Human Trafficking and health: a cross-sectional survey of NHS professionals’ contact with victims of human trafficking

Objective: 1) estimate proportion of NHS professionals who come into contact with trafficked people and 2) measure knowledge and confidence to respond to human trafficking.

Cross-sectional survey at training sessions. N=782 (response rate 84.4%) in variety of health professions.

Results:

• 13% had previous contact with HT victim
  • this was 20% among maternity service professionals
  • knowledge was due to another professionals’ disclosure (25%), patient disclosure (32%) , other reasons (11%) including foster care or police, unknown (32%)
• 86.8% reported lacking knowledge on what questions to ask to identify potential victims
• 78.3% had insufficient training to assist victims
• 71%, 67.5% and 53.4% lacked confidence in making referrals for men, women, and children respectively.
• 95.3% were unaware of the scale of HT in the UK
• 76.5% were unaware that calling the police could put people in more danger

Did cronbach’s alpha for subscales, and MLE factor analysis

 

Understanding Victim Resistance: An Exploratory Study of the Experiences of Service Providers Working with Victims of Child Trafficking

Amanda West and  Diane N. Loeffler. 2015. Journal of Applied Research on Children: Informing Policy for Children at Risk. 6(1):

“client resistance can be defined as a normative response stemming from ambivalence in the face of a life change”The purpose of this exploratory, qualitative study was to better understand the experiences of those who have been trafficked and their relationship(s) with the provision of available services. Interviewed 15 services providers (2 males; 3 non-white).

– judgements re: how a victim should behave contribute to resistance. e.g. “good” and “bad” victims

– identification with the trafficker — “the bond that the victim develops with the trafficker can be a significant hindrance to seeking and using services. (page 8)”.

– Self-identification as a victim of any type of abuse, let alone an exploitive and systemically enforced process of abuse, is a significantly difficult process.

– building trust “…with victims was described as both essential and time-consuming, requiring the financial resources that can withstand this extended period, which are often limited because of a shortage of funding in human services programming (page 11).”

– perceived punitive relationship and lack of empowerment

The Role of Youth Problem Behaviors in the Path From Child Abuse and Neglect to Prostitution: A Prospective Examination

Helen W. Wilson and  Cathy Spatz Widom. 2010. Journal of Research on Adolescence. 20(1): 210–236

Like the research here and the pathways analysis. I have difficulty  with the language “problem behaviors” of the young person and “neorologically based weaknesses” — seems to put the individual responsibility for preventing future abuse on the child. Though to be fair the authors clearly note in their discussion that these “problem behaviors” are (maladaptive) coping mechanisms to toxic stress/abusive situations.

Behaviors beginning in childhood or adolescence may mediate the relationship between childhood maltreatment and involvement in prostitution. This paper examines five potential mediators, of which 4 were significant:

1. early sexual initiation – indicates risk for sexual risk taking; strongest predictor
2. running away – survival sex, being around “deviant” peer group that normalizes prostitution
3. juvenile crime – indicates devient behavior
4. school problems – disadvantage in terms of getting jobs
5. early drug use — no relationship observed. but contrary to a lot of literature.

prospective cohort design — abused and neglected children (ages 0–11) matched with non-abused, non-neglected children and followed into young adulthood. In-person interviews at age 29 and arrest records through 1994. Structural Equation Modeling tested path models.

Results:  victims of abuse and neglect were at increased risk for all problem behaviors, except drug use. Only early sexual initiation was significant as a mediator in the pathway from child abuse and neglect to prostitution. Findings were consistent for physical and sexual abuse and neglect.

Findings suggest that interventions to reduce problem behaviors among maltreated children may also reduce their risk for prostitution later in life.

Adolescent female sex workers: Invisibility, violence, and HIV

Jay Silverman. 2011. Archives of Disease in Childhood. 96: 478-481

Strategies that address STI and HIV prevention among FSWs in international context (India, Nepal, Thailand, Canada) do not readily apply to adolescents.

