Mental health problems
Trafficked men and women are frequently exposed to severe psychological trauma, characterised by physical and sexual violence and threats while trafficked.1 However, evidence on the nature of psychological and psychiatric disorders among victims of human trafficking (TPs) is limited.2
While most mental health problems are elicited by major and/or ongoing stressors, stressors of a traumatic nature may precede symptoms of three disorders, in particular: the acute stress disorder, the posttraumatic stress disorder, and complex PTSD. The most frequently identified mental health problems among TPs are symptoms of PTSD, depression, and anxiety; the latter two conditions are not necessarily trauma-related.
Acute stress disorder
In the first days to weeks after having experienced traumatic events, people may exhibit mental health problems that can be consistent with an acute stress disorder (ASD). The disorder includes intrusive memories and flashbacks, negative mood, avoidance, and increased arousal. A quarter to a half of the people with ASD will adapt without formal intervention. Sometimes, however, ASD develops into a posttraumatic stress disorder, which can be diagnosed after four weeks following exposure to trauma.3
Posttraumatic stress disorder (PTSD)
PTSD is a mental health condition that is triggered by one or more terrifying events; and symptoms may include intrusive, repetitive, and upsetting memories or uncontrollable thoughts of the ordeal, flashbacks (intrusive reliving of traumatic events), nightmares and severe anxiety, blunting of emotions or increased arousal, negative thoughts and feelings and, sometimes, severe personality changes.4
Complex PTSD
Several research studies have found that an increasing number of different types of trauma (trauma complexity) are associated with an increasing number of different types of symptoms beyond PTSD (symptom complexity). Typically, these include emotion regulation difficulties, interpersonal difficulties, substance abuse problems, anger, dissociation, and suicidality.5 In the upcoming version of the International Classification of Diseases (ICD-11), complex PTSD will be defined as a separate disorder – sharing symptoms of PTSD, but with the added symptom domains of: (1) affect dysregulation; (2) negative self-concept; and (3) interpersonal disturbances.6 Complex PTSD may develop following exposure to an event, or series of events, of an extreme and prolonged or repetitive nature, that is experienced as extremely threatening or horrific, and from which escape is difficult or impossible; examples of such events are torture, slavery, genocide campaigns, prolonged domestic violence, and repeated childhood sexual or physical abuse.7
Depression and anxiety
Depression is a disorder marked especially by sadness, the inability to feel pleasure, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and, sometimes, suicidal tendencies. In anxiety disorder, people suffer from worry and fear that are constant and overwhelming.
Other mental health problems
The experience of trafficking is easily understood to be traumatic and capable of inducing symptoms of anxiety and depression. Before discussing surveys among TPs yielding exact prevalence rates of these symptoms, this chapter will first address various stressors TPs may have experienced. This may clarify why other mental health problems, such as symptoms of attachment or personality disorder, may also arise, and, in sexually exploited victims in particular, may be equally relevant. Unfortunately, studies on TPs so far have not addressed such problems.
Stressors reported by trafficked persons
While it is obvious that the experience of trafficking is highly stressful, mental health problems may also be induced or preceded by disrupting experiences before or after the trafficking period.
Pre-trafficking stressors
Abas et al. studied 120 female TPs returning to Moldova, aged 14–44 years, 81% of whom had been sexually exploited.8 It was found that 25% had not completed secondary school. Before being trafficked, a vast majority had been unemployed and had encountered socio-economic problems such as poverty and housing problems; nearly one quarter had experienced emotional abuse, two thirds had experienced physical abuse, and one third sexual abuse. Zimmerman et al. studied 192 female TPs accessing post-trafficking assistance services in seven European countries. They found that 59% had experienced pre-trafficking physical or sexual violence.9 Among the same study population, Hossain et al. found that 15% of 204 female TPs aged 15 years or older had been exposed to child sexual abuse, and one quarter to sexual violence in adulthood.10
A recent study among 174 vulnerable, mostly African-American women, 23% of whom reported sexual exploitation, examined variables associated with adolescent versus adult onset of sexual exploitation, and identified potential risk and resiliency factors differentiating adolescence-limited sexual exploitation from early-onset-adult persistent exploitation. Adolescent sexual victimisation, younger age at first alcohol/drug use, being a victim of intimate partner violence, and sense of stigmatisation of sexual self/others were all variables associated with adolescent onset of sexual exploitation. The level of education was strongly linked to cessation of exploitation by adulthood.11
Trafficking experiences
In the above-mentioned study, Hossain et al. found that 93% of the TPs assessed had been exposed to sexual violence before and during trafficking; an equal proportion had experienced direct threats or threats against family or loved ones; more than three quarters experienced physical violence with or without the use of a weapon; and 59% had been seriously injured.12 Kiss et al. studied 1,015 TPs (women, men, and children). They found that nearly half had been exposed to physical or sexual violence, or both; over two thirds reported working seven days per week, with almost half of the men working ten hours or more a day; 59% had experienced extreme restriction of movement, while one in every five had been locked in a room; over one fifth reported suffering serious injury at work, of whom 33% reported a few times and 22% reported many times; and only slightly more than one quarter of those seriously injured reported receiving medical care.13
Post-trafficking stressors
After escape from exploitation, existing stressors may persist and new ones may arise – such as: a prolonged and arduous asylum procedure; separation from family and/or children; fear of retaliation by perpetrators; physical problems due to injury or infection; stigma and marginalisation resulting from HIV-infection; pregnancy or motherhood resulting from rape; loss of honour and respect; gossip and judgements; family shame; being held accountable; lack of social support or being excluded; domestic violence; and stigmatisation of children.
