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Volume 2, Issue 1, Summer 2013


By Vincent J. Felitti, M.D.

Emotional, mental, and physical trauma during childhood are correlated with higher risk for many diseases that occur during adulthood, including coronary heart disease, depression, autoimmune disease, and drug addiction.  The Adverse Childhood Experiences (ACE) Study, a long-term study spanning over a decade representing middle-class urban America, revealed invaluable data linking child abuse to the risk of chronic diseases.   Children and adolescents who are victims of sex or labor trafficking experience the same types of trauma, but to a greater extent and are thus at elevated risk for chronic diseases later in life.  They are a group to which the ACE Study directly applies and represent a population that will continue to add to the economic burden of chronic diseases on society, if the proper public health attention is not given to this widespread problem.


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Childhood Trauma Is Linked to Chronic Diseases

The Adverse Childhood Experiences (ACE) Study is a collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the U.S. Centers for Disease Control and Prevention (CDC).  The ACE Study cohort has over 17,000 individuals: 80% white including Hispanic, 10% black, and 10% Asian; the average age being 57 years.  74% of patients had attended college and approximately half were men, half were women.  ACE Score is a count of categories of adverse experiences during the first 18 years of life, encompassing abuses and household dysfunction (See scoring system on page 1).  Multiple traumatic experiences within each category are only counted once (which actually understates the dramatic findings in the data).  One third of the population had score of 0, having experienced none of the abuses.  1 in 6 had a score of 4 or more, and 1 in 9 had a score of 5 or more.  Women were 50% more likely than men to have had experienced 5 or more categories of abuse [1]. 


The most obvious medical problems that people who had traumatic childhood experiences suffer from are mental health issues. There was a direct correlation between ACE Score and risk of chronic depression during adulthood, with women exhibiting a larger effect than men.  Consistent with this, higher ACE Scores are directly proportional to the percentage of patients who use prescribed antidepressants decades later [2, 3].  Not surprisingly, increasing ACE Scores are proportional to the percentage of patients that attempted suicide [4].  The percentage of patients who suffered from alcoholism or addiction to illegal street drugs was also proportional to ACE Score [5, 6]. Also very interesting is that increasing ACE Scores were proportional to diseases that have no obvious connection to traumatic emotional events.  Higher ACE Scores correlated with an increased risk for a wide range of autoimmune diseases [7] and coronary artery disease [8].  Taken together, it is not surprising that those with an ACE Score of 6 or more have almost a 20-year reduction in life expectancy [9].


Children Coerced Into Sexual Slavery

Over 70 journal or book publications have resulted from the ACE Study in the past 15 years, yet very few have discussed the obvious application of these data to children who are sold into slavery.  It is estimated that 100,000 to 300,000 children per year in North America are trafficked into prostitution; the technical term being Commercially Sexually Exploited Children (CSEC).  The average age of entry of these girls in the U.S. is 12-14.  The vast majority of adult prostitutes entered the sex industry as children [10].

So what is the relevance of the ACE study on CSEC?  Emotional and physical abuse is part and parcel to being trafficked, let alone the sexual abuse that is inherent to the industry.  Children are tricked into slavery by adults who pretend to be in love with them; using this relationship to coerce them into selling sex.  But once enticed, there are few routes of escape because of the emotional manipulation that can be accompanied by physical assault and the threat of violence to family members.


Former Victims Recount Their Childhood Trauma

I was bullied as a child.  I looked for someone, an older guy, to protect me and keep me safe. I got into a secret relationship with a 22 year-old when I was 14; a "Romeo." Romeos, once they have figured out how to get your mind in a cage, they don't need to lay a hand on you to get you to do what they want.  He began selling me.  He was about to trade me into a bigger ring, but thanks to a wiretap six days before, the FBI showed up at my house and rescued me.  It's a nightmare trying to recover from this.  I've made a lot of progress, but this crime should never have happened in the first place."

   Stacy Lundgren
   Founder of the Stacy Project


As a former exploited First Nations [Native American] child, I can say that I never wanted to service a multitude of different men. Those men exploited my innocence, my trust; they fed on me like wolves. I also blame colonialism for setting up and allowing such oppression and abuse to happen to Canada’s Anishnawbe Kwe (a word meaning “females”). The seven grandfather teachings of the Ojibway nation espouse: wisdom, love, respect, courage, honesty, humility, and truth.  There is no room within these teachings for the existence of abuse and exploitation. Still to this day, I live with the psychological scars and trauma from those wolves. I am 36 years-old and still sleep with the lights on.  We need to recognize that sexual exploitation, and the majority of prostitution, is not a choice by the victim. It is an abuse of power and misogyny at its finest. What we need is more support and understanding from the public so that a child doesn’t have to be involved in prostitution. It is the lack of choice that places and keeps them there.

   Bridget Perrier
   Co-Founder of Sextrade101


I endured four years of abuse from my trafficker, starting at the age of 14. I was punched, raped, spat upon, and sold more times than I can count. Now, as an 11-year survivor of child sex trafficking I have to say that I would not wish this recovery process on my worst enemy. My pain did not stop when I escaped. My nightmares and PTSD symptoms were so severe I thought I was losing my mind at one point. I have hope now and as such I am a hope restorer for exploited youth and their families. I will never forget my abuse or my healing process....  And, I will never stop fighting!

