of efficacious prevention and intervention to eliminate this type of violence against children and youth may be hindered.
Based on our findings, earlier identification of CSE factors through screening is paramount in preventing further sexual exploitation of vulnerable children and adolescents. Most tertiary and primary health settings frequently screen for other risks, such as substance use and suicidality; however, despite the pervasiveness of sexual violence and CSE, these are rarely a focus of screening.79,80 Youth presenting to health services with sexual risk behaviors, sexually transmitted infection and HIV testing, a history of sexual violence online or offline, and a profile of trauma symptoms (eg, PTSD, externalizing problems, anxiety, or emotional dysregulation) warrant thorough assessment for potential CSE risk.
Prior research implicates unresolved childhood trauma as the single most significant factor associated with subsequent contact with the mental health system.83 Although current CSE intervention research is limited, most programs focus on broad psychosocial issues, such as prevention of homelessness or sexually transmitted infection,33 and do not address the need for psychological treatment of trauma symptoms. Furthermore, meta-analytic research indicates that efficacious CSE intervention programs should include both knowledge and skill building; however, few studies include both.33,82 Finally, although psychoeducational programs with respectful relationships curricula can improve healthy relationship knowledge and attitudes for youth in schools,84 these programs are not tailored to meet the complex needs of intervention for youth affected by CSE, especially given the overrepresentation of disengagement from formal school settings in youth populations affected by trauma.85 Therefore, our results suggest future CSE interventions would benefit from integrating the psychological treatment of trauma symptoms (eg, PTSD, externalizing disorders, emotion dysregulation, and anxiety) with a psychoeducation program that includes sexual safety both online and offline.
The present results should be interpreted with the understanding that the findings are correlational and cannot imply causation of CSE. Further, there were discrepancies in the number of studies and sample sizes across factors, leading to some large variances in effect size estimates. Caution should also be exercised owing to the high proportion of data sampled from criminal records and child protection, which may bias generalizability. Further, some variables, such as self-esteem and personality, had very few studies included in the meta-analysis. Finally, because several identified factors are often co-occurring, additive and interactive effects are recommended for exploration in future research.
Risk factors associated with CSE must be addressed to prevent this type of sexual violence and to provide pathways for recovery for affected young people. The present study reports findings consistent with research that suggests early experiences of sexual violence may distort interpersonal relationships,86-88 normalize sexual risk,89 strengthen stereotypes regarding sex and violence,90 and perpetuate ongoing repeated exposure to violence and/or abuse.91 According to our meta-analytic results, adolescents or children presenting to primary or tertiary services with risky sexual behaviors, prior exposure to sexual violence online and offline, and mental health risk factors associated with trauma warrant further assessment for CSE. Trauma-informed intervention planning and design for youth affected by CSE should incorporate the psychological treatment of trauma symptoms alongside supportive psychoeducation regarding sexual safety online and offline. This review informs the current evidence base and the design of initiatives seeking to prevent and intervene early for CSE among children and adolescents.50
Accepted for Publication: July 13, 2020.
Published: September 22, 2020. doi:10.1001/jamanetworkopen.2020.17682
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Laird JJ et al. JAMA Network Open.
Corresponding Author: Bianca Klettke, PhD, School of Psychology, Faculty of Health, Deakin University, 221 Burwood Hwy, Burwood, VIC 3125, Australia (bianca.klettke@deakin.edu.au).
Author Contributions: Ms Laird and Dr Hallford had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Laird, Klettke, Hall, Hallford.
Acquisition, analysis, or interpretation of data: Laird, Klettke, Clancy, Hallford.
Drafting of the manuscript: Laird, Hall, Hallford.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Laird, Hallford.
Administrative, technical, or material support: Laird, Hallford.
Supervision: Klettke, Hall, Hallford.
Conflict of Interest Disclosures: None reported.
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