The mental health of sexually trafficked female survivors in Nepal

Abstract

Background:

Despite further recent research into the consequences associated with human sex trafficking, scant evidence associated with the mental health outcomes among victims of sex trafficking remains, including within Nepal where trafficking continues to be a growing problem.

Aim:

To investigate the prevalence and explanatory factors of depression, anxiety and post-traumatic stress disorder (PTSD) symptoms among female survivors being housed and supported by two non-governmental organisations (NGOs) in Nepal.

Methods:

A total of 66 female sex trafficking survivors being housed by two NGOs were purposively sampled. Anxiety and depression symptomatology were measured using the Hopkins Symptoms Checklist–25 instrument and PTSD symptomatology was measured using the PTSD Checklist–Civilian Version.

Results:

In all, 87%, 85.5% and 29.7% of the sample scored above anxiety, depression and PTSD thresholds, respectively. HIV-positive status and length of workday during trafficking period significantly associated with at least one outcome measure.

Conclusion:

The results contribute further evidence of how damaging sex trafficking can be to victims, particularly in terms of being at risk of clinical depression and/or anxiety. Continued efforts to prevent trafficking from occurring as well as effective, timely intervention for survivors are needed.

Keywords

Sex trafficking Nepal women mental health depression anxiety

Introduction

The United Nations (UN) have defined human trafficking as the recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat, force and/or other forms of coercion, to achieve the consent of a person having control over another person for the purpose of exploitation including the exploitation of the prostitution of others or other forms of sexual exploitation (UN, 2000). The issue of trafficking has attracted a growing amount of public health attention over the last decade (Bales, 2005; European Commission, 2004; Gozdziak & Collett, 2005; Nawyn, Birdal, & Glogower, 2013; Yakushko, 2009). It represents one of the largest sources of illegal income in the world (Belser, 2005) and the fastest growing criminal industry globally (UN, 2012). The United Nations Office on Drugs and Crime (UNODC; 2012) conservatively estimates that there are 2.5 million victims at any one time, while United Nations Children’s Fund (UNICEF, 2006) estimates that 1.2 million children are trafficked every year and that approximately 80% of all trafficked individuals are women. Estimates reported by the International Labour Organization (2012) point to around 20.9 million victims of forced labour (11.4 million of whom are women and girls, and 9.5 million of whom are men and boys), with about 3 out of every 1000 persons worldwide being in forced labour at any given point in time. They also estimate that 4.5 million people are victims of forced sexual exploitation, and that the Asia-Pacific region accounts for by far the largest number of forced labourers – 11.7 million (56% of global total). The Global Slavery Index (Walk Free Foundation, 2014) estimates that Nepal is one of the most widely affected by this phenomenon with an estimated 230,000 victims compared to an estimated 60,000 victims in the United States and 8300 victims in the United Kingdom. Only 19 countries (out of 167) were reported to have a higher proportion of victims per total population. This highlights the magnitude of the crime in Nepal that is also likely to be both under-estimated and growing. For example, Huntington (2002) asserts that 5000–7000 Nepali girls and women are trafficked every year. Furthermore, Nepal remains one of the world’s poorest countries, ranking 145th out of 187 countries and territories according to the latest United Nations Human Development Index (United Nations Development Programme (UNDP), 2014) report. As such, Nepal remains highly vulnerable to the crime of human trafficking. However, it is important to note that such statistics may be crude and unreliable measures of trafficking. For example, Gallagher (2014) argues that statistics reported in the Global Slavery Index are the result of an unclear methodology reliant upon survey data of highly variable quality, while Broome and Quirk (2015) point to such rankings of ‘best’ and ‘worst’ performers as a reflection of simplification and symbolic judgements in the interest of a normative agenda of global benchmarking.

One of the most harmful consequences of trafficking is the profound impact it has upon victims’ mental health. This is reflected in Zimmerman, Hossain, and Watts’ (2011) conceptual model of the human trafficking process where examples of forms of psychological abuse include the intimidation of individuals and threats against loved ones, deception and blackmail to coerce individuals into discouraging victims from seeking help from authorities, unsafe and unpredictable events and environments, and forced social isolation. The findings from Kiss et al.’s (2015) large multi-country study in South-East Asia evidences this. Their analysis of data collected from 1015 male and female trafficking survivors across Cambodia, Thailand and Vietnam identified wide-scale reports of violence and movement restrictions including physical and/or sexual violence (47.6% reported this), threats (47.1%), being never free to do what victims wanted (58.8%) and being locked in a room (19.5%). The overall reported prevalence of depression, anxiety, post-traumatic stress disorder (PTSD) and suicidal attempts (in past month) was estimated to be 61.2%, 42.8%, 38.9% and 5.2%, respectively, thus powerfully evidencing the harmful consequences of such experiences. Oram, Stöckl, Busza, Howard, and Zimmerman (2012) examined mental health outcomes as part of their systematic review of the health consequences of human trafficking. Their review identified four studies of women and girls trafficked for sexual exploitation that had reported mental health outcomes data from which very high rates of anxiety (48%–97.7%), depression (54.9%–100%) and PTSD (19.5%–77%) were reported. Abas et al.’s (2013) study remains the only study conducted to date that has used a diagnostic instrument to assess mental disorder among female survivors of trafficking. Their analysis of a retrospective cohort of 176 adult women returned to Moldova found that 6 months following their return, 54% (n = 95) met the criteria for a Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV) mental disorder. Among these survivors, 35.8% had PTSD (alone and co-morbid), 12.5% had depression (without PTSD) and 5.8% had another type of anxiety disorder. Tsutsumi, Izutsu, Poudyal, Kata, and Marui’s (2008) study of mental health consequences among victims of trafficking from Nepal interviewed female survivors of human trafficking who had returned to Nepal from the destination of trafficking and who were at the time supported by governmentally authorised local non-governmental organisations (NGOs) in Kathmandu (the capital of Nepal). Their findings highlighted an alarmingly high prevalence of anxiety (97.7% and 87.5%) and depression (100% and 80.8%) among women who had been trafficked for sexual and labour exploitation, respectively. The study also found that women who had been trafficked for sexual exploitation were at a significantly increased risk of PTSD compared with women who had been trafficked for labour exploitation (29.5% vs 7.5%; p < .01).

