STOLEN SMILES Physical and mental health consequences of women and adolescents trafficked in Europe Funding from the European Commission’s Daphne Programme, Sigrid Rausing Trust, International Organization for Migration

How big is the trafficking problem?

Health risks and opportunities Destination Travel and transit Pre-departure Detention, deportation, criminal evidence Integration and reintegration

Trafficked women Sex workers Violence against women & Torture victims Migrant women Exploited labourers

ACCEPTS OFFER Vulnerabilities Hopes Strengths + = CREDIBILITY OF THE OFFER Timing of the offer Quality of the offer PUSH & PULL FACTORS DECIDING FACTORS Recruitment Equation

Study participants: Women & adolescents accessing services in Moldova, Ukraine, United Kingdom, Italy, Bulgaria, Czech Republic & Belgium. Trafficked into forced sex work (92%) domestic labour (4%), and both (3%). Ages 15 to 45 from 14 countries, the majority from Moldova and Ukraine. 38% had children, of whom 82% were single parents. 81% exploited for at least one month, 20% over one year. Three interviews conducted: 207 women interviewed 0-14 days after entry into care, 170 between days, and 63 at 90+ days. Study of trafficked women accessing services in seven European countries

Violence women experienced prior to being trafficked

Violence women experienced during trafficking

Identifying a trafficking situation “How often were you free?”

Multiple physical health symptoms that improve with support services 0-14 Days28-56 Days90+ Days

81% headaches 71% dizzy spells 69% back pain 60-70% various sexual health problems 63% memory problems 82% fatigue The most common physical health symptoms reported by women at 0-14 days

How the memory gets disrupted Fight or flight response to danger Peritraumatic dissociation Loss of details

Levels of psychological distress are high, with multiple presenting symptoms 0-14 days days90+ days

What is a post-traumatic response? Severe or prolonged traumatic experiences can result in an individual being unable to turn-off” their basic biological and safety alarm mechanisms or cause them to have an “all-or- nothing” physical and emotional response to negative stimuli Repetitive helplessness of this kind may result in disorganising the cognitive processes, or disable an individual’s instinctive ability to respond appropriately.

Post-traumatic stress disorder

Changes in post-traumatic stress symptom levels Post-traumatic stress disorder symptoms

Mental health improvements 0-14 days28-56 days90+ days Depression Anxiety Hostility

Trafficked women’s mental health compared to a general female population 0-14 days28-56 days90+ days

Maybe some people could call me a “ dirty whore”, but for others I might be the girl who can give them good advice. Moldovan woman trafficked to Turkey I feel like they’ve taken my smile and I can never have it back. Lithuanian woman trafficked to London Reactions are individual

WORKING WITH WOMEN WHO HAVE BEEN TRAFFICKED

1. EXPLAIN AND INFORM The purpose for the questions and the process, step by step. General subjects that will be discussed and acknowledge difficulty of some questions. Who will and who will NOT have access to the information. She may return to difficult questions later. If she does not understand something, she should ask for it to be repeated slowly or explained differently. Give Control and Establish Trust

2. INQUIRE ABOUT HER How are you feeling? Are you currently in any pain or discomfort? Are you hungry or thirsty? Do you want to use the toilet? Is there anything that is making you feel unsafe right now, or that you might be harmed? Do you have any questions that you want to ask me? Do you have any urgent concerns or fears that you want to tell me about before I ask you some questions? Are you ready to start? Give Control and Establish Trust

3. BE ON HER SIDE Ask questions in a way that shows she is believed and that you have concern for her: What was done to her vs. “what she did” Did you feel free to go where you wanted? vs. Did you ever try to escape?” Did anyone hurt you while you were in this country? before “How did you enter this country?” Are you worried for anyone in your family? before “What is your home address?” Give Control and Establish Trust

Physical comfort Comforted, comfortable individual More thoughtful, more reliable, accurate information Psychological comfort + Time + Of benefit to the victim = benefit to the case

About Sexual Violence RISK-TAKING: sexual substance misuse A history of sexual violence

A Complex Victim Group Disclosure barriers Fear of retaliation by traffickers Guilt of her perceived complicity in what occurred Guilt over any criminal activities in which she participated Shame about what she has done, particularly sexual activities Little trust in officials, e.g., police, immigration, health workers

Interpreters 1.Security- DO NOT USE ‘VOLUNTEER’ INTERPRETERS 2.No discrimination - against sex work, migrants, women 3.No neighbours – no one from the same village or town, or local destination community 4.Gender – may prefer a female or male 5.Warn against any disclosure, with criminal sanctions, e.g., official secrets, data protection act CHECK ACCEPTABILITY OF INTERPRETER WITH THE WOMAN HERSELF

I feel that she was really too scared, but it was her decision. Our offer was made in fairly hostile conditions, during a police interview. This is a case where a three month “reflection” period would have been useful. London Metropolitan police officer A senior police officer referring to a victim who refused to cooperate

Trafficking legislation and “the recovery and reflection period” Council of Europe Convention on Action Against Trafficking Article 13 – Recovery and reflection period 1. Each Party shall provide in its internal law a recovery and reflection period of at least 30 days…Such a period shall be sufficient for the person concerned to recover and escape the influence of traffickers and/or to take an informed decision on cooperating with the competent authorities.

1.Recognise the serious health consequences of trafficking 2.Pass legislation requiring a full range of health services be provided to trafficked women, regardless of their legal status. 3.Establish procedures to require authorities to ensure that upon contact with a woman suspected of having been trafficked, her health needs are assessed and urgent needs are immediately addressed. Recommendations (1)

Recommendations (2) 4. Legislate a minimum 90 day period of reflection and recovery during which time women will: –receive appropriate and adequate support services –not be required to make decisions about cooperating with authorities or about returning home 5. Prohibit the detention, removal or deportation of trafficked women until their health needs have been met and their safety for return assessed 6. Provide services based on models of good practice used for survivors of other forms of violence and for minority or refugee communities.

7. Increase involvement of health sector in trafficking dialogue and activities. 8. Train relevant health professionals to provide appropriate physical, sexual, reproductive and mental health care for trafficked women’s needs 9. Codes of service provision should draw on models of good practice used for survivors of other forms of violence, and/or minority communities & refugees. Recommendations (3)

Guiding principles for conducting ethical and safe interviews with women who have been trafficked Do no harm Ensure safety, security and comfort Ensure privacy Ensure confidentiality Provide information Request informed consent Ask questions in a sensitive and sensible manner by paying attention to the purpose, sequence and tone of the question Listen actively and responsively by not talking, asking questions and providing clarification, giving the person time to answer, being perceptive and acknowledging what the person says Observe signs indicating the woman needs a break during the procedure Consider any preconception and prejudices you may hold Believe, do not judge Maintain professionalism while treating persons with respect and compassion Ensure trafficked persons feel in control of their body and communications Reassure trafficked persons they are not to blame Inform trafficked persons of their right to a forensic medical exam and report Inform the individual of their rights to copies of all health & medical records Remind the trafficked person of their strengths

Zimmerman, C Presentation on the health consequences among women who have been trafficked and their implications for services and policy. London: London School of Hygiene & Tropical Medicine. The full report, Stolen Smiles, is available at: Suggested citation