   Leah Albright-Byrd
   Founder of Bridget’s Dream


After about a year of being under the watch of a pimp and the girls in his stable, I began soaking in the tricks of the trade in order to survive.  It didn’t take long after being groomed for this business before I was propositioned by my aunt’s neighbor for sex. I spent the next 8 years or so enduring drug abuse, sexual abuse, physical abuse, and worst of all mental abuse. Even though I was given an opportunity to escape my pimp, I didn't take it.  Why? Because I was led to believe that this was my worth; that there was nothing better for me out there. Now, however, I've escaped from that imprisonment and have been clean for about 4 years from drugs. I will continue to struggle from the emotional trauma for the rest of my life. Despite the odds, I'm now in college, getting straight A's, and working as a support worker in a safe house for trafficked victims. I was also recently awarded for my efforts on a national level for my advocacy work with Sextrade101, an activism coalition committed to ending sexual slavery.

   Christine Barkhouse
   Sextrade101 National Advocate


I was a young, naive, and scared little girl who thought I had met my dream lover. He very quickly became my nightmare. Every day I lived in fear of how he would hurt me or what the clients would do to me. Eventually, it became the norm for me. I was completely entrenched in a horrible nightmare. I endured the pain and did what I knew how: SURVIVE. Fortunately, I managed to escape the life of sexual exploitation, became a mother of two boys, and a graduate from the police foundations program at Humber College. I also help to raise societal support and provide education and awareness surrounding issues child trafficking in Canada.

   Sextrade101 National Advocate



Not Just an Ethical Problem. It's an Economic Problem.

An article in this same issue of Cancer InCytes talks about how the mental health problems of the homeless costs a city tens of millions of dollars per year.  In it the author interviews a homeless woman who tells about the sexual abuse that happened to her at home as a child, and how that caused her to end up on the streets [11].  The trafficking of children is a growing problem, since repeatedly selling a child has become more lucrative than selling one-time use drugs.  If victims are not killed by their pimps or clients, they must deal with an increased risk of health problems for the rest of their lives.  Recovery is possible, and there are ways of mitigating risk, but from a public health and economic perspective, prevention is the best medicine.  An ACE publication showed that increasing ACE Score is directly proportional to the percentage of patients who self-reported inadequate performance in the workplace [12].  Other researchers have also reported the economic impact of cognitive impairment in the workforce due to adverse childhood experiences. They highlight the importance of improving environments for child development in disadvantaged populations as a worthwhile investment for society [13].

Prior to the public health and economic dilemma of child trafficking, there is the ethical and legal imperative to stop this crime, which local, federal, and even private law enforcement agencies increasingly recognize.  In this same issue of Cancer InCytes, the Federal Bureau of Investigation (FBI) writes about its effort to stop human trafficking in America [14].  The Association for the Recovery of Children, a private organization founded by former Central Intelligence Agency (CIA) and military agents, also recognizes that protecting children is an investment in a society’s prosperity [15].        


Vincent J. Felitti, M.D., is an internist at Kaiser Permanente and Clinical Professor of Medicine at University of California, San Diego. He and Robert F. Anda, M.D., are the co-Principal Investigators of the Adverse Childhood Experiences (ACE) Study. Over for the past 15 years they have published over seventy peer-reviewed journal articles or book chapters about the association between ACE and chronic diseases.





1. Felitti VJ, Anda RF: The relationship of adverse childhood experiences to adult disease, psychiatric disorders and sexual behavior: implications for healthcare. In The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Edited by Lanius RA, Vermetten E, Clare P: Cambridge University Press; 2010: 77-87

2. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF: Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of affective disorders 2004, 82:217-225.

3. Chapman DP, Dube SR, Anda RF: Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals 2007, 37:359–364.

4. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH: Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA : the journal of the American Medical Association 2001, 286:3089-3096.

5. Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB: Adverse childhood experiences and personal alcohol abuse as an adult. Addictive behaviors 2002, 27:713-725.

6. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF: Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics 2003, 111:564-572.

7. Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB: Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic medicine 2009, 71:243-250.

8. Dong M, Giles WH, Felitti VJ, Dube SR, Williams JE, Chapman DP, Anda RF: Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation 2004, 110:1761-1766.

9. Brown DW, Anda RF, Tiemeier H, Felitti VJ, Edwards VJ, Croft JB, Giles WH: Adverse childhood experiences and the risk of premature mortality. American journal of preventive medicine 2009, 37:389-396.

10. Estes RJ, Weiner NA: The Commercial Sexual Exploitation of Children In the U.S., Canada and Mexico: Executive Summary. In Book The Commercial Sexual Exploitation of Children In the U.S., Canada and Mexico: Executive Summary (Editor ed.^eds.). City; 2001.

11. Lankford SM: Even the homeless have healthcare needs. Cancer InCytes 2013, 2.

12. Anda RF, Fleischer S, Felitti VJ, Edwards VJ, Whitfield CL, Dube SR, Williamson DF: Childhood Abuse, Household Dysfunction, and Indicators of Impaired Worker Performance in Adulthood. The Permanente journal 2004:30-38.

13. Knudsen EI, Heckman JJ, Cameron JL, Shonkoff JP: Economic, neurobiological, and behavioral perspectives on building America's future workforce. Proc Natl Acad Sci U S A 2006, 103:10155-10162.

14. Mertz J: The FBI’s Innocence Lost National Initiative:  Child Prostitution is not a “Game”. Cancer InCytes 2013, 2:e.

15. Baz B: Boots On the Ground. Cancer InCytes 2013, 2:e.


cancer research, adulthood trauma, physical trauma, disease, adverse childhood experiences, ACE, vincent J. Felitti, M.D.
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