Ottisova et al. (Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) in their updated systematic review of 37 studies on prevalence and risk of violence and physical, mental and sexual health problems among trafficked people, provide a sound overview of the state of epidemiological research in these fields. The researches included in the review tend to confirm high rates of experience of violence inflicted to victims during and in some cases before trafficking, and a high prevalence of symptoms suggestive of anxiety, depression and post-traumatic stress disorder (PTSD). However, as far as mental health is concerned, the heterogeneity within results for each mental disorder −i2 = 97.0–98.5% (Ottisova et al.
Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue)- would question investigation methods and highlight how this body of enquiry is limited in scope and hampered by the quality of sample size and selection, thematic focus and reliability of the tools adopted. Indeed, the overall epidemiological mental health research in this domain still focuses primarily on women trafficked for sexual exploitation, on victims within post rescue-assistance programmes, is for the large part not longitudinal and based on self-report checklists rather than clinical interviews, and in the case of PTSD, in some instances, on old symptomatology surpassed by recent revisions of relevant diagnostic manuals. As such it introduces biases that do not allow for reliable and definitive gender, population or regional comparative analyses. The same biases make it difficult to correlate specific pathologies with forms of exploitation, spectrums of violence, sectors of employment and distance in time from the trafficking experience. The limitations of conducting mental health epidemiological research on victims of trafficking are, however, objective and difficult to overcome.
First, trafficking is a global phenomenon, invests multiple industries and forms of exploitations, and intensity of violence. It regards different populations, genders and age groups.Footnote
1
As much as human traffickers continually change their means of control and patterns of exploitation, so too does the psychological experience of victims and related mental health and psychosocial support interventions. Ottisova et al. (Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) imply that there is still a temporal research lag towards a precise understanding of the impact on changes of means of control and patterns of exploitation used by human traffickers as well channels of supply and demand and the socio-demographic background of victims and perpetrators and how this may, if at all, impact on prevalence and risk of violence and the associated mental, physical and sexual health problems. While it is true that analysing these correlations and differentiations would be necessary in order to have a comprehensive vision of the mental health problems at stake, statistical cross-analysis of these data across regions, populations and trafficking experiences may be not only difficult to make but probably unnecessary in terms of informing response programmes that require to be context and population specific. In this sense, context and population-specific epidemiological data could be corroborated and complemented by qualitative research that could give valid information and provide for a more composite understanding of these correlations and differentiations.
Moreover, longitudinal research would be necessary to understand the complex and complete experience of rehabilitation and reintegration of an individual from a trafficking experience over time, which is a most relevant information for the design of effective mental health and psychosocial programming and responses. However, this would mean to continue reminding victims of their experiences past, in reintegration contexts where association of the individual with an experience of trafficking can bring to stigmatisation. This creates ethical constraints, highlighting the necessity to consider the best interest of the individuals involved. During the reintegration path, victims may have other urgent priorities to attend to rather than be the subject of a research of the sort. By contrary and not to generalise, full considerations should be given to the willingness of some victims to make their experience of value for others through testimony and research thus informing advances in the rehabilitation, reintegration and support programmes for victims of trafficking in their same context.
A final consideration is that while for research of mental health outcomes, self-report checklists are usually a less valid investigation tool than clinical interviews; the latter are not always possible with victims after rescue, due to environmental, administrative and time constraints, as well as choices and priorities of the victims. Moreover, investigation checklists may be the most appropriate tool for the reduced cognitive capacities of individuals under toxic levels of stress (Lupien et al. Reference Lupien, McEwen, Gunnar and Christine2009).
To conclude, the cumulative result of the researches critiqued in the systematic review ‘indicates a high burden of mental and physical health problems’ (Ottisova et al. Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue). Biases and limitations in the researches are evident and probably unavoidable, but these do not undermine this general indication and specific vulnerability to anxiety, depression and PTSD, that regard men, women and children of different contexts and coming from trafficking experiences alike. Quite the contrary, these data are critical to informing advocacy purposes and advancements. For these data to be relevant to programmes more research is needed, but in the words of the authors ‘the next critical step […] is to investigate potentially effective psychological interventions […]’ (Ottisova et al. Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) and those assessments should be context and populations-specific, and adapted to the different needs of different rehabilitation and reintegration paths. In so doing this should switch the focus from a need-based approach into a right-based one, since, as stated in the relevant international protocols, access to mental health care and forms of counselling and psychosocial support is a fundamental right of the victims of trafficking and an integral part of their reparation (refer to Art. 6, 7, 8 UN, 2000; OHCHR, 2002; Chapter III, Council of Europe, 2005). This right is however in some experiences of assistance and reintegration of victims limited by the unavailability of specialised and focused mental health services in places where the victims come from and return to. Ensuring the existences of these services must remain a priority of programmes and interventions; And in providing these services for victims of trafficking in areas where they were previously unavailable, entire communities of return can gain access to a fundamental service, limiting environmental vulnerabilities of all and therefore mitigating risk of new or repeat instances of trafficking.
