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Human Trafficking Health Research: Progress and Future Directions
Phuongthao d le.
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Keywords: human trafficking, sex trafficking, labor trafficking, child trafficking, commercial sexual exploitation, health, mental health, health research, public health, children, adults, human rights
Human trafficking is a global public health concern. A growing body of literature has examined issues ranging from the physical, emotional and sexual violence experienced by victims, to the increased vulnerability to sexually transmitted infections (STIs) and HIV among individuals trafficked into commercial sexual exploitation (CSE), to the immense psychosocial challenges for survivors as they attempt to reintegrate into their communities. In a recent systematic review published in 2016, 1 which updated a systematic review conducted only four years prior, 2 researchers found almost a three-fold increase in the number of publications retrieved from the major health research databases, indicating the increasing interest to understand the health impacts of human trafficking. In the same vein, this issue of Behavioral Medicine showcased eight articles that explored a diverse set of health outcomes and research methodologies, with the goal of advancing the science on the biopsychosocial aspects of human trafficking.
In the article by Hopper and Gonzalez, the authors compared psychological symptoms in survivors of sex and labor trafficking. The study derived data from psychological evaluations of participants (n=131) served by REACH, an anti-trafficking project that also provides individual and group intervention with domestic and foreign national trafficking survivors in the U.S. Analyses found high levels of depression and post-traumatic stress disorder (PTSD) among the study participants, and that although the differences were nonsignificant, sex trafficking survivors reported more pre-trafficking childhood abuse, sexual and physical violence during trafficking, and worse psychological symptoms (including comorbid depression and PTSD) than labor trafficking survivors. PTSD symptoms were exacerbated by exposure to sex trafficking versus labor trafficking, regardless of childhood abuse exposure. This is one of the few published studies that contains data on labor trafficking survivors, and one that also examines the impact on transgender individuals. The study found that compared to female and male survivors, transgender survivors reported significantly more PTSD symptoms and had higher rates of qualifying for PTSD diagnosis. The article also provided important empirical evidence of the suspected high rates of Complex PTSD among trafficking survivors, reporting that the majority of the survivors described at least one symptom of Complex PTSD, and two-thirds of survivors met the criteria for multiple categories of Complex PTSD. These findings confirm the suggestion from the literature that survivors of trafficking experience a multitude of complex psychological issues and that some subgroups are more vulnerable than others.
As illustrated by the next two articles, qualitative research methods can provide a deeper understanding of some of the complex health issues experienced by trafficking survivors. Rajaram and Tidball set out to illuminate the “lived experiences” of a sample (n=22) of sex trafficking survivors in Nebraska, U.S. The themes that emerged from these in-depth interviews highlighted the lack of awareness that still exists about human trafficking, especially in small towns, as well as the current inadequacies of services provided to trafficking survivors. Gerassi’s article, which drew from interviews with 30 women who were impact by CSE and 20 service providers affiliated with an anti-trafficking organization and an addiction treatment center in a Midwestern city in the U.S., also noted such deficiencies. In particular, the sobriety requirements (e.g., women had to test negative for drugs and alcohol in order to be admitted; participants were evicted from the facilities if they did not remain sober) created many barriers for the participants as they sought substance use treatment. For example, to test negative, they would have gone through a period of time of not using drugs (and for the drug to clear in the urine), which can be extremely difficult for women who were still involved ‘in the streets.’ Different approaches to aid recovery and to prevent recidivism among trafficking survivors are sorely needed.
Recovery can indeed be challenging for many survivors of trafficking, as they have limited resources and capacities to cope with the many barriers posed to them in this process. The study by Okech and colleagues explored some of these factors affecting trafficking survivors’ reintegration. Using a conditional process model, the authors examined the role of social support, dysfunctional coping, and community reintegration on PTSD among former participants of a program for at risk and survivors of trafficking in Ghana. As hypothesized, analyses revealed that community reintegration indirectly influenced PTSD through social support, and that coping moderated the relationship between social support and PTSD. This is the first known study that used quantitative measures to examine the relationship between social support and (dysfunctional) coping on mental health outcomes among trafficked individuals. These findings provide further credence to prior qualitative reports and studies that have noted the importance of ensuring adequate social support among survivors of trafficking in order to facilitate their successful reintegration.
