The Health of Trafficked Women: A Survey of Women Entering Posttrafficking Services in Europe

Abstract

Trained counselors interviewed 192 women who had been trafficked and sexually exploited about abuse and evaluated their physical and mental health status within 14 days of entry into posttrafficking services. Most reported physical or sexual violence while trafficked (95%), pre-trafficking abuse (59%), and multiple posttrafficking physical and psychological problems.

Newly identified trafficked women require immediate attention to address posttrauma symptoms and adequate recovery time before making decisions about participating in prosecutorial or immigration proceedings or returning home.

My wounds are inside. They are not visible.

—Moldovan woman trafficked to Italy

Human trafficking has been defined as the “recruitment, transportation or harboring of persons by means of threat or use of force or other forms of coercion, of abduction, of fraud or deceptions for the purpose of exploitation.”1 In practice, women and girls who are trafficked and sexually exploited are frequently lured by individuals known to them or their families with promises of jobs as waitresses, nannies, or cleaners, and then forced into sex work or exploited while working as domestic help, street beggars, or factory or agricultural laborers.

The trafficking of women and adolescents is increasingly recognized as one of the world’s fastest growing crimes and a significant violation of human rights.2 Despite the compelling need for evidence on the physical and psychological health consequences to inform rapidly emerging policies and services for trafficked persons, there is limited evidence about the needs of women who have been trafficked. We investigated the health of women and adolescent girls trafficked for sexual exploitation in Europe who were entering posttrafficking services.

METHODS

Study Design

Between January 2004 and June 2005, interviews were conducted with a consecutive sample of eligible women and adolescent girls accessing posttrafficking assistance services provided by nongovernmental and international organizations in Belgium, Bulgaria, Czech Republic, Italy, Moldova, Ukraine, and the United Kingdom. The multicountry design reflected the global nature of trafficking. Women judged to be psychologically unable to participate were excluded.

We followed the World Health Organization Ethical and Safety Recommendations for Interviewing Trafficked Women3 and conducted the study in secure service settings that offered access to health care and other assistance. Participants were interviewed by experienced counseling staff (psychologists or social-support workers) of partner organizations who were well positioned to react appropriately to difficult emotions, recognize when to terminate an interview, and organize medical care. Efforts were made to separate the study from the standard intake procedures and to stress the voluntary nature of participation to minimize any perceived pressure to participate.

Women’s physical symptoms were measured using a tool derived from the Miller Abuse Physical Symptoms and Injury Survey.4^,5 Mental health symptoms were measured with (1) the depression, anxiety, and hostility subscales of the Brief Symptom Inventory (a short validated alternative to its parent instrument, the SCL-90-R [Symptom Checklist-90-Revised])6^,7 and (2) the posttraumatic symptom scale from the Harvard Trauma Questionnaire,8 a set of 16 items derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for posttraumatic stress disorder (reexperiencing the trauma or intrusive memories, numbing or avoidance, and arousal).9

Both the Brief Symptom Inventory and the Harvard Trauma Questionnaire have been found to have very good reliability7^,9 and high internal consistency reliability,10^–14 and test–retest reliability, ranging from 0.79 to 0.84 for the Brief Symptom Inventory subscale measurements7 and 0.89 to 0.92 for the Harvard Trauma Questionnaire.13^,15 Although neither instrument has been validated among trafficked women, both have been used in cross-cultural settings and among other traumatized populations.11^,16^–21 Budget constraints prohibited clinical exams and diagnostic testing for this study.

The semistructured questionnaire was translated from English into Bulgarian, Czech, Italian, Lithuanian, Polish, Russian, and Ukrainian. Each version was back-translated and reviewed for cultural meaning by bilingual social workers, psychologists, or cultural mediators.

Data Analysis

Data was entered using EpiData Entry version 3.1 (EpiData Association, Odense, Denmark) and analyzed using Stata version 9 (StataCorp LP, College Station, Tex). The standard scoring method was used for Brief Symptom Inventory subscales (i.e., an overall symptom score was calculated from response options 0–4, with 0 meaning “not at all” and 4 meaning “extremely”).

For the Harvard Trauma Questionnaire, the standard cut-off item score of 2.5 or higher was used to indicate a probable post-traumatic stress disorder diagnosis among women who were in the trafficking situation for 1 month or more.

RESULTS

Of 213 women invited to participate, 212 agreed. Twenty interviews were excluded because the respondents did not meet the eligibility criteria (e.g., being in the assistance program less than 14 days, trafficked for sex work or domestic service). The final data came from 192 women and adolescent girls interviewed within 14 days of their entry into posttrafficking care.

