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MHRN South London & South East Hub
MHRN South London & South East Hub

Mental health services in South London are providing care for trafficked individuals. Preliminary findings show that compared to non-trafficked patients, trafficked individuals are more likely to be referred through maternity services and experience detention under the Mental Health Act or adverse pathways involving police intervention. The study aims to better understand the needs and experiences of trafficked individuals within mental health systems to improve identification and care.

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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
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)
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.
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).
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
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
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
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.
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
Case Register Interactive System
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
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)
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
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)
Adult trafficked service users: primary diagnoses
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
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)*
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).
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.
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.
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
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

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Mhrn presentation oram

  • 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
  • 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

Editor's Notes

  • #8: Studies collected data on:Violence (n=9)Physical health (n=4)Mental health (n=4)Sexual health (n=6). High prevalence of PTSD, depression and anxiety (range 20% -100%); 1 study using SCID 50% at follow-upPsychological symptoms associated with violence prior to and during exploitation, and duration of exploitationSymptom levels significantly reduced among women who have been out of the trafficking situation for ≥3 months
  • #12: The remainder of the presentation will focus on the demographic, clinical and service use profile of trafficked ADULTS only.
  • #16: Extracted as diagnosis at most recent contact with SLaM services. Breakdown of diagnoses:Schizophrenia and related disorders: Schizophrenia n=6, Acute and transient psychotic disorders n=6, schizoaffective disorders n=2Substance misuse: alcohol n=4, opioids n=1 Other: unspecified disorder of psychological development n=1, unspecified mental retardation n=1
  • #17: Trafficked: Other clinical speciality – 2 x neurology, 2 x unclear, 1 x HIV team, 1 x team relating to haemotypsis, 1 x team relating to stroke. Controls: Other clinical speciality – 4 x GU/HIV, 1x Gynaecology, 7 x neurology, 2 x CNS, 1 x health visitor, 2 x IAPTS, 2 x DAS
  • #18: Duration of contact with SLaM services defined as: number of days between date of first ever referral to final discharge (or 24/01/2013 for active patients), less any periods between referrals. Â