Supporting the mental health of trafficked people.

1048 www.thelancet.com/psychiatry Vol 2 December 2015 Traffi cking of people represents a gross violation of human rights that carries serious health consequences, including an increased risk of HIV, sexually transmitted infections, and violence. Although research on traffi cking and health has primarily focused on HIV and sexually transmitted infections, much less information is available regarding other aspects of traffi cked people’s health, including mental health issues relating to the trauma, violence, and human rights violations traffi cked people often experience. In The Lancet Psychiatry, Sîan Oram and colleagues report prevalence of mental health morbidity among traffi cked people in South London using data from a clinical registry of secondary mental health services. Although previous research has suggested a high prevalence of depression and post-traumatic stress disorder in populations receiving health and social services after traffi cking, few studies have examined the mental health of traffi cked people in broader populations. The use of routinely collected clinical records is a particularly important feature of the study by Oram and colleagues, in view of the complex ethical and practical challenges associated with the collection of primary data on traffi cking and health. In the study by Oram and colleagues, 103 (77%) of 133 traffi cked people were female, and over half were traffi cked for sexual exploitation. Although traffi cking of people occurs across diverse occupational sectors— including the sex industry, domestic work, agriculture, and manufacturing—traffi cking for sexual exploitation has often been singled out. The UN Protocol to Prevent, Suppress and Punish Traffi cking in Persons, Especially Women and Children (the Palermo Protocol) defi nes traffi cking of people as involving actions by a third party (eg, recruitment and transportation); use of force, deception, or other fraudulent means; and purposes of exploitation (eg, forced labour). However, traffi cking for sexual exploitation has often been confl ated with sex work (ie, the sale or exchange of consensual adult sexual services) for ideologically and politically motivated reasons and because of challenges in defi ning and identifying traffi cking. The Palermo Protocol defi nition remains complex and challenging to apply within health research, in part because of its criminal justice origins and emphasis on the actions of traffi ckers, rather than the experiences of traffi cked people. Additionally, traffi cking for sexual exploitation and sex work are often confl ated on ideological and political grounds, as exemplifi ed by the anti-prostitution pledge in the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, which required all recipients of funding from the US President’s Emergency Plan for AIDS Relief to explicitly oppose sex work, its legalisation, and sex traffi cking until its repeal in 2013. Posing additional concerns to the accurate identifi cation of traffi cked people is the fact that health and social services providers in many contexts rarely receive evidence-based training in accurately screening and assisting traffi cked people; indeed, previous work suggests that sex workers are often assumed to be traffi cked by service providers and law enforcement, in part because of institutional policies and media messages that confl ate sex work and traffi cking. Future eff orts to ensure that traffi cked people are accurately and safely identifi ed and supported must remain a priority within both research and service provision. Research done in partnership with sex workers and traffi cking survivors would be especially useful for establishing the most relevant and accurate means of identifying traffi cked people in diverse settings. Additionally, continued eff orts to train front-line workers (eg, health-care providers, law enforcement, and social workers) using evidence-based methods for identifying and assisting traffi cked people are needed. Traffi cked people who were receiving secondary mental health services in the study by Oram and colleagues experienced several severe traumas over their lifecourse. A large proportion (69 [52%] of 133) reported abuse during childhood before traffi cking and ongoing violence and threats after traffi cking. 60% of traffi cked adults experienced some form of physical or sexual abuse during adulthood; 14% of traffi cked adults also reported physical abuse and 10% sexual abuse after traffi cking, thus showing the complex and cyclical nature of violence in traffi cked people’s lives, which is rarely restricted to the traffi cking experience alone. The fact that traffi cked people were more likely to be compulsorily admitted into mental health care (adjusted odds ratio 7·61, 95% CI 2·18–26·60; p=0·002) and had longer admissions once in care (1·48, 1·01–2·15; p=0·045) than those who had not experienced traffi cking calls attention to the need Supporting the mental health of traffi cked people