Cites literature that 20-40% of FSWs enter commercial sex work as adolescents. Notes that of the 8 studies including data on the relationship between age or age at entry and HIV, 6 demonstrate that younger FSWs are at greater risk for HIV. Greater risk due to:

• biological reasons:
  • greater cervical ectopy, providing increase opportunity for infection
  • repeated trauma (sexual violence) to immature genital tract increases likelihood of tearing, increasing risk of infection
• greater violence
  • Violence against FSWs (being beaten and raped) generally is prevalent and leads to greater infection rates. But vulnerability to violence is greater among adolescents. Emotional distress (e.g. attempted suicide) is prevalent.
•  relatively high levels of sexual risk behaviors — less power to negotiate condom use, greater condom failure, less condom use, more anal sex. A study of ‘trafficked’ FSWs (90% were adolescents) were significantly more likely to report these sexual risk exposures, and lower levels of HIV knowledge.
• Younger FSWs report more clients per day than older FSWs.
• Experience of violence linked to lower ART initiation and adherence and higher risky alcohol use, which in turns compounds the other risk factors.

Author asserts adolescents are invisible form the literature for several reasons:

• ethical constraints re: research with vulnerable minors
• hierarchical structure of commercial sex work, which  participatory models do not acknowledge. problematic if adolescents are there involuntarily
• if adolescents are considered “trafficked”, reporting becomes necessary, which means less cooperation from sex work managers, which means researchers “don’t ask don’t tell” leading to invisibility

HIV researchers and child advocates do not tolerate each other but need to come together.

‘Moved around like bags of rubbish nobody wants’: How multiple placement moves can make young women vulnerable to sexual exploitation

Maddy Coy. 2009. Child Abuse Review. 18:254-266

An exploratory study but one of the better ones on CSEC.

This paper takes theory seriously and delves into the relationship between foster care and multiple placements on the one hand, and vulnerability to exploitation on the other. “By exploring how looked after young women describe frequent placement moves as instrumental in their routes into prostitution, the paper attempts to map some possible links between stability and outcomes.”

Addresses how sense of identity is developed… and gives insights into the vulnerability of young women to coercive pressures, economic desperation.

(*Note – language below pasted from the original article. Language is not my own.)

Culture of care defined as discontinuity in placements, instability and multiple placements.

Based on Bourdieu’s (1977) notion of habitus — describes how environments create a set of attitudes that determine identity formation and subsequent actions in accordance with self-identity. Helps understand how the generative force of environments and previous experiences influence action.

• 6 of the 14 women directly linked their involvement in prostitution to their care experiences.
• 10 disclosed CSA
• most felt abuse and neglect did not stop once in care

Women described:

• severance of bonds with others and the distress it caused
• frequent and unexpected changes without consultation
• inability to assert their own needs and desires
• Disinvestment in the placements; some resisted attempts to settle where they perceived their views were disregarded
• an inability to settle emotionally as well as geographically; inability to develop meaningful relationships with non-abusive adults or authority figures
• street prostitution community as a “family”

Running away is:

• a form of protest at not being heard
• a striving to assert own voice and choices
• rejection of support services may represent attempt to retain sense of control over one’s life

Selling sex and vulnerability to exploitation is due to:

• unable to support themselves financially; lack of options for housing, resources
• coercion
• willingness to conform to others’ expectations (in seeking stability)
• a way of exercising agency/autonomy, even if it involved self-harm

 

 

 

Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States

J M Edwards, B J Iritani, D D Hallfors. Sexually Transmitted Infections. 2006. 82:354-358

Data from National Longitudinal Study of Adolescent Health waves I (1995) and II (1996). Estimate among the general adolescent population.

Lifetime prevalence of exchanging sex 3.5%, and  2/3 of these are boys. Odds are higher for African American youth, youth in single parent HH, and youth with parent with less than HS education.

Odds of exchanging sex are higher for youth who:

• had used drugs (more likely to ever use alcohol or binge drink, use marijuana, cocaine, injection drugs, other illegal drugs, inhalants, cigs, snuff)
• had run away from home (nearly 3x as many had runaway among those who exchanged sex)
• were depressed (2x as many were depressed among those who exchanged sex)
• and had engaged in sexual risk behaviors.

Similar correlates for boys and for girls.

Among boys:

• same mean age first intercourse
• nearly 5x more lifetime sex partners
• more same sex behaviors than those not exchanging sex; but most partners are opposite sex. (NOTE it is not known if the partners with whom sex was exchanged were same or opposite sex.)
• 10x more likely to have forced someone to have sex
• 15% or girls (compared to 2% who did not exchange sex) had STI

Among girls:

• younger mean age at first intercourse but not significant
• more same sex behaviors than those not exchanging sex; but most partners are opposite sex. (NOTE it is not known if the partners with whom sex was exchanged were same or opposite sex.)
• 2x more likely to have been forced to have sex
• 20% or girls (compared to 4% who did not exchange sex) had STI

15% of boys and 20% of girls who had exchanged sex had reported being told they had HIV or another STI. Elevated risk of STIs may result from more partners, risky partners, and more unprotected sex.