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Ottisova et al. (Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) in their updated systematic review of 37 studies on prevalence and risk of violence and physical, mental and sexual health problems among trafficked people, provide a sound overview of the state of epidemiological research in these fields. The researches included in the review tend to confirm high rates of experience of violence inflicted to victims during and in some cases before trafficking, and a high prevalence of symptoms suggestive of anxiety, depression and post-traumatic stress disorder (PTSD). However, as far as mental health is concerned, the heterogeneity within results for each mental disorder −i2 = 97.0–98.5% (Ottisova et al. Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue)- would question investigation methods and highlight how this body of enquiry is limited in scope and hampered by the quality of sample size and selection, thematic focus and reliability of the tools adopted. Indeed, the overall epidemiological mental health research in this domain still focuses primarily on women trafficked for sexual exploitation, on victims within post rescue-assistance programmes, is for the large part not longitudinal and based on self-report checklists rather than clinical interviews, and in the case of PTSD, in some instances, on old symptomatology surpassed by recent revisions of relevant diagnostic manuals. As such it introduces biases that do not allow for reliable and definitive gender, population or regional comparative analyses. The same biases make it difficult to correlate specific pathologies with forms of exploitation, spectrums of violence, sectors of employment and distance in time from the trafficking experience. The limitations of conducting mental health epidemiological research on victims of trafficking are, however, objective and difficult to overcome.
First, trafficking is a global phenomenon, invests multiple industries and forms of exploitations, and intensity of violence. It regards different populations, genders and age groups.Footnote 1 As much as human traffickers continually change their means of control and patterns of exploitation, so too does the psychological experience of victims and related mental health and psychosocial support interventions. Ottisova et al. (Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) imply that there is still a temporal research lag towards a precise understanding of the impact on changes of means of control and patterns of exploitation used by human traffickers as well channels of supply and demand and the socio-demographic background of victims and perpetrators and how this may, if at all, impact on prevalence and risk of violence and the associated mental, physical and sexual health problems. While it is true that analysing these correlations and differentiations would be necessary in order to have a comprehensive vision of the mental health problems at stake, statistical cross-analysis of these data across regions, populations and trafficking experiences may be not only difficult to make but probably unnecessary in terms of informing response programmes that require to be context and population specific. In this sense, context and population-specific epidemiological data could be corroborated and complemented by qualitative research that could give valid information and provide for a more composite understanding of these correlations and differentiations.
Moreover, longitudinal research would be necessary to understand the complex and complete experience of rehabilitation and reintegration of an individual from a trafficking experience over time, which is a most relevant information for the design of effective mental health and psychosocial programming and responses. However, this would mean to continue reminding victims of their experiences past, in reintegration contexts where association of the individual with an experience of trafficking can bring to stigmatisation. This creates ethical constraints, highlighting the necessity to consider the best interest of the individuals involved. During the reintegration path, victims may have other urgent priorities to attend to rather than be the subject of a research of the sort. By contrary and not to generalise, full considerations should be given to the willingness of some victims to make their experience of value for others through testimony and research thus informing advances in the rehabilitation, reintegration and support programmes for victims of trafficking in their same context.
A final consideration is that while for research of mental health outcomes, self-report checklists are usually a less valid investigation tool than clinical interviews; the latter are not always possible with victims after rescue, due to environmental, administrative and time constraints, as well as choices and priorities of the victims. Moreover, investigation checklists may be the most appropriate tool for the reduced cognitive capacities of individuals under toxic levels of stress (Lupien et al. Reference Lupien, McEwen, Gunnar and Christine2009).
To conclude, the cumulative result of the researches critiqued in the systematic review ‘indicates a high burden of mental and physical health problems’ (Ottisova et al. Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue). Biases and limitations in the researches are evident and probably unavoidable, but these do not undermine this general indication and specific vulnerability to anxiety, depression and PTSD, that regard men, women and children of different contexts and coming from trafficking experiences alike. Quite the contrary, these data are critical to informing advocacy purposes and advancements. For these data to be relevant to programmes more research is needed, but in the words of the authors ‘the next critical step […] is to investigate potentially effective psychological interventions […]’ (Ottisova et al. Reference Ottisova, Hemmings, Howard, Zimmerman and Oram2016, this issue) and those assessments should be context and populations-specific, and adapted to the different needs of different rehabilitation and reintegration paths. In so doing this should switch the focus from a need-based approach into a right-based one, since, as stated in the relevant international protocols, access to mental health care and forms of counselling and psychosocial support is a fundamental right of the victims of trafficking and an integral part of their reparation (refer to Art. 6, 7, 8 UN, 2000; OHCHR, 2002; Chapter III, Council of Europe, 2005). This right is however in some experiences of assistance and reintegration of victims limited by the unavailability of specialised and focused mental health services in places where the victims come from and return to. Ensuring the existences of these services must remain a priority of programmes and interventions; And in providing these services for victims of trafficking in areas where they were previously unavailable, entire communities of return can gain access to a fundamental service, limiting environmental vulnerabilities of all and therefore mitigating risk of new or repeat instances of trafficking.