Despite the continued increase of human trafficking, there remains very limited research into the consequences of mental health for victims of trafficking. This is demonstrated by Oram et al.’s identification of just four studies to have empirically examined this relationship. Furthermore, to the best of our knowledge, there has not been another study conducted in Nepal to add to the evidence originally produced by Tsutsumi et al. This is in spite of the large and growing problem of trafficking in Nepal. To attempt to address this, we examined the mental health status of female survivors of sex trafficking being housed by the NGOs ‘Maiti Nepal’ and ‘Shakti Samuha’. These organisations, located in Kathmandu (capital of Nepal), have previously supported similar research. This includes Silverman et al. (2007) who identified a HIV infection prevalence of 38% among 109 Nepalese female survivors (girls and women) being housed by Maiti Nepal, and that there was an increased risk of being detained in multiple brothels for longer periods among survivors trafficked at 15 years of age or earlier. Buet, Bashford, and Basnyet (2012), with the support of Shakti Samuha, recruited and assessed the health status of 56 Nepalese female survivors, 75% of whom had been living in community for 10 years or more. Among their findings were reports, from three quarters of the respondents, of fear, concern and hopelessness associated with their future. They also found that 78.6% felt sad, tired and/or angry towards their trafficker, and that 46.4% felt negative feelings about their body. The objectives of this study were to investigate the prevalence of depression, anxiety and PTSD symptoms among female survivors of sex trafficking, to describe survivors’ socio-demographic and background profile and to explore which factors significantly associated with mental health outcomes.

Methods

Setting

An ethical and safe method towards accessing trafficking survivors is through trafficking assistance programmes since sampling participants outside of such organisations may risk exposing individuals as trafficked to communities which may lead to stigmatisation and rejection (Brunovskis and Surtees, 2010). There are several NGOs housing survivors of trafficking in Nepal. Maiti Nepal and Shakti Samuha, two of such organisations located in Kathmandu, agreed to support the current study. Maiti Nepal has rescued and helped support more than 12,000 Nepali girls and women since its establishment in 1993 (Maiti Nepal, 2013). Shakti Samuha was established in 2000. It was established and run by the survivors of sex trafficking who fled from India in 1996. Both organisations have previously supported health-related research studies (Buet et al., 2012; Silverman et al., 2007).

Sampling and study procedure

A non-randomised purposive sampling method was used because of the unavailability of an appropriate sampling frame. Females aged 18 or above who were previously trafficked for sexual exploitation and being housed by either Maiti Nepal and Shakti Samuha during the data collection period (20 June to 9 August 2014) were eligible to participate. The study took place after obtaining ethical approval from the University of Bedfordshire’s Institute of Health Research Ethics Committee and written approval from the two participating organisations.

For the data collection process, we chose to adopt the procedure employed by Tsutsumi et al. (2008) which recognised and resolved the challenge of poor literacy and cultural distrust towards written paperwork among this population. This involved using a structured one-to-one interview approach undertaken by experienced female interviewers available to both NGOs. To ensure privacy and sensitivity, interviews were conducted in a private room. The interviewers read through the information document to each potential participant who ensured that any participation was entirely voluntary and that anonymity and confidentiality would be maintained throughout. Participants who were illiterate provided verbal consent. Interviewers offered to pause or terminate the interview if participants became distressed during the process. Participants were also referred for psychological support through the NGO if they expressed such a desire.

Data collection tool

The questionnaire included the following basic socio-demographic questions: age, ethnicity, educational level, religion, religiosity and marital status. We were particularly curious to explore religiosity since this has not previously been explored in relation to mental health outcomes among trafficking survivors, and also because high religiosity has been frequently evidenced to be protective for mental health, including, for example, in relation to suicidal behaviour (Burshtein et al., 2016), PTSD in survivors of intimate partner violence (Lilly, Howell, & Graham-Bermann, 2015) and natural disasters (Stratta et al., 2013). To further describe the background profile and experiences of the survivors, the questionnaire also collected data on the length of the trafficking period, age when trafficked, where they were trafficked from, the key person who tricked them into trafficking, what promises were made to lure them into being trafficking, length of workday during trafficking period, who rescued them and HIV status. All survivors are tested for HIV when they are first housed by Maiti Nepal or Shakti Samuha.

