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© 2008 American Public Health Association
DOI: 10.2105/AJPH.2006.108357
RESEARCH AND PRACTICE |
Cathy Zimmerman, Mazeda Hossain, Brenda Roche, Linda Morison, and Charlotte Watts are with the Gender Violence and Health Centre, London School of Hygiene & Tropical Medicine, London, England. Katherine Yun is with the Yale University School of Medicine, New Haven, Conn. Vasil Gajdadziev, Natalia Guzun, and Maria Nenette Motus are with the International Organization for Migration, Kiev, Ukraine, and Chisinau, Moldova. Maria Tchomarova is with the Animus Association Foundation and La Strada–Buglaria, Sophia. Rosa Angela Ciarrocchi and Stefania Scodanibbio are with Associazione On the Road, Martinsicuro, Italy. Anna Johansson is with Eaves Housing, London. Anna Kefurtova is with La Strada–Czech Republic, Prague.
Correspondence: Requests for reprints should be sent to Cathy Zimmerman, London School of Hygiene & Tropical Medicine, Department of Public Health and Policy, Keppel St, London WC1E 7HT, UK (e-mail: cathy.zimmerman{at}lshtm.ac.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Trained counselors interviewed 192 women who had been trafficked and sexually exploited about abuse and evaluated their physical and mental health status within 14 days of entry into posttrafficking services. Most reported physical or sexual violence while trafficked (95%), pre-trafficking abuse (59%), and multiple posttrafficking physical and psychological problems.
Newly identified trafficked women require immediate attention to address posttrauma symptoms and adequate recovery time before making decisions about participating in prosecutorial or immigration proceedings or returning home.
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INTRODUCTION |
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My wounds are inside. They are not visible.
—Moldovan woman trafficked to Italy
Human trafficking has been defined as the "recruitment, transportation or harboring of persons by means of threat or use of force or other forms of coercion, of abduction, of fraud or deceptions for the purpose of exploitation."1 In practice, women and girls who are trafficked and sexually exploited are frequently lured by individuals known to them or their families with promises of jobs as waitresses, nannies, or cleaners, and then forced into sex work or exploited while working as domestic help, street beggars, or factory or agricultural laborers.
The trafficking of women and adolescents is increasingly recognized as one of the world’s fastest growing crimes and a significant violation of human rights.2 Despite the compelling need for evidence on the physical and psychological health consequences to inform rapidly emerging policies and services for trafficked persons, there is limited evidence about the needs of women who have been trafficked. We investigated the health of women and adolescent girls trafficked for sexual exploitation in Europe who were entering posttrafficking services.
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METHODS |
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Study Design
Between January 2004 and June 2005, interviews were conducted with a consecutive sample of eligible women and adolescent girls accessing posttrafficking assistance services provided by nongovernmental and international organizations in Belgium, Bulgaria, Czech Republic, Italy, Moldova, Ukraine, and the United Kingdom. The multicountry design reflected the global nature of trafficking. Women judged to be psychologically unable to participate were excluded.
We followed the World Health Organization Ethical and Safety Recommendations for Interviewing Trafficked Women3 and conducted the study in secure service settings that offered access to health care and other assistance. Participants were interviewed by experienced counseling staff (psychologists or social-support workers) of partner organizations who were well positioned to react appropriately to difficult emotions, recognize when to terminate an interview, and organize medical care. Efforts were made to separate the study from the standard intake procedures and to stress the voluntary nature of participation to minimize any perceived pressure to participate.
Women’s physical symptoms were measured using a tool derived from the Miller Abuse Physical Symptoms and Injury Survey.4,5 Mental health symptoms were measured with (1) the depression, anxiety, and hostility subscales of the Brief Symptom Inventory (a short validated alternative to its parent instrument, the SCL-90-R [Symptom Checklist-90-Revised])6,7 and (2) the posttraumatic symptom scale from the Harvard Trauma Questionnaire,8 a set of 16 items derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for posttraumatic stress disorder (reexperiencing the trauma or intrusive memories, numbing or avoidance, and arousal).9
Both the Brief Symptom Inventory and the Harvard Trauma Questionnaire have been found to have very good reliability7,9 and high internal consistency reliability,10–14 and test–retest reliability, ranging from 0.79 to 0.84 for the Brief Symptom Inventory subscale measurements7 and 0.89 to 0.92 for the Harvard Trauma Questionnaire.13,15 Although neither instrument has been validated among trafficked women, both have been used in cross-cultural settings and among other traumatized populations.11,16–21 Budget constraints prohibited clinical exams and diagnostic testing for this study.