A group of survivors who can be especially impacted by trafficking are children and adolescents. Yet, relatively few studies have included them. Four articles in this issue of Behavioral Medicine explored the needs of this vulnerable population. My colleagues and I conducted a systematic review of the health problems facing commercially sexually exploited or sex trafficked children and youth, focusing on those within the U.S. We found 27 studies that satisfied our inclusion and exclusion criteria, and they demonstrated that trafficked children face a range of issues including substance use, mental health, sexual and reproductive health, and physical and other health-related issues such as childhood abuse and healthcare utilization. In addition to providing a comprehensive summary of the findings from the included studies, we also discussed health outcomes and methodological challenges that warrant further research. The two articles that followed touched on some of these issues.
Cook et al . conducted a retrospective case review of court files of commercially sexually exploited/trafficked youth (n=184) admitted to a California specialty trafficking court, and described the mental health and substance use profiles, including treatment for these issues, of this understudied population. They also examined the relationships between pre-trafficking abuse and mental health problems and/or substance use. They found that the majority of these participants had documented mental health problems and prior illicit drug use, those with known substance use had higher rates of mental health problems than those without documented substance use, and compared to those with no documented history of abuse, those with a known abuse history reported higher rates of substance use. The article also highlighted two important issues. First, the study’s finding that almost half of the participants reported ever being hospitalized for a mental health problem suggests that hospitalizations due to mental health issues “represent a critical opportunity for detecting and addressing [youth] involvement in CSE.” Second, by illustrating that prior abuse was related to mental health problems and substance use, this study bolstered the call for a comprehensive, trauma-informed care approach.
A critical component of a trauma-informed approach is an understanding of how different types of trauma are manifested and the effects of multiple traumas. The study by Ottisova and colleagues explored this aspect. Using data obtained from a large database of patients who came in contact with a secondary mental health service provider in England, the authors compared Complex PTSD symptoms between trafficked children with a diagnosis of PTSD (n=11) and matched non-trafficked children with a history of multiple traumas (n=21) or single trauma (n=9). The trafficked children endorsed the highest average number of Complex PTSD symptoms, followed by the non-trafficked multiple trauma group, then the non-trafficked single trauma group; however, differences between the trafficked children and the non-trafficked children with multiple trauma were not statistically significant. The study also included analyses of Complex PTSD symptom clusters, which revealed that alterations in emotional regulation was the most frequently reported cluster, and that the trafficked children and the multiple trauma children also endorsed with high proportions in other clusters including dissociation, alterations in relations, alterations in meaning, affect dysregulation, and altered self-perceptions. These findings confirm the suspected presence of Complex PTSD in trafficked children, and indicate the need to conduct more extensive research to understand the idiosyncrasies of mental health issues among trafficked children, as well as how the experience of this group compare to those with different or multiple traumas such as childhood abuse, domestic violence, and torture.
In the last article, Rothman and colleagues discussed seven ethical and practical challenges they have encountered in collecting research data from commercially sexually exploited children (CSEC). These seven issues fall under the themes of data quality and the impact of research on participants, researchers, and others. Some of these challenges - age of research participants, informed consent from parents or guardians, over-interrogation of youth, and concerns that research participation may further exploit youth - are specific to the CSEC population. However, others - such as navigating the role of researcher and advocate, and secondary trauma and burnout - also apply to the larger field of trafficking health research. These types of reflections are rare in academic journals, but they should be encouraged so that we, in the words of the authors, can “expand the capacity of fellow researchers to collect primary data from [trafficking] survivors with rigor and responsiveness.”
