Summary of the impact

Research conducted by LSHTM put the physical and mental health of women trafficked for sexual exploitation firmly on the international agenda. The research generated the first-ever guidance for health providers caring for trafficking victims and internationally recognised ethical and safety recommendations from WHO. The research resulted in the UK giving trafficked women a longer period to decide whether to cooperate with any criminal investigation against their traffickers, and police training on victim symptoms and interview timing to support recovery. Findings and health care recommendations have been incorporated into guidance materials globally.

Underpinning research

Millions of women and girls are thought to be trafficked globally, including within the EU, and the UK is no exception. Violence, deprivation and exploitation are key features of human trafficking. The resulting damage to women's health and wellbeing is often profound and enduring.

Prior to research led by Dr Cathy Zimmerman, Senior Lecturer working with Charlotte Watts (LSHTM since 2000, then Research Fellow), the health of trafficked persons and their particular medical needs were widely neglected within policy discussions and guidance documents. Pre-2006 editions of the US State Department Trafficking in Persons Report, the most comprehensive global trafficking report, are a case in point: the focus of anti-trafficking initiatives was immigration and law enforcement.

As Zimmerman showed in the research on which this case study is based, the trafficking of women into forced sex work has serious implications for their physical, sexual and, above all, mental health.

Zimmerman initially led a two-year qualitative study on women's health and trafficking in the EU in 2000-2003 with the aim of highlighting the health risks and consequences of trafficking in women and providing information on their health needs for service providers, law enforcement officials and policy-makers.

A second study, Stolen Smiles, carried out in 2003-2005, surveyed 207 women in seven European cities who had either been trafficked into sex work or sexually abused as domestic labourers. Results of this study, the first quantitative survey of the physical and mental health of trafficked persons, were produced as a report by LSHTM and highlighted in a Lancet editorial in 2006.The study, funded by the European Commission and the International Organization for Migration, was the first to employ rigorous epidemiological methods to investigate the physical, sexual and mental health of trafficked women and adolescents.

The Stolen Smiles survey found that trafficked women's physical and sexual health problems include high levels of injury and sexually transmitted infections, for which the women are often unable to seek treatment.^3.1 However, the most persistent problems are related to mental health.^3.2 Up to 14 days after entry into post-trafficking care, 58% of women showed symptoms associated with post-traumatic stress disorder (PTSD). Symptoms of depression and anxiety were in the 90th percentile compared to a general population of adult women who had not been trafficked. For over 50% of trafficked women, these symptoms did not decrease significantly even 90 days after entering an assistance programme.

Based on this research, Zimmerman, collaborating with Amnesty UK, recommended that the `recovery and reflection' period — the period trafficked people are given to decide on whether to cooperate with any criminal investigation — should be extended to at least 90 days to ensure that the women's health had improved sufficiently for them to be able to make informed and thoughtful choices.

Follow-on research, designed to strengthen the knowledge base related to human trafficking and health and further raise awareness, has provided a basis for conceptual thinking about policy, implementation and research,^3.3 and undertaken a systematic review of the prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking.^3.4

References to the research

Key grants

• Zimmerman and Watts, Prospective, Multi-site Survey on Health Risks and Consequences of Women Trafficked for Forced Sex Work, European Commission, Daphne Programme, 11/2005-12/2007, €250,000.

• Zimmerman and Watts, Qualitative Study on Health Risks and Consequences of Trafficking in Women, European Commission, Daphne Programme, 8/2002-9/2005, €150,000.

Details of the impact

Zimmerman's findings have put the issue of human trafficking and health on the international agenda, and important changes have been made in how trafficked women are treated by government departments and law enforcement agencies overseas and in the UK.

Zimmerman's work on health, psychological trauma and trafficking was the only research cited in a text box in the introduction to the US State Department's Trafficking in Persons Report, the US government's principal diplomatic tool to engage other countries on human trafficking^5.1 and the most recognised annual, global report on trafficking. The text states (p. 41): `Research has shown a clear link between sex trafficking and both pre-trafficking domestic violence and trafficking-related gender-based violence. Cathy Zimmerman, a noted authority on victim trauma, identified domestic and sexual violence as a key "push" factor that makes a woman vulnerable to trafficking.'

The anti-human trafficking manual for criminal justice practitioners produced by the UN Office of Drugs and Crime (UNODC) drew directly from Zimmerman's work in the module on the psychological reactions of victims.^5.2 Similarly, the Organisation for Security and Co-operation in Europe (OSCE) highlighted Zimmerman's findings in its report, Combating Trafficking as Modern-Day Slavery.^5.3 Former OSCE Special Representative on Combating Trafficking in Human Beings stated to Zimmerman in 2012: `The fact that more and more countries are providing health services - not just emergency care — free of charge to victims of trafficking, and that victims of trafficking are no longer being forced to return to states where their needs cannot be met, has its roots — to a large extent — in Cathy Zimmerman's work. She has been able to provide sustainable insight and inspiration for stakeholders, activists, and policy-makers — including myself.'^5.4