The semistructured questionnaire was translated from English into Bulgarian, Czech, Italian, Lithuanian, Polish, Russian, and Ukrainian. Each version was back-translated and reviewed for cultural meaning by bilingual social workers, psychologists, or cultural mediators.
Data Analysis
Data was entered using EpiData Entry version 3.1 (EpiData Association, Odense, Denmark) and analyzed using Stata version 9 (StataCorp LP, College Station, Tex). The standard scoring method was used for Brief Symptom Inventory subscales (i.e., an overall symptom score was calculated from response options 0–4, with 0 meaning "not at all" and 4 meaning "extremely").
For the Harvard Trauma Questionnaire, the standard cut-off item score of 2.5 or higher was used to indicate a probable post-traumatic stress disorder diagnosis among women who were in the trafficking situation for 1 month or more.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Of 213 women invited to participate, 212 agreed. Twenty interviews were excluded because the respondents did not meet the eligibility criteria (e.g., being in the assistance program less than 14 days, trafficked for sex work or domestic service). The final data came from 192 women and adolescent girls interviewed within 14 days of their entry into posttrafficking care.
Participants ranged in age from 15 to 45 years, with the largest group aged 21 to 25 years (42%). Most participants were interviewed in their countries of origin, with the largest groups from Moldova (38%) and Ukraine (26%; Table 1
).
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Experiences of Violence
More than half the women and adolescent girls (59%; Table 1
) reported pretrafficking experiences of sexual or physical violence, and 12% had a forced or coerced sexual experience before age 15 years; 26% cited more than 1 perpetrator, with many naming a father or stepfather (data not shown). Nearly all the women and adolescent girls (95%) reported physical or sexual violence while in the trafficking situation; 76% reported physical abuse, and 90% reported sexual abuse. There are complex psychological and social reasons, such as women’s perceptions of what constitutes sexual violence, ignorance of the crime of trafficking, self-blame, and stigma, that may help explain why some women did not report being sexually abused. Physical injuries were reported by 57% of the participants (data not shown). The participants cited severe restrictions of personal freedoms: 76% said they were "never" able to do as they wished or go where they wanted.
Physical Symptoms
The women and adolescent girls were asked about 26 physical symptoms experienced in the past 2 weeks and to rate how much this symptom bothered them (Table 2). Headaches (82%), feeling easily tired (81%), dizzy spells (70%), back pain (69%), memory difficulty (62%), stomach pain (61%), pelvic pain (59%), and gynecological infections (58%) were among the most common and severely felt symptoms.
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Nearly two thirds (63%) of the participants reported more than 10 concurrent physical health problems upon entering posttrafficking programs, highlighting the compounding pain and discomfort experienced by a majority of this population.
Mental Health Symptoms
The Cronbach coefficient alpha measure of internal-consistency reliability for this sample was estimated to be 0.89, 0.91, and 0.77 for the Brief Symptom Inventory depression, anxiety, and hostility subscales, respectively, and 0.94 for the posttraumatic stress disorder subscale of the Harvard Trauma Questionnaire.
The mean scores for symptoms associated with depression, anxiety, and hostility were 2.09, 1.90, and 1.21, respectively, according to the Brief Symptom Inventory subscales (Table 3). Compared with a general US population of adult women, the study participants’ symptoms were in the 95th percentile and in the 51st percentile compared with female psychiatric patients. (This comparison rate is offered in the Brief Symptom Inventory manual and is derived from a population studied in the United States.7) Symptoms associated with depression were most often reported, with 39% of the participants acknowledging having had suicidal thoughts within the past 7 days.
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More than half of the women and adolescent girls (57%) scored at or above the 2.5 cut-off point in the posttrauma-symptom subset of the Harvard Trauma Questionnaire, suggesting posttraumatic stress disorder (data not shown). Only the participants who had been trafficked for more than 1 month (89%) were included in this analysis, to meet the criteria that symptoms associated with posttraumatic stress disorder were present 1 month or more following traumatic events.9
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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To our knowledge, this was the first study to quantitatively document the health symptoms of trafficked women and adolescent girls. A study of this nature has several significant challenges. In particular, because we excluded women and adolescent girls still in the trafficking situation (because of the high risk of harm and our inability to provide assistance) and those who never sought assistance, this sample of women and adolescent girls accessing services undoubtedly represents the smallest minority of women and girls who are trafficked. It is unclear how well these findings apply to all trafficked women.
Because no instruments were previously validated in this population, we drew on several tools validated in culturally diverse populations exposed to high levels of trauma. These instruments may have failed to fully capture the unique and extreme features of the physical and psychological trauma and the culturally different ways these were experienced or expressed by these women and adolescent girls.
Despite these limitations, we believe we provide urgently needed empirical data for policies and services. The severe symptom patterns identified suggest that diagnostic and treatment services should be made immediately available to survivors of trafficking. Dissecting the constellation of women’s symptoms and formulating treatment plans are not likely to be easy or short-term tasks. For example, gastrointestinal problems are well-described somatic manifestations of anxiety and stress,22 but for trafficked women, they may also be associated with poor nutrition or sexual and urogenital problems.
Further complicating diagnosis and care is trafficked women’s complex history of pretrafficking and trafficking-related violence. Existing studies on violence suggest that multiple exposures to trauma of this type can have multiple long-term effects on women’s health.23,24 Services for such women should be based on good practices used for victims of domestic violence, sexual assault, and torture and for migrants and refugees. These include strategies for crisis intervention, confidentiality, security, shelter, social support, forensics, counseling, and medical cultural competency.
The symptoms found in our sample of trafficked women and adolescent girls reveal that when authorities (e.g., police and immigration personnel) encounter trafficked women, the women are likely to be suffering pain and distress, especially memory problems that may affect their ability to engage in criminal investigations and asylum petitions. For example, during police interrogations, women may be unable to immediately recall details of the crime, substantiate their status as a victim, or make decisions about cooperating in a prosecution. Legal procedures should ensure that trained health staff and support resources are immediately available to help alleviate pain and provide necessary care.
Trafficking survivors are often quickly deported or obliged to cooperate in criminal investigations as a condition of assistance.25 For women who agree to participate in legal proceedings, investigative and judicial procedures should be developed that are sensitive to possible memory difficulties, psychological distress, and victim protection needs. The multiplicity and severity of symptoms indicate that trafficked women may not be capable of making rapid decisions about their safety. Granting trafficking survivors an adequate period of recovery and reflection (i.e., temporary legal residency with access to posttrafficking services) or asylum status might foster improvements in survivors’ health and enable them to make considered decisions about their security and future well-being.
In the study sites, organizations assisting trafficking survivors struggled to acquire adequate human and financial resources to provide the necessary support. Given that the abuse suffered by trafficking victims occurs on the territory of destination states and is often perpetrated by, or involves the participation of, citizens of these states, their governments have an obligation to fund and foster services that aim to help survivors to regain their health, well-being, and dignity.
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Acknowledgments |
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Funding for this study was provided by the European Commission’s Daphne Programme (grant JAI/DAP/02/082/WY), with additional funding by the International Organization for Migration and the Sigrid Rausing Trust.
Special gratitude is offered to the trafficking survivors who participated in this study and to their support workers. Thanks to Melanie Abas for reviewing this brief and to Sarah Stephens-Smith, Anne Vauthier, and Sandra Dickson for their contributions. Partner organizations for the study included Animus Association Foundation/La Strada, Associazione On the Road, Eaves Housing, International Organization for Migration in Ukraine and Moldova, La Strada–Czech Republic, and Pag-Asa.
Human Participant Protection
Research ethical approval was received from the research ethics committee of the London School of Hygiene & Tropical Medicine and local partners.
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Footnotes |
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Peer Reveiwed
Contributors
C. Zimmerman, K. Yun, and C. Watts originated and designed the study, with input from M. Tchomarova, M.N. Motus, and L. Morison. C. Zimmerman and C. Watts coordinated and supervised the study. V. Gajdadziev, N. Guzun, M. Tchomarova, R.A. Ciarrocchi, A. Johansson, A. Kefurtova, and S. Scodanibbio collected the data. C. Zimmerman, M. Hossain, K. Yun, B. Roche, L. Morison, and C. Watts analyzed and interpreted the data, with support from V. Gajdadziev, M. Tchomarova, A. Johansson, A. Kefurtova, and S. Scodanibbio. C. Zimmerman, M. Hossain, K. Yun, L. Morison, and C. Watts prepared the brief, and all authors contributed to its editing and gave final approval.
Accepted for publication July 5, 2007.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Office of the United Nations High Commissioner for Human Rights. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organized Crime. GA Res. 55/25, Annex 2, UN GAOR 55th Sess, Supp No 49, at 60, UN Doc A/45/49/Vol 1 (2000). Available at: http://www.ohchr.org/english/law/protocoltraffic.htm. Accessed September 19, 2007.
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