Participants ranged in age from 15 to 45 years, with the largest group aged 21 to 25 years (42%). Most participants were interviewed in their countries of origin, with the largest groups from Moldova (38%) and Ukraine (26%; Table 1 ▶).

TABLE 1—

Characteristics of Female Trafficking Survivors (n = 192): Europe, 2004–2005

	No. (%)
Country where interviewed
Moldova	75 (39.1)
Ukraine	49 (25.5)
Italy	26 (13.5)
United Kingdom	18 (9.4)
Bulgaria	16 (8.3)
Czech Republic	5 (2.6)
Belgium	3 (1.6)
Country of origin
Moldova	72 (37.5)
Ukraine	50 (26.0)
Other Europeana	50 (26.0)
West African, Caribbeanb	12 (6.3)
No data	8 (4.2)
Age, y
15–17	23 (12.0)
18–20	41 (21.3)
21–25	80 (41.7)
26–45	47 (24.5)
No data	1 (0.5)
Marital status before trafficking
Single	135 (70.3)
Married/living as married	22 (11.5)
Separated/divorced	33 (17.2)
Widowed	1 (0.5)
No data	1 (0.5)
Maternal status
Children	73 (38.0)
No children	118 (61.5)
No data	1 (0.5)
Time spent in trafficking situation
1 day to 3 mo	64 (33.2)
3.1–6 mo	37 (19.3)
6.1 mo to 1 y	38 (19.8)
> 1 y	36 (18.8)
No data	17 (8.9)
Violence experienced before traffickingc,d
Any physical abuse	94 (48.9)
Any sexual abuse	59 (30.7)
Physical and sexual abuse	40 (20.8)
Physical or sexual abuse	113 (58.9)
None	79 (41.1)
Violence experienced during traffickingc,e
Any physical abuse	145 (75.5)
Any sexual abuse	172 (89.6)
Physical and sexual abuse	135 (70.3)
Physical or sexual abuse	182 (94.8)
None	10 (5.2)
Threats experienced during trafficking
Woman was threatened	171 (89.1)
Woman’s family was threatened	67 (34.9)
Woman and family were threatened	62 (32.3)
Personal freedoms experienced during traffickingf
Never	145 (75.5)
Seldom	20 (10.4)
Occasionally	9 (4.7)
Often	5 (2.6)
Always	7 (3.7)
No data	6 (3.1)

^aIncludes member states of the Organization for Security and Co-operation in Europe: Bulgaria, Czech Republic, Kyrgyzstan, Lithuania, Romania, Russian Federation, and Slovak Republic.

^bIncludes Cameroon, Nigeria, and Jamaica.

^cPercentages total to greater than 100% because most women reported more than 1 form of abuse.

^d To measure physical abuse experienced before being trafficked, participants were asked, “Before you left home, did any of the following people ever physically hurt you when you were a child or an adult?” To measure forced or coerced sexual intercourse, they were asked, “Before/after you were 15 years old did any of the following people ever make you or persuade you to do something sexual when you didn’t want to?”

^e To measure physical abuse experienced during trafficking, participants were asked, “Did anyone ever hit, kick, or otherwise physically hurt you? To measure forced sexual abuse, they were asked, “While you were in the trafficking situation, did anyone physically force you to have sex or do something sexual when you didn’t want to?” To measure coerced sexual abuse, they were asked, “Did you ever have sex with someone or perform some sexual act because you were afraid something bad would happen?”

^f To measure restrictions of personal freedoms, women were asked, “How often were you free to do what you wanted or go where you wanted?”

Experiences of Violence

More than half the women and adolescent girls (59%; Table 1 ▶) reported pretrafficking experiences of sexual or physical violence, and 12% had a forced or coerced sexual experience before age 15 years; 26% cited more than 1 perpetrator, with many naming a father or stepfather (data not shown).

Nearly all the women and adolescent girls (95%) reported physical or sexual violence while in the trafficking situation; 76% reported physical abuse, and 90% reported sexual abuse. There are complex psychological and social reasons, such as women’s perceptions of what constitutes sexual violence, ignorance of the crime of trafficking, self-blame, and stigma, that may help explain why some women did not report being sexually abused. Physical injuries were reported by 57% of the participants (data not shown). The participants cited severe restrictions of personal freedoms: 76% said they were “never” able to do as they wished or go where they wanted.

Physical Symptoms

The women and adolescent girls were asked about 26 physical symptoms experienced in the past 2 weeks and to rate how much this symptom bothered them (Table 2 ▶). Headaches (82%), feeling easily tired (81%), dizzy spells (70%), back pain (69%), memory difficulty (62%), stomach pain (61%), pelvic pain (59%), and gynecological infections (58%) were among the most common and severely felt symptoms.