In the UK, Department of Health (DH) staff have consulted regularly with Zimmerman and her colleagues, and she contributed significantly to the report for the Taskforce on the Health Aspects of Violence Against Women and Children through membership of the Harmful Traditional Practices and Human Trafficking subgroup.^5.5

Zimmerman translated her findings into an International Organization for Migration (IOM) handbook to guide health providers treating trafficked people.^5.6 This has been translated into at least five languages and was viewed 29,643 times (downloaded 4,199) between July 2009 and June 2012 on IOM's website. In 2011, training materials complementing the handbook were translated into Spanish and Arabic and pilot-tested by Zimmerman, IOM and local health authorities in the Middle East, Caribbean and Central America, with 200 health providers receiving training.

Zimmerman co-authored the Ethical and Safety Recommendations for Interviewing Trafficked Women for WHO^5.7 which was translated into eight languages. Although originally produced in 2003, this remains the main WHO document on trafficking in women. Zimmerman also authored WHO's fact sheet on human trafficking (downloaded 2,533 times between November 2012 and February 2013) and the human trafficking page for Public Health England.

Many law enforcement training materials in the UK, Europe and other regions have incorporated Zimmerman's findings and their potential implications for investigations, including the UK's Central Police Training and Development Authority (Centrex, internal police documents), UNODC and OSCE.

Zimmerman's research has contributed to policy changes resulting in significant practical benefits for trafficked women. Amnesty UK and other advocacy groups used Zimmerman's evidence to persuade the Home Office to extend the victim `recovery and reflection' period. Amnesty's former Women's Division Director states: `LSHTM's evidence enabled Amnesty to promote support for victims as primarily a health rather than an immigration issue and thus was central to the UK government agreeing to sign the Council of Europe Convention on Action Against Trafficking and extend the minimum reflection period.'^5.8 Although legislators stopped short of extending the period to a full 90 days, it was extended to 45, going beyond the minimum 30 days required in the European Convention Against Trafficking. Ratified in December 2008, the new regulations allow for the period to be prolonged further if the victim's health and other circumstances require it. A former Minister of State (Home Office) (Policing, Crime & Security) commented that evidence from Zimmerman's research `indeed contributed to action both at the UK and EU level'.^5.9

Zimmerman has regularly conducted police training on victim health and care for police personnel associated with the UK Human Trafficking Centre (UKHTC), influencing the `victim-centred' approach, including delayed timing of full interviews with trafficking victims to foster recovery time and more consistent testimony. Based on her research, Dr Zimmerman has offered training sessions over a number of years for police personnel dealing with cases of trafficking, contributing to our understanding of a victim's needs and a victim-centred approach.^5.10

Sources to corroborate the impact

5.1 US Department of State (2009) Trafficking in Persons Report 2009. Washington, DC: US Department of State, http://www.state.gov/j/tip/rls/tiprpt/2009/ (accessed 12 September 2013) (Zimmerman's work cited pp. 15, 41).

5.2 UNODC (2009) Anti-human Trafficking Manual for Criminal Justice Practitioners: Module 3: Psychological Reactions of Victims of Trafficking in Persons. Vienna: UNODC, http://www.unodc.org/documents/human-trafficking/TIP_module3_Ebook.pdf (accessed 12 September 2013).

5.3 Office of the Special Representative and Co-ordinator for Combating Trafficking in Human Beings (2010) Combating Trafficking as Modern-Day Slavery: A Matter of Rights, Freedoms and Security. Vienna: OSCE, http://www.osce.org/cthb/74730 (accessed 12 September 2013) (Zimmerman's work cited pp. 22, 27, 63).

5.4 Former OSCE Special Representative on Combating Trafficking in Human Beings.

5.5. Taskforce on the Health Aspects of Violence Against Women and Children (2010) Report from the Harmful Traditional Practices and Human Trafficking Sub-group: Responding to Violence against Women and Children — The role of the NHS, http://fflm.ac.uk/upload/documents/1268670730.pdf (accessed 12 September 2013) (Zimmerman's work cited pp. 11, 17, membership of subgroup p. 43).

5.6. International Organization for Migration, UN Global Initiative to Fight Human Trafficking & LSHTM (2009) Caring for Trafficked Persons: Guidance for Health Providers, http://www.unodc.org/documents/hiv-aids/publications/Caring_for_Trafficked_Persons_Guidance_for_Health_Providers_2009.pdf (accessed 12 September 2013).

5.7 Zimmerman, C and Watts, C (2003) WHO Ethical and Safety Recommendations for Interviewing Trafficked Women. London: WHO, LSHTM & Daphne Programme of the European Commission,
http://www.who.int/gender/documents/en/final%20recommendations%2023%20oct.pdf (accessed 12 September 2013).

5.8 Former Women's Division Director, Amnesty.

5.9 Former Minister of State (Home Office) (Policing, Crime & Security).

5.10 Former Tactical Adviser to the United Kingdom Human Trafficking Centre.