Surveys of post-trafficking mental health problems
As nearly half of the TPs are adult females – and, on average, sexual exploitation is the most prevalent form of exploitation globally – most research findings apply to sexually exploited women. Studies into the mental health problems of TPs show various constraints, which are due to: using screening scales rather than diagnostic instruments;14 almost exclusively focusing on symptoms of PTSD, depression, and anxiety; including women at different stages of trafficking; and combining populations from different ethnicities, and thereby limiting internal validity.15 Overall, research has established some evidence for common psychopathology and associated impairments in functioning in sexual exploitation victims.16
In the aforementioned study among female TPs returning to Moldova, Abas et al. found that at an average of six months post-return, over half of the women met diagnostic criteria for mental disorder. Nearly 36% had PTSD (alone or comorbid), 12.5% had depression without PTSD, and nearly 6% had another anxiety disorder.17 A study among 204 female TPs in seven European countries found that 55% had high levels of symptoms of depression, 48% of anxiety, and 77% of PTSD.18 Kiss et al. interviewed 1,102 men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: 61% reported symptoms of depression, 43% symptoms of anxiety, 39% symptoms
of PTSD, and 5% had attempted suicide in the past month.19 In the same study cohort, 56% of 387 children and adolescents aged 10 to 17 years screened positive for depression, 33% for an anxiety disorder, and 26% for PTSD; 12% tried to harm or kill themselves in the month before the interview.20 In a study of 164 TPs in Nepal who had returned from the destination country, Tsutsumi et al. found that rates for depression and PTSD were significantly higher in the sex worker group than in the non-sex worker group (100% vs. 80%, and 30% vs. 8%, respectively).21
As shown by all the studies mentioned, symptoms of depression, PTSD, and other anxiety disorders are highly prevalent in TPs. It may also be concluded that little is known about other mental health problems possibly prevailing. The following section will show how particular stressors are related to specific mental health problems, and how possible other mental health consequences of pre-trafficking stressors have not been surveyed in the existing studies.
Relationship between stressors and mental health problems
The study of Hossain et al. showed that sexual violence and reported injuries during trafficking were significantly associated with post-trafficking depression, as well as with anxiety and PTSD. TPs who had been in the trafficking situation over six months were two times more likely to have higher levels of depression and anxiety symptoms than those who had spent less time in trafficking.22
Abas et al. found that childhood sexual abuse, an increased number of post-trafficking unmet needs, and post-trafficking social support were independently predictive for mental disorder at an average of six months post-return, and that the duration of trafficking showed a borderline association with mental disorder.23 The duration of trafficking may serve as a proxy for trafficking adversity: being associated with prolonged and repeated exposure to violence, exploitation, and restricted freedom.24 This result fits with existing evidence from other PTSD populations that multiple traumas are more difficult to process than single traumas, as are traumas of longer duration, which are unpredictable, and which include sexual or other interpersonal violence.25
Pre-trafficking abuse
As indicated by the aforementioned studies, child abuse, whether sexual or physical abuse or neglect, appears to be highly prevalent in sexually exploited persons. This calls for special attention, as child sexual abuse is a known predictor of problems in adult life, particularly of being abused again – and therefore being trafficked anew. The high prevalence rates of pre-trafficking abuse among sexually exploited persons is particularly striking, as the prevalence of sexual abuse in the general population is lower, although shockingly high in itself. A meta-analysis of surveys in 22 countries showed that, in community and student populations worldwide, 8% of men and 20% of women had suffered some form of sexual abuse prior to the age of 18.26 This difference in prevalence rates between sexually exploited persons and the general population implies that pre-trafficking abuse is not only associated with post-trafficking mental health problems – as brought forward above – it may also act as a risk factor for the ordeal of being trafficked itself.
An understanding of this relationship may provide insight into mental health problems and vulnerabilities which can be considered as personality features. This may inform psychological treatment methods for sexually exploited persons which, rather than solely focusing on the processing of trafficking-related traumas, then may also address a victim’s complete life story and its consequences. This may also provide perspectives towards empowerment and posttraumatic growth.