TABLE 2—

Physical Symptoms and Severity Levels Experienced by Female Trafficking Survivors (n = 192): Europe, 2004–2005

		Symptom Severity Ranking, No. (%)
Symptom Category	Total No. (%)	Not Ranked	Not At All	A Little	Quite A Bit	Extremely/Very Much
Constitutional symptoms
Easily tired	156 (81.25)	2 (1.28)	. . .	38 (24.36)	49 (31.41)	67 (42.95)
Weight loss	91 (47.39)	. . .	4 (4.40)	24 (26.37)	23 (25.27)	40 (43.96)
Loss of appetite	119 (61.98)	. . .	3 (2.52)	43 (36.13)	27 (22.69)	46 (38.66)
Neurological symptoms
Headaches	158 (82.29)	. . .	2 (1.26)	33 (20.89)	38 (24.05)	85 (53.80)
Dizzy spells	135 (70.31)	. . .	. . .	44 (32.59)	48 (35.56)	43 (31.85)
Memory difficulty	119 (61.98)	1 (0.84)	2 (1.68)	35 (29.41)	36 (30.25)	45 (37.82)
Fainting	40 (20.83)	1 (2.50)	. . .	23 (57.50)	10 (25.00)	6 (15.00)
Gastrointestinal symptoms
Stomach pain	117 (60.94)	. . .	1 (0.86)	32 (27.35)	54 (46.15)	30 (25.64)
Upset stomach, vomiting, diarrhea, constipation	84 (43.75)	1 (1.19)	. . .	31 (36.9)	37 (44.05)	15 (17.86)
Urogenital symptoms
Urination pain	33 (17.19)	3 (9.09)	. . .	6 (18.18)	13 (39.40)	11 (33.33)
Pelvic pain	113 (58.85)	7 (6.20)	2 (1.77)	21 (18.58)	33 (29.20)	50 (44.25)
Vaginal discharge	134 (69.79)	2 (1.49)	2 (1.49)	32 (23.89)	45 (33.58)	53 (39.55)
Vaginal pain	48 (25.00)	. . .	. . .	20 (41.67)	17 (35.42)	11 (22.91)
Vaginal bleeding (not menstruation)	18 (9.38)	. . .	. . .	3 (16.67)	11 (61.11)	4 (22.22)
Gynecological infection	112 (58.33)	3 (2.68)	. . .	20 (17.86)	38 (33.93)	51 (45.53)
Cardiovascular symptoms
Chest/heart pain	96 (50.00)	. . .	1 (1.04)	40 (41.67)	39 (40.63)	16 (16.66)
Breathing difficulty	76 (39.58)	. . .	2 (2.63)	32 (42.11)	31 (40.79)	11 (14.47)
Musculoskeletal symptoms
Back pain	132 (68.75)	3 (2.27)	. . .	34 (25.76)	46 (34.85)	49 (37.12)
Fractures/sprains	24 (12.50)	. . .	3 (12.50)	9 (37.50)	5 (20.83)	7 (29.17)
Joint or muscle pain	68 (35.42)	1 (1.47)	2 (2.94)	18 (26.47)	29 (42.65)	18 (26.47)
Tooth pain	111 (57.81)	1 (0.90)	1 (0.90)	37 (33.33)	21 (18.92)	51 (45.95)
Facial injuries	18 (9.38)	1 (5.56)	. . .	4 (22.22)	6 (33.33)	7 (38.89)
Eye, ear, and upper respiratory symptoms
Eye pain	63 (32.81)	1 (1.59)	. . .	25 (39.68)	25 (39.68)	12 (19.05)
Ear pain	28 (14.58)	. . .	1 (3.57)	15 (53.58)	9 (32.14)	3 (10.71)
Cold, flu, sinus infection	58 (30.21)	. . .	4 (6.89)	26 (44.83)	17 (29.31)	11 (18.97)
Dermatological symptoms
Rashes, itching, sores	54 (28.13)	. . .	1 (1.85)	20 (37.04)	24 (44.44)	9 (16.67)

Note. The listed categories refer to general symptom groupings only. They are not intended to reflect a diagnosis or symptom origin for individual women.

Nearly two thirds (63%) of the participants reported more than 10 concurrent physical health problems upon entering posttrafficking programs, highlighting the compounding pain and discomfort experienced by a majority of this population.

Mental Health Symptoms

The Cronbach coefficient alpha measure of internal-consistency reliability for this sample was estimated to be 0.89, 0.91, and 0.77 for the Brief Symptom Inventory depression, anxiety, and hostility subscales, respectively, and 0.94 for the posttraumatic stress disorder subscale of the Harvard Trauma Questionnaire.