The articles included in this issue of Behavioral Medicine each made meaningful contributions to the study of trafficking and health. And collectively, they highlight several areas that deserve priority considerations in future research efforts:
Use multiple research methods, including qualitative research. The two qualitative studies by Rajaram and Tidball and by Gerassi illustrated that these in-depth analyses can provide a deeper understanding of health-related issues experienced by trafficked individuals, and that some insights cannot be captured by quantitative data alone.
Incorporate survivors’ voices and inputs. Survivors’ experiences, as told from their perspectives, can shine the spotlight on issues that are missed by researchers and others. For example, in-depth interviews with survivors in Gerassi’s study revealed that some trafficking survivors employed creative strategies to overcome barriers and challenges, demonstrating that even those who have been victimized and marginalized can be resourceful and resilient.
Address the complex, cumulative mental health impacts of human trafficking. This includes research that examines the presence of comorbid mental health issues as well as qualitatively different psychological symptoms that have previously been under-explored, such as Complex PTSD.
Adopt a trauma-informed approach. Several articles underscored this need. Although this recommendation was directed at service providers, researchers can play an important role in promoting the trauma-informed approach. For example, they can explain how the current care models are failing to meet the needs of survivors, as Rajaram and Tidball and Gerrasi have done, or researchers can incorporate analytic designs that can arrive at a more nuanced understanding of the specific effects of different and multiple types of trauma, as Ottisova and colleagues have demonstrated in their study.
Examine multiple health outcomes and how different health issues are potentially interconnected. Much of the trafficking literature have focused only on single health issues, but trafficked individuals can certainly experience comorbid health conditions. And as Cook and colleagues illustrated in their study, an understanding of the interplay of different types of health issues (in their case, substance use and mental health problems) can greatly enhance the interpretation of the data.
Explore and compare health needs of different survivor groups. The majority of trafficking research have focused on sex trafficking and have included mostly adult survivors. Little is known about the experiences of survivors of other forms of trafficking, such as labor trafficking. The study by Hopper and Gonzalez added to the scarce number of studies of labor trafficking, showing that differences likely exist between sex and labor trafficking survivors. However, much more research on the health needs of this population is needed. Similarly, more inclusion of child survivors of trafficking in future studies, and comparative analyses between adult versus child trafficking survivors, can enhance the understanding of the potentially distinct experiences of these survivor groups.
Apply advanced statistical analysis techniques to improve the understanding of the mechanisms by which human trafficking can influence health. For example, in Okech et al .’s study, the authors used a conditional process model within a structural equation modeling framework to examine the potential moderators and mediators of PTSD. Similar efforts should be pursued.
Delineate the relationships between childhood abuse, trafficking trauma, and health outcomes, especially mental health. Prior studies as well as several of the articles included in this issue have linked childhood abuse to vulnerability to trafficking, especially among children. However, more studies that examine the dynamics of these relationships - such as the potential causal pathways - are needed, so that future efforts can be directed on where, when, and how to intervene.
The collection of articles in this issue of Behavioral Medicine comprised but a small sample of the research being conducted on the biopsychosocial issues associated with human trafficking. They offered a view into the paramount task of documenting and understanding the range and complexities of the health impacts of trafficking. However, they also provided some concrete, constructive data and insights to advance trafficking health research. These contributions are crucial, as only with an evidence-based understanding of the issues, derived from appropriate sources and research methods, can we design intervention efforts that can achieve the most effective and far-reaching impact for those affected by human trafficking.
Acknowledgments
The author would like to acknowledge the support of training grant T32MH103210 from the National Institute of Mental Health.
- 1. Ottisova L, Hemmings S, Howard LM, Zimmerman C, Oram S. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: An updated systematic review. Epidemiology and Psychiatric Sciences. 2016;25(4):317–341. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 2. Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review. PLOS Medicine. 2012;9(5):e1001224. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
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