Human trafficking, a modern form of slavery, is a fundamental abuse of human rights and dignity estimated to affect 21 million individuals worldwide (International Labour Organization (ILO), 2016). One definition is ‘the act of recruiting, harbouring, transporting, providing or obtaining a person for compelled labour or commercial sex acts through the use of force, fraud or coercion’ (US Department of State, 2015). Trafficking is a major assault on freedom, fuelled by poverty, discrimination, corruption, poor governance and enforcement and exploited by transnational organised crime. It is often the sad betrayal, by deception, coercion or force, of promise for a better future life in a new location. The systematic review by Ottisova et al. (Reference Ottisova, Hemmings, Howard and Zimmermanthis issue) is a welcomed update to a systematic review by Oram et al. (Reference Oram, Stöckl, Busza, Howard and Zimmerman2012) and adds vital and timely information.
The context of human trafficking is diverse and although it often involves movement between nations, it may occur within national or local boundaries. It can involve young children, as well as older adults, but young adults are its primary target. Both sexes are trafficked in similar numbers, but usually for different types of exploitation; women for the sex trade and domestic servitude and men for agriculture, factory, fishing and construction labour. Children may be used for begging, labour, military service and/or sexual exploitation (US Department of State, 2015). The extent of human trafficking for organ procurement remains unclear. Processes leading to trafficking often occur during recruitment through misrepresentation of the job, contract terms, recruitment fees, debt bondage (unlawful fees for transportation, recruitment or personal ‘sale’), confiscation of identity documents or various combinations of these. These ‘costs’ (plus interest), may result in victims spending years in exploited labour to repay what they ‘owe’ before realising any wages. While sources for human trafficking are primarily poverty stricken areas of Asia, Africa, Latin America and Eastern Europe; it also occurs in economically deprived areas of developed countries in Europe and the Americas, including among indigenous peoples. Destination countries are usually in the developed world (North America, Europe, Australia and the Gulf States), where trafficked individuals are usually found in industries that rely on low skilled or unskilled labour that may be dirty, dangerous, difficult and seasonal. In general, human trafficking may be involved throughout the global supply chain and marketplace and many services we purchase (including food and clothing) may be linked to human trafficking labour (US Department of State, 2015).
Although human trafficking has occurred throughout history, recent international and national efforts have occurred to combat it through Conventions, legislation, enforcement, attacking root causes, warning potential victims, punishing perpetrators and empowering survivors. The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (2000) was a leader in identifying the special vulnerability of women and children, assisting trafficking victims and promoting cooperation between State parties to meet objectives through research, law enforcement, information exchange and training. The United States of America Department of State publishes an annual Trafficking in Persons (TIP) Report (2015) which ranks all countries on their efforts to acknowledge and combat human trafficking. Other countries have developed initiatives and policies; the United Kingdom passed the Modern Slavery Act (2015) which outlines offences, prevention, enforcement, victim protection, supply chain transparency and other related topics.
Despite the above efforts, human trafficking remains largely hidden. This is especially true of the physical and mental health sequelae associated with it. The systematic review and meta-analyses by Ottisova et al. (Reference Ottisova, Hemmings, Howard and Zimmerman2016) found high levels of violence while trafficked and high prevalence of physical illness, depression, anxiety, posttraumatic stress disorder and somatic symptoms in the post-trafficking period. Our first papers on human trafficking (Stewart & Gajic-Veljanoski, Reference Stewart and Gajic-Veljanoski2005; Gajic-Veljanoski & Stewart, Reference Gajic-Veljanoski and Stewart2007) revealed a dearth of high-quality studies, especially relating to health effects. The fact that Ottisova et al., using rigorous methodology, were able to identify 37 papers on health risks and outcomes is a most encouraging sign of a rapidly developing interest and research in trafficking! As the current authors point out, the papers were largely from low to middle-income countries, revealing gaps in information about human trafficking in developed regions, including the Gulf States that need to be addressed. The papers were also mostly conducted among women and girls trafficked into the sex industry, leaving further gaps about other forms of exploited labour in trafficked individuals-especially men. Notably only four studies were conducted in clinical settings, likely revealing the low rates of victim identification. Our study of Canadian medical students found that 88.8% of participants were not familiar with the signs and symptoms of trafficked persons, although 76% thought this was important to learn about in medical school, especially identifying trafficked persons and their health needs (Wong et al. Reference Wong, Hong, Leung, Yin and Stewart2011). It is unlikely that practicing health care providers, including psychiatrists, would score any better, suggesting the need for education on this topic at all levels of health service training and practice.
