1. Mental health and
human trafficking
Dr Sian Oram, Dr Melanie Abas,
Charlotte MacKenzie, Dr Cathy Zimmerman,
Prof Louise M Howard.
PROTECT - Provider Responses, Treatment and Care for Trafficked People

2. What is human trafficking?
• (a) the recruitment or
movement of persons
• (b) most often by force,
fraud, coercion or deception
• (c) for the purposes of
exploitation.
(United Nations, 2000)

3. Types of exploitation
• Forced sex work
• Domestic servitude
• Forced or exploitative labour in:
– Agriculture
– Construction
– Food packaging and processing
– Nail bars
– Restaurant and hotel trade
– Markets, street selling and shop work
• Forced criminality, (e.g. cannabis cultivation,
theft, and begging).
• Organ harvesting.

4. Human trafficking in the UK
2,077 potential victims known to services in 2011:
• 54% female
• 69% adult
• 75 countries of origin, including Romania (10%), Slovakia
(8%), Nigeria (8%), Poland (8%), and Czech Republic (8%).
• 31% sexually exploited, 22% exploited in labour
settings, 17% exploited through criminal activity, 11%
exploited through domestic servitude.
(SOCA Intelligence Assessment 2011).

5. Health risks associated with human
trafficking
• Physical abuse, deprivation
• Threats, intimidation, abuse
• Sexual abuse
• Substance misuse
• Social restrictions, emotional abuse
• Economic exploitation
• Legal insecurity
• Occupational hazards
• Social marginalization

6. Stages of the trafficking process
Post-trafficking
Exploitation Detention
STRESSORS
Prosecution
Asylum
Travel processes
Repatriation
Pre-departure Re-trafficking
Zimmerman et al Social Science & Medicine 2011

7. Systematic review: health problems among
trafficked people
• 16 studies identified
• 4 collected data on mental health outcomes
Cwikel 2004 Tsutsumi 2008 Hossain 2010 Ostrovschi 2011
N=84 N=44 N=204 N=120
- 97.7% 48.0%
Anxiety (HSCL-25) (BSI)
Depression 57.1% 100.0% 54.9% 16.7%
(CES-D) (HSCL-25) (BSI) (SCID)
PTSD 19.5% 29.5% 77.0% 35.8%
(PCL-C) (PCL-C) (HTQ) (SCID)
Oram et al Plos Medicine 2012

8. Mental health needs and use of
services
• Previous studies of human trafficking and mental disorder:
– are mainly limited to women trafficked for sexual exploitation
– have been conducted with shelter samples.
• No research describing the clinical profile of trafficked people in contact with
health services, or their use of healthcare.
• We aimed to:
– Describe the number, socio-demographic, and
clinical characteristics of identified trafficked
people in contact with a large inner city
mental health service;
– Identify trafficked people’s pathways into
mental health services compared with non-
trafficked people.

9. Methods
• Study population:
– SLaM service users whose clinical records indicate they may have
been trafficked;
– SLaM service users who have not been trafficked, matched for
gender, age (+/- 2 years), primary diagnosis, type of initial
care, and year of most recent contact.
• Identification of study population:
– Case Register Interactive Search (CRIS) database (Stewart et al
2009)
– 200,000 patient records.
– Covers service use between 2006 and 2012.
– Anonymised and searchable
– Updated daily

10. Case Register Interactive System

11. Identifying the cohort
Step 1: Free text searches 1. Victim of trafficking
2. Sex trafficking
691 patient records contained 1+ search 3. Trafficked
terms 4. Traffiked
5. Poppy project
Step 2: Screening 6. Sex traffickers
One researcher assessed eligibility. 7. Human trafficking
8. Forced prostitution
Second researcher independently assessed 9. Child trafficking
10. People trafficking
the first 10 records and an additional 11. Trafiked
random 10%. 12. Forced labour
13. Trafficking
14. Sexual slavery
135 records of people who had been
trafficked: 98 adults and 37 children.
Step 3: Data checking
86 trafficked adults with a diagnosed psychiatric disorder
Step 4: Random generation of matched non-trafficked adult service user records
315 non-trafficked adult service users
Exposed: non-exposed = 1: 3.7

12. Adult trafficked service users:
socio-demographic characteristics
N=98
Female 79 (80.6)
Mean age at first contact with services 26.8 (SD 6.8, range 18-49)
Marital Status:
• Single 71 (72.4)
• Married/cohabiting 6 (6.1)
• Divorced 5 (0.5)
• Widowed 1 (0.1)
• Unknown 15 (15.3)
Interpreter Required 39 (39.8)

13. Adult trafficked service users: countries of
origin
Most common
countries of
origin
(n) % 5 most common
Nigeria 17 17.3 countries of
China 9 9.2 origin
Uganda 7 7.1
Other countries
Albania 6 6.1
of origin
Lithuania 6 6.1
Not countries of
origin