The Hopkins Symptoms Checklist–25 (HSCL-25) (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) was used to evaluate anxiety (10 items) and depression (15 items) on a 1–4 Likert scale, with higher scores indicating a greater likelihood of anxiety and depression. This tool has been previously applied in the Nepali context (Shrestha et al., 1998; Tsutsumi et al., 2008). It has also been validated by Thapa and Hauff (2005) in their study on psychological distress among displaced persons where a dichotomised cut-off point of both subscales was set at above average scores of 1.75 or more. This cut-off score was also applied for both scales in the current study. Lhewa, Banu, Rosenfeld, and Keller (2007) have previously reported excellent alpha-coefficient reliability scores of .89 and .92 for the anxiety and depression subscales respectively among the neighbouring Tibetan population.

The 17-item PTSD Checklist–Civilian Version (PCL-C) (Weathers, Litz, Herman, Huska, & Keane, 1993) was used to measure PTSD symptoms. All items consist of a 1–5 Likert scale with higher scores indicating higher trauma symptoms. The PCL-C has been tested across several population groups and the instrument has obtained best results in homogeneous groups (Brewin, 2005). The instrument was also used by Tsutsumi et al. (2008) and validated by Thapa and Hauff (2005) among the Nepalese population who reported a dichotomised total score cut-off point of 50 or more as being appropriate in identifying PTSD symptoms. This cut-off was applied in the current study.

The previously translated versions of both outcome tools were used in this study. For the study-specific socio-demographic background questions, forward and back translation was conducted following the World Health Organization (WHO, 2014) guidelines on the process of translation and adaptation of instruments that calls for clear, simple, conceptually and culturally equivalent words or phrases rather than a literal translation.

Statistical analysis

Study data were analysed using IBM SPSS (v.19; IBM Corp., Armonk, NY, USA). Data cleaning and checking were initially conducted. A descriptive analysis examining the sample characteristics and central tendencies of the study outcome measures was conducted. Non-parametric inferential Spearman’s rho, Mann–Whitney U-tests and Kruskal–Wallis H-tests were used where appropriate to establish which factors significantly associated/correlated with the outcome measures. Due to the particularly small sample size, a significance level of .01 was set.

Results

Participant characteristics

A total of 66 women who were identified as eligible across the two organisations were invited to participate, two of whom declined because of the potential distress involved in recalling their trafficking experience. Of the remaining 64 participants, two accepted their interviewer’s offer of terminating the interview before completion due to distress. HSCL data were therefore not collected from either of these participants. In all, 35 of the participants were recruited from Shakti Samuha and 29 from Maiti Nepal. The mean sample age was 25.8 years (standard deviation (SD) = 5.5years), with the majority describing their ethnicity as Janajati (n = 37, 57.8%) and their religion as Hindu (n = 33, 51.6%) followed by Buddhist (n = 29, 45.3%). Most participants were single (n = 44, 68.8%) and most named primary education as their highest educational achievement (n = 29, 45.3%). In all, 20 participants (31.3%) reported that they were currently HIV-positive. A full breakdown of the socio-demographic characteristics is provided in Table 1.

Table 1.

Socio-demographic characteristics of participants.

	n	%
Ethnicity
Khas	12	18.8
Janajati	37	57.8
Newar	5	7.8
Terai Madhesi	1	1.6
Dalits	9	14.1
Education
No education	15	23.4
Primary education	29	45.3
Secondary education	20	31.3
Religion
Hindu	33	51.6
Buddhist	29	45.3
Christian	1	1.6
Muslim	1	1.6
Religiosity
Very religious	7	10.9
Fairly religious	41	64.1
Somewhat religious	16	25
Marital Status
Single	44	68.8
Married	14	21.9
Separated	6	9.4
	Mean (SD)	Range
Age	25.8 (5.5)	18–35

SD: standard deviation.

Sex trafficking profile

As can be seen in Table 2, the mean reported age when initially trafficked was 16.8 years (SD = 5.8 years), the youngest of which was just 8 years. The mean reported period of being trafficked was 33.6 months (SD = 28 years, range = 1 month to 8 years), while the mean reported number of hours worked per day was 11.8 hours (SD = 4.4 hours, range = 2–20 hours). The most frequently cited promise made to lure victims was the promise of employment (56% reported this). The results also revealed that women were trafficked from 21 different places in Nepal, with the most frequent being Kathmandu (36%) followed by Hetauda (14%). Most women were lured into trafficking by a local broker (65.2%) or a close relative (18.8%). The majority of women were rescued by an NGO (n = 26, 40.6%) or by the police (n = 17, 26.6%), while 17.2% (n = 11) reported managing to escape on their own.

Table 2.

Participants’ sex trafficking profile.

	Mean (SