The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women

Trafficking in persons is a human rights violation that occurs around the world. Human trafficking involves the recruitment and movement of individuals-generally by force, coercion, or deception-for the purposes of criminal exploitation or abuse.1Statistics on trafficking are notoriously difficult to obtain, although the International Labor Organization has estimated that approximately 12.3 million people are in situations of forced or bonded labor, half of whom are believed to be women and girls. Although men, women, and children are trafficked and exploited in such economic sectors as construction, farming, fishing, textiles, and mining, the trafficking of women and girls for forced prostitution is among the most well-recognized forms of trafficking. Because of the often extreme sexual, physical, and psychological abuses associated with this form of gender-based violence, women and girls who are trafficked and sexually exploited through forced sex work or in other circumstances such as domestic servitude, are a population of particular concern for mental health specialists. Researchers and advocates continue to call for urgently needed psychological support services for trafficked persons-and for sexually abused women and girls in particular5-but there is little research-based information about the mental health needs of this population.

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Some trafficked girls and women do not suffer extraordinary levels of abuse; nevertheless, assault, coercion, threats of harm to themselves and their families, and severely restricted freedom are common. Indeed, many of the menacing tactics used to control trafficked girls and women are readily comparable with the characteristics of abuse described in the literature on torture. Like torture victims, girls and women who are in a trafficking situation have little ability to predict or manage events that affect their health and safety. Many are unable, for example, to determine when they work or sleep, what they eat, how many and which clients they accept, or whether they protect themselves by condom use, and a significant number are subjected to sudden physical punishment. "Unpredictability" and "uncontrollability" are theorized to be predictive of more intense or prolonged psychological reactions to abuse.8The association between such experiences and an increased risk of posttraumatic stress disorder (PTSD) and depression has been identified in other situations of trauma, such as interpersonal violence, and co-occurrence of these symptoms is also frequently found. Women trafficked for sexual exploitation have also commonly experienced violence prior to being trafficked, which may have contributed to their vulnerability to being trafficked and may put them at greater risk of mental disorders later.

There is currently only a small body of published research on the health consequences of any form of human trafficking, and there is an extremely limited body of research on the mental health consequences of trafficking. Most trafficking-related health studies have focused on sexually transmitted infections among women trafficked for sexual exploitation, particularly HIV in Asia. A study on mental health that was carried out with women in Nepal who were trafficked for sex work and various forms of labor (n = 164) found that sexually exploited women reported higher levels of anxiety, depression, and PTSD than did women exploited for other purposes. An earlier study that explored the mental health of migrant sex workers awaiting deportation in Israel (n = 47) reported that 79% had depression symptoms and 17% had symptoms of PTSD. A small study in Greece found that women who were victims of trafficking (n = 11) had a higher risk of developing PTSD than did other abused women. Our earlier findings on women receiving posttrafficking services in Europe (n = 197) highlighted women's exposure to multiple forms of abuse and the high symptom levels of PTSD, depression, and anxiety among survey participants, but we did not examine the links between their symptoms and risk factors. In the current study, we sought to identify associations between girls' and women's experiences prior to and during the period when they were trafficked and symptoms of common mental disorders.

Given the absence of evidence on common mental disorders in the posttrafficking care setting, we decided a priori to measure anxiety, depression, and PTSD separately. Specifically, given our earlier developmental work,4 we wanted to test whether posttrafficking mental health symptoms could be explained by trafficking-related exposures to violence, independent of experiences of violence before trafficking. We also wanted to explore the extent to which any of the trafficking-related exposures were associated with anxiety, depression, or PTSD. This is the first study to test such associations among a cohort of girls and women entering posttrafficking assistance centers and to consider the implications for policies and services that respond to the needs of this vulnerable and often stigmatized group.

From January 2004 through June 2005, we conducted face-to-face interviews with women and adolescent girls (aged 15-45 years) who had been trafficked and sexually exploited and were currently accessing posttrafficking services provided by a nongovernmental or international organization. Interviews were conducted in Belgium, Bulgaria, the Czech Republic, Italy, Moldova, Ukraine, and the United Kingdom. Four of the study sites were locations where organizations provided posttrafficking services in destination or transit countries (Belgium, the Czech Republic, Italy, and the United Kingdom). At these 4 sites, participants were most commonly referred to posttrafficking care by law enforcement, legal services, or any of a variety of nongovernmental organizations. The other 3 study sites were support centers in participants' countries of origin (Bulgaria, Ukraine, and Moldova). At these 3 sites, participants were primarily referred to posttrafficking services by groups in destination settings as part of a return-and-reintegration process. More rarely, some participants self-referred to a posttrafficking organization.

Posttrafficking services provide care to women following a trafficking experience. This care generally includes an assessment of posttrafficking needs (e.g., acute medical or mental health needs) and the provision of assistance in accessing a range of support, including social work, counseling, health care, and legal and immigration advice. Specific approaches to posttrafficking care varied among study sites.

Because of the numerous ethical and safety concerns associated with interviewing trafficked persons, we contacted and interviewed only those girls and women who had already entered a service setting; no one was interviewed while still in a trafficking situation.19 Given the unpredictable and fluctuating number of clients entering posttrafficking services, restrictions on research time, and limitations on resources, we opted to extend consecutive invitations to participate to every eligible girl or woman who entered a study-site service setting between January 2004 and June 2005. Girls and women were eligible to participate if they had been sexually exploited while in a trafficking situation and if a trained support worker deemed them emotionally capable of engaging in an interview.

A total of 220 girls and women were eligible and were invited to participate. Seven of the 220 declined, and 9 interviews were excluded either because the respondents were trafficked for other purposes (i.e., panhandling, petty theft), interviews were terminated early, or interviews were incomplete. A total of 204 girls and women were included in this analysis, the majority of whom were interviewed in Ukraine and Moldova. Trained counselors obtained written consent from each participant and carried out face-to-face interviews to ensure that any participant requiring follow-up had access to medical care, that all participants were observed for distress, and that participants experiencing distress received appropriate follow-up care.19 The multicountry design was adopted to reflect the global nature of trafficking and to improve the representation of trafficked women's and girls' experiences within Europe.

Translation and Data Collection

The study questionnaire was developed in collaboration with the posttrafficking service providers and was translated from English into Italian, Russian, Ukrainian, Bulgarian, Czech, Polish, and Lithuanian. Professional translators were used, and mental health professionals who were fluent in the target languages checked the resulting questionnaires and adjusted them for cultural equivalency. Each participant was asked about abuses prior to being trafficked (including experiences of physical and sexual violence), the duration and circumstances of her trafficking experience (including risks, violence, and freedoms), and physical and mental health symptoms within the 2 weeks prior to the interview.

Measures

We chose to use screening instruments that were relatively easy to translate and had been validated and used among diverse populations in low- and middle-income countries (or that had a closely related version that had been validated and used in that way). To measure mental health symptoms, we used 2 instruments: (1) the depression and anxiety subscales of the Brief Symptom Inventory20 (BSI; a short, validated alternative to its parent instrument, the SCL-90-R20,21), which is closely related to another widely used tool, the Hopkins Symptom Checklist,22,23 and (2) the posttraumatic symptom subscale from the Harvard Trauma Questionnaire (HTQ).24 Both instruments have been used among diverse populations and...