The mean scores for symptoms associated with depression, anxiety, and hostility were 2.09, 1.90, and 1.21, respectively, according to the Brief Symptom Inventory subscales (Table 3 ▶). Compared with a general US population of adult women, the study participants’ symptoms were in the 95th percentile and in the 51st percentile compared with female psychiatric patients. (This comparison rate is offered in the Brief Symptom Inventory manual and is derived from a population studied in the United States.7) Symptoms associated with depression were most often reported, with 39% of the participants acknowledging having had suicidal thoughts within the past 7 days.

TABLE 3—

Brief Symptom Inventory Mental Health Subscale Scores of Female Trafficking Survivors (n = 189): Europe, 2004–2005

		Percentile Ranking in Comparison With Published Normsa
Subscale	Mean Score (95% CI)	Nonpatient	Psychiatric Outpatient
Depression	2.09 (1.94, 2.23)	98th	51st
Anxiety	1.90 (1.76, 2.04)	97th	51st
Hostility	1.21 (1.10, 1.33)	95th	51st

Note. CI = confidence interval.

^a Trafficked women’s Brief Symptom Inventory subscale scores were compared with available published norms of a US-based adult female nonpatient population and an adult female psychiatric outpatient population.

More than half of the women and adolescent girls (57%) scored at or above the 2.5 cut-off point in the posttrauma-symptom subset of the Harvard Trauma Questionnaire, suggesting posttraumatic stress disorder (data not shown). Only the participants who had been trafficked for more than 1 month (89%) were included in this analysis, to meet the criteria that symptoms associated with posttraumatic stress disorder were present 1 month or more following traumatic events.9

DISCUSSION

To our knowledge, this was the first study to quantitatively document the health symptoms of trafficked women and adolescent girls. A study of this nature has several significant challenges. In particular, because we excluded women and adolescent girls still in the trafficking situation (because of the high risk of harm and our inability to provide assistance) and those who never sought assistance, this sample of women and adolescent girls accessing services undoubtedly represents the smallest minority of women and girls who are trafficked. It is unclear how well these findings apply to all trafficked women.

Because no instruments were previously validated in this population, we drew on several tools validated in culturally diverse populations exposed to high levels of trauma. These instruments may have failed to fully capture the unique and extreme features of the physical and psychological trauma and the culturally different ways these were experienced or expressed by these women and adolescent girls.

Despite these limitations, we believe we provide urgently needed empirical data for policies and services. The severe symptom patterns identified suggest that diagnostic and treatment services should be made immediately available to survivors of trafficking. Dissecting the constellation of women’s symptoms and formulating treatment plans are not likely to be easy or short-term tasks. For example, gastrointestinal problems are well-described somatic manifestations of anxiety and stress,22 but for trafficked women, they may also be associated with poor nutrition or sexual and urogenital problems.

Further complicating diagnosis and care is trafficked women’s complex history of pretrafficking and trafficking-related violence. Existing studies on violence suggest that multiple exposures to trauma of this type can have multiple long-term effects on women’s health.23^,24 Services for such women should be based on good practices used for victims of domestic violence, sexual assault, and torture and for migrants and refugees. These include strategies for crisis intervention, confidentiality, security, shelter, social support, forensics, counseling, and medical cultural competency.

The symptoms found in our sample of trafficked women and adolescent girls reveal that when authorities (e.g., police and immigration personnel) encounter trafficked women, the women are likely to be suffering pain and distress, especially memory problems that may affect their ability to engage in criminal investigations and asylum petitions. For example, during police interrogations, women may be unable to immediately recall details of the crime, substantiate their status as a victim, or make decisions about cooperating in a prosecution. Legal procedures should ensure that trained health staff and support resources are immediately available to help alleviate pain and provide necessary care.

Trafficking survivors are often quickly deported or obliged to cooperate in criminal investigations as a condition of assistance.25 For women who agree to participate in legal proceedings, investigative and judicial procedures should be developed that are sensitive to possible memory difficulties, psychological distress, and victim protection needs. The multiplicity and severity of symptoms indicate that trafficked women may not be capable of making rapid decisions about their safety. Granting trafficking survivors an adequate period of recovery and reflection (i.e., temporary legal residency with access to posttrafficking services) or asylum status might foster improvements in survivors’ health and enable them to make considered decisions about their security and future well-being.

In the study sites, organizations assisting trafficking survivors struggled to acquire adequate human and financial resources to provide the necessary support. Given that the abuse suffered by trafficking victims occurs on the territory of destination states and is often perpetrated by, or involves the participation of, citizens of these states, their governments have an obligation to fund and foster services that aim to help survivors to regain their health, well-being, and dignity.