The high rates of exposure to physical or sexual violence while trafficked in 18 papers identified by Ottisova et al. are concerning but not surprising given previous research by the current authors and others. Violence is especially prevalent in men trafficked for exploited labour, women in the sex trade and in children. Despite the difficulties and fear many trafficked individuals experience in seeking health care, it is vital that trafficking be considered in all individuals seeking health care for conditions possibly related to violence.
Although high rates of mental disorders have been identified by trafficked men, women and children in several papers, the prevalence of trafficking in the overall population seeking mental health care is unknown as most are not identified. A very useful contribution of Ottisova et al.'s paper is their identification of risk factors for mental health problems in trafficked individuals. These include violence before and during trafficking, poor living and working conditions, restricted movement while trafficked, longer duration of exploitation and unmet social needs after escape; all factors commonly present in trafficked individuals. Sensitive inquiry into these general factors while assessing patients presenting with mental health disorders may assist in identifying more trafficking victims.
While the present scope of human trafficking is unknown, one must consider whether the current global refugee crisis might radically increase its prevalence. Desperation is a key motivator. Although there is confusion around the definitions of people smuggling and trafficking, people who chose to be smuggled can easily be trafficked if their freedom or finances are restricted at destination. Given the 4.6 million registered Syria refugees (United Nations High Commissioner for Refugees, 2016) and the over 40 million ‘populations of concern’ (United Nations High Commissioner for Refugees, 2015), human trafficking is likely to escalate. We need to scale up our education, identification, social and health services, including promising psychological and other interventions for trafficked individuals. Mental health services must play a vital role and the time to start was yesterday!
Human trafficking, a modern form of slavery, is a fundamental abuse of human rights and dignity estimated to affect 21 million individuals worldwide (International Labour Organization (ILO), 2016). One definition is ‘the act of recruiting, harbouring, transporting, providing or obtaining a person for compelled labour or commercial sex acts through the use of force, fraud or coercion’ (US Department of State, 2015). Trafficking is a major assault on freedom, fuelled by poverty, discrimination, corruption, poor governance and enforcement and exploited by transnational organised crime. It is often the sad betrayal, by deception, coercion or force, of promise for a better future life in a new location. The systematic review by Ottisova et al. (Reference Ottisova, Hemmings, Howard and Zimmermanthis issue) is a welcomed update to a systematic review by Oram et al. (Reference Oram, Stöckl, Busza, Howard and Zimmerman2012) and adds vital and timely information.
The context of human trafficking is diverse and although it often involves movement between nations, it may occur within national or local boundaries. It can involve young children, as well as older adults, but young adults are its primary target. Both sexes are trafficked in similar numbers, but usually for different types of exploitation; women for the sex trade and domestic servitude and men for agriculture, factory, fishing and construction labour. Children may be used for begging, labour, military service and/or sexual exploitation (US Department of State, 2015). The extent of human trafficking for organ procurement remains unclear. Processes leading to trafficking often occur during recruitment through misrepresentation of the job, contract terms, recruitment fees, debt bondage (unlawful fees for transportation, recruitment or personal ‘sale’), confiscation of identity documents or various combinations of these. These ‘costs’ (plus interest), may result in victims spending years in exploited labour to repay what they ‘owe’ before realising any wages. While sources for human trafficking are primarily poverty stricken areas of Asia, Africa, Latin America and Eastern Europe; it also occurs in economically deprived areas of developed countries in Europe and the Americas, including among indigenous peoples. Destination countries are usually in the developed world (North America, Europe, Australia and the Gulf States), where trafficked individuals are usually found in industries that rely on low skilled or unskilled labour that may be dirty, dangerous, difficult and seasonal. In general, human trafficking may be involved throughout the global supply chain and marketplace and many services we purchase (including food and clothing) may be linked to human trafficking labour (US Department of State, 2015).