Need to better understand the context and youths’ definition or perception of “sex exchange”. Where do sex exchanges occur? who are the partners? what precipitates the exchange?

Prevalence and Correlates of Survival Sex among Runaway and Homeless Youth

Greene, Jody M., Susan T. Ennett, Christopher L. Ringwalt. American Journal of Public Health. 89(9):1406-1409

Data source: sample of shelter youth (national; probability sample) and convenience sample of street youth in 10 cities. Data collection in 1992.

“Survival sex is an economic survival strategy linked to the circumstances and duration of homelessness.”

– Evident by the positive relationship between participation in survival sex and length of time away from home

– Rates of survival sex were greater among street sample than among shelter sample; and greater among shelter sample with previous street experiences than among those without street experiences.”

– Both street and shelter youth were twice as likely to report survival sex if they also reported physical ause by family members. Among shelter youths, emotional abuse and drug use were also correlates.

– Prostitution is among the sequelae of abuse

—> Need alternative to sex trade to meet basic needs

Trading Sex: Voluntary or Coerced? The Experiences of Homeless Youth

Tyler, Kimberly A. & Johnson, Katherine A.. Journal of Sex Research: 43(3):208-216.

Qualitative interviews with homeless youth in 4 Midwest states. 13 of the 40 had some experience with trading sex for money.

• 4 (1 female, 3 male) were propositioned but refused; they believed they had other options to have their needs met (e.g. high service utilizers)
• 7 (all female) had direct experience – most through coercion or manipulation, including being desperate for food, shelter, or drugs. All with multiple abuse experiences in early life.
• 3 (2 male, 1 female) had friends/acquaintances who traded sex

Authors note it’s not always easy to tell when “decision” to trade sex (even if due to desperation) could be called voluntary.

Also trading sex led to victimization for some young women.

Trafficking in the Mekong region and health

Kiss, L., Pocock, N. S., Naisanguansri, V., Suos, S., Dickson, B., Thuy, D., … others. (2015). Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study. The Lancet Global Health, 3(3), e154–e161.

F-t-F interviews with 1102 people receiving post-trafficking services in Cambodia, Thailand, Vietnam. Measured anxiety and depression (Hopkins symptom checklist), PTSD (Harvard Trauma Qnnr), living and working conditions, violence, health. The worse the conditions, the more likely respondents were to report health and mental health problems. Conclusions: There is no single profile of a trafficked person. This is base don the inclusion of adult men and labor trafficked individuals in the sample. This has implications for post-trafficking services. Still, there are common patterns of abuse and health consequences.

Some figures:

– 32% in sex work

– 35% of females reporting sexual violence

– 61% with depression, 43% with anxiety, 39% with PTSD, 2% with suicidality

Symptoms more likely among those with restricted freedom, threats, or severe violence

– extreme restriction (never being free) reported by 75% of men, 66% of women, 33% of children (31% of girls, 51% of boys)

Among minors m(n=344),

– 20% were age 10-14

– 58% in sex work (contrast with 44% of adult women, <1% of adult men)

Another article about CSEC and health

Greenbaum, J., Crawford-Jakubiak, J. E., &amp; COMMITTEE ON CHILD ABUSE AND NEGLECT. (2015). Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims. PEDIATRICS, 135(3), 566–574. http://doi.org/10.1542/peds.2014-4138

The article has some guidance for pediatricians. Most of it is nonspecific and cannot really be used to guide action. This is largely awareness raising.

1. victims may present for a variety of reasons. This is not specific enough to be helpful, but the authors note that youth may have numerous referrals.

2. Victims rarely self-identify. The authors note some risk factors but most of the list is not easily accessible to medical personnel (CPS involvement, law enforcement/JJ system involvement, running away, truancy, child maltreatment history). Multiple STIs or pregnancy. Substance use.

3. Evaluations are challenging so be nonjudgmental and open.

4. Medical evaluations involve assessing the reasons youth came in for treatment. This is a non

5. Advocate for youth by educating professionals and provide guidance on internet safety.

6. CSEC falls under mandated reporting requirements. Authors note that reporting may not lead to positive interventions and can be harmful. But they do not suggest how practitioners should deal with this situation.