Child abuse is often perpetrated by relatives or carers whom the child depends on for its well-being and development.27 This interwovenness in abusers of nurturing and caring, on the one hand, and inflicting pain and violation, on the other, causes the child victim to develop a confused image of interpersonal relationships and intimacy. As there is no constancy in an ‘object’ (person) for attachment that is also abusive, learning about emotional bonding becomes complicated, and the child may develop what in psychiatric terms is called a reactive attachment disorder. Such a disorder may be of the inhibited kind, and be marked by withdrawn and detached behaviour, holding back emotions, being unresponsive to comforting, or displaying a mixture of contact-seeking and avoidant behaviour. It may also manifest itself in disinhibited behaviour such as indiscriminate sociability and inappropriately familiar behaviour. In relationships later in life, attachment problems may continue to manifest themselves in a lack of trust, recurrent feelings of threat and hostility, and a disturbed experience of closeness. Child abuse may also lead to the distorted cognition that violence and intimacy simply belong together in close relationships.
At the same time, an abused child may have great difficulty in developing a feeling of identity: as the flourishing of identity requires loving stimulation and coaching, and the unfolding of personal characteristics and the child’s own will needs appreciation. Such an approach also ensures ‘basic trust’ arises: the quasi self-evident assumption that one is basically welcome in the social world and that, in principle, things will be all right. For an abused child, the lack of emotional continuity – or even evident hostility – in the caring environment may result in a lack of feeling of identity and basic trust, and therefore in great emotional instability.
The likely impact of child sexual abuse, as pictured here, may cause a person to develop a deficient feeling of personal confinement, and a greater susceptibility to relationships where moral and physical boundaries are easily violated, and where abuse and possibly exploitation lie ahead. Even though such personality features cannot always be diagnosed in psychiatric terms as a personality disorder, they do reflect emotional deficits, and clearly represent mental health needs.
It has been suggested that pre-trauma experiences – such as childhood abuse – can also act, through neurobiological mechanisms, to increase the risk of PTSD in adulthood.28 The brain’s system responsible for the regulation of a person’s response to fear can become disrupted by severe trauma. As a consequence, it may be triggered by a current stressor to react inadequately – which then leads to deficiently processing the stressor.29 Additionally, recollections of childhood abuse can be reactivated by a later similar trauma, and can add to the negative meaning of the new trauma.30
Post-trafficking social support
Post-trafficking experiences also appear to be important in predicting mental health problems. Although the nature of the trauma, and trauma-related psychological processes such as appraisals (e.g., fear, alienation, self-blame) are the strongest predictors of PTSD, a lack of social support and recognition by the environment are consistent risk factors for PTSD;31 and PTSD patients will recover faster with proper social support. This is confirmed by studies among traumatised asylum-seeking populations, which revealed that post-migration stressors – including discrimination, socio-economic conditions, and family issues – are independently associated with mental disorder.32
Implications for treatment
Given the high likelihood of post-trafficking mental health problems among TPs, it is important to gain insight into how best to provide mental health care. Evidence around psychological treatment for TPs in particular, however, is limited to non-existent.
Indicators associated with positive treatment outcomes in TPs remain unknown. Clinicians engaging in psychotherapy for TPs currently base treatment decisions on evidence and experience with other populations with more or less comparable backgrounds (e.g., asylum seekers, ‘voluntary’ sex workers, and gender-based violence victims) or similar symptoms of PTSD, anxiety, depression, attachment problems, or personality disorder. These therapeutic (mostly trauma-focused) approaches do not necessarily address specific needs of TPs, especially sexual exploitation victims.
Another gap exists in the studies conducted so far: the identification of the above-mentioned personality features resulting from pre-trafficking sexual abuse. This seems highly relevant, as treatment methods addressing personality-linked vulnerabilities may promote self-respect and the guarding of
personal boundaries, and therefore prevent unhealthy relationships and re-victimisation.
Clearly, there is a clinical need for a greater evidence base on comprehensive diagnoses, and for greater insight into the response to treatment of mental health problems in TPs. Current methods, as applied in the psychological treatment of post-trauma mental health problems, are described below.
Acute stress disorder
Treatment for ASD is aimed at reducing acute stress responses and preventing development into PTSD.33 First-line treatment for ASD is trauma-focused cognitive-behavioural therapy, which has been found to reduce the likelihood of PTSD development.34 It typically includes patient education, cognitive restructuring, and exposure. Educating patients about posttraumatic reactions should aim to: normalise the stress response; heighten expectancy of recovery; and explain the stress responses in terms of conditioning models that require the patient to learn that reminders are no longer dangerous. Cognitive restructuring is used to address maladaptive or unrealistic appraisals the patient may have about the trauma, his or her response to the event, and fears of potential future harm.35 In imaginal exposure, clients provide a detailed narrative of their traumatic experiences. By reliving these memories repeatedly with the use of relaxation techniques and the therapist’s support, gradual extinction of stress responses happens, and clients learn that the salient reminders of the traumas are no longer a threat and do not result in aversive outcomes. For certain trauma victims, however, early treatment including exposure is not recommended: in cases of extreme psychological reactions, it is necessary to delay exposure therapy for several months into the PTSD phase.36 Short-term use of a tranquilliser (benzodiazepine) may be useful for reducing acute arousal and sleep disturbance.
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