14. Adult trafficked service users:
experiences
Trafficking characteristics N=98
Types of exploitation
• Sexual exploitation 56 (57.1)
• Domestic servitude 11 (11.2)
• Other labour exploitation 9 ( 9.2)
• Unknown 25 (25.5)
Mean age in yrs when trafficked (SD, range) 22.4 (SD 7.3, range 9-42)
(n=57)
Median duration in yrs of trafficking (range) 1.5 (0-14)
(n=37)

15. Adult trafficked service users: primary
diagnoses

16. Adult service users: routes into SLaM care
Trafficked Non Trafficked X2 statistic
Service Users Service Users (P Value)
N=86 n=315
Accident & Emergency 27 (31.4) 103 (32.7) 0.05 (0.819)
Department
General Practitioner 29 (33.7) 104 (33.0) 0.01 (0.902)
Maternity Services 8 (9.3) 9 (2.9) 6.91 (0.009)**
Other Clinical Speciality 8 (9.3) 19 (6.0) 1.15 (0.283)
Other Mental Health Trust 1 (1.2) 11 (3.5) -
Police 3 (3.5) 14 (4.4) -
Self 0 (0.0) 18 (5.7) -
Social Services 2 (2.3) 7 (2.2) -
Voluntary Sector 3 (3.5) 1 (0.3) -
Other 2 (2.3) 10 (3.2) -
Unknown 2 (2.3) 18 (5.7) -
* p<0.05; ** p<0.01

17. Adult service users: use of SLaM services
Trafficked Non Trafficked X2 value
Service Users Service Users (P value)
n=86 n=315
Median duration of contact with SLaM 603 316 n/a
services (days) (range) (2-3395) (1-5451)
Detained under Mental Health Act (S2 or 20 (23.3) 38 (12.1) 6.8402
S3) (0.009)**
Subject to Mental Health Act S136 9 (10.5) 15 (4.8) 3.9052
(police section) (0.048)*

18. Summary
• Mental health services in South
London are caring for trafficked
people with a range of diagnoses
• Early findings suggest that, compared
to matched controls, trafficked
people are more likely to:
– be referred for psychiatric care by
maternity services;
– be detained under the Mental Health
Act;
– have adverse pathways to care (i.e.
Section 136).

19. Implications
• Mental health professionals need
to be aware of indicators of
possible trafficking and how to
respond;
• Maternity services may be an
important route to mental health
care;
• Research is needed on the
effectiveness of mental health
interventions for this group of
patients.

20. Planned CRIS research
• Adults: for trafficked and non-trafficked service
users, compare:
– Functioning at referral and discharge using the Health of the
Nation Outcome Scale;
– Clinical care pathways;
– The pharmacological and psychological therapies received;
• Children: describe clinical and service use
characteristics.

21. Acknowledgements
This report is independent research commissioned and funded by the Department of Health
Policy Research Programme (Optimising Identification, Referral and Care of Trafficked People
within the NHS 115/0006). This study was supported by the Clinical Records Interactive Search
(CRIS) system funded and developed by the National Institute for Health Research (NIHR)
Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation
Trust and King’s College London and a joint infrastructure grant from Guy’s and St Thomas’
Charity and the Maudsley Charity. The views expressed in this publication are those of the
author(s) and not necessarily those of the Department of Health. The sponsors had no further
role in the study design; in the collection, analysis or interpretation of data; in the writing of the
report; and in the decision to submit the paper for publication.
PROTECT - Provider Responses, Treatment and Care for Trafficked People

22. References
• IOM/LSHTM (2009) Caring for Trafficked People: Guidance for Health Providers. Geneva:
International Organization for Migration.
• Oram S, Stoeckl H, Howard LM, Zimmerman C, Busza J (2012). Prevalence and risk of
violence and the physical, mental and sexual health problems associated with human
trafficking: systematic review. PLoS Med 9(5): e1001224
• SOCA (2012). UKHTC: A Baseline Assessment on the Nature and Scale of Human
Trafficking in 2011. London: Serious Organised Crime Agency.
• Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, Hotopf M,
Thornicroft G, Lovestone S. The South London and Maudsley NHS Foundation Trust
Biomedical Research Centre (SLAM BRC) Case Register: development and descriptive
data. BMC Psychiatry 2009; 9: 51.
• United Nations Protocol to Prevent, Suppress, and Punish Trafficking in persons,
especially women and children, supplementing the United Nations Convention Against
Transnational Organized Crime, Article 3 (a-d), G.A. res. 55/25, annex II, 55 U.N. GAOR
Supp. (No. 49) at 60, U.N. Doc. A/45/49 (Vol. I).
• Zimmerman C, Hossain M, Watts C (2011). Human trafficking and health: a conceptual
model to inform policy, intervention and research. Soc Sci Med 73(2):327-35