Although human trafficking has occurred throughout history, recent international and national efforts have occurred to combat it through Conventions, legislation, enforcement, attacking root causes, warning potential victims, punishing perpetrators and empowering survivors. The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (2000) was a leader in identifying the special vulnerability of women and children, assisting trafficking victims and promoting cooperation between State parties to meet objectives through research, law enforcement, information exchange and training. The United States of America Department of State publishes an annual Trafficking in Persons (TIP) Report (2015) which ranks all countries on their efforts to acknowledge and combat human trafficking. Other countries have developed initiatives and policies; the United Kingdom passed the Modern Slavery Act (2015) which outlines offences, prevention, enforcement, victim protection, supply chain transparency and other related topics.
Despite the above efforts, human trafficking remains largely hidden. This is especially true of the physical and mental health sequelae associated with it. The systematic review and meta-analyses by Ottisova et al. (Reference Ottisova, Hemmings, Howard and Zimmerman2016) found high levels of violence while trafficked and high prevalence of physical illness, depression, anxiety, posttraumatic stress disorder and somatic symptoms in the post-trafficking period. Our first papers on human trafficking (Stewart & Gajic-Veljanoski, Reference Stewart and Gajic-Veljanoski2005; Gajic-Veljanoski & Stewart, Reference Gajic-Veljanoski and Stewart2007) revealed a dearth of high-quality studies, especially relating to health effects. The fact that Ottisova et al., using rigorous methodology, were able to identify 37 papers on health risks and outcomes is a most encouraging sign of a rapidly developing interest and research in trafficking! As the current authors point out, the papers were largely from low to middle-income countries, revealing gaps in information about human trafficking in developed regions, including the Gulf States that need to be addressed. The papers were also mostly conducted among women and girls trafficked into the sex industry, leaving further gaps about other forms of exploited labour in trafficked individuals-especially men. Notably only four studies were conducted in clinical settings, likely revealing the low rates of victim identification. Our study of Canadian medical students found that 88.8% of participants were not familiar with the signs and symptoms of trafficked persons, although 76% thought this was important to learn about in medical school, especially identifying trafficked persons and their health needs (Wong et al. Reference Wong, Hong, Leung, Yin and Stewart2011). It is unlikely that practicing health care providers, including psychiatrists, would score any better, suggesting the need for education on this topic at all levels of health service training and practice.
The high rates of exposure to physical or sexual violence while trafficked in 18 papers identified by Ottisova et al. are concerning but not surprising given previous research by the current authors and others. Violence is especially prevalent in men trafficked for exploited labour, women in the sex trade and in children. Despite the difficulties and fear many trafficked individuals experience in seeking health care, it is vital that trafficking be considered in all individuals seeking health care for conditions possibly related to violence.
Although high rates of mental disorders have been identified by trafficked men, women and children in several papers, the prevalence of trafficking in the overall population seeking mental health care is unknown as most are not identified. A very useful contribution of Ottisova et al.'s paper is their identification of risk factors for mental health problems in trafficked individuals. These include violence before and during trafficking, poor living and working conditions, restricted movement while trafficked, longer duration of exploitation and unmet social needs after escape; all factors commonly present in trafficked individuals. Sensitive inquiry into these general factors while assessing patients presenting with mental health disorders may assist in identifying more trafficking victims.
While the present scope of human trafficking is unknown, one must consider whether the current global refugee crisis might radically increase its prevalence. Desperation is a key motivator. Although there is confusion around the definitions of people smuggling and trafficking, people who chose to be smuggled can easily be trafficked if their freedom or finances are restricted at destination. Given the 4.6 million registered Syria refugees (United Nations High Commissioner for Refugees, 2016) and the over 40 million ‘populations of concern’ (United Nations High Commissioner for Refugees, 2015), human trafficking is likely to escalate. We need to scale up our education, identification, social and health services, including promising psychological and other interventions for trafficked individuals. Mental health services must play a vital role and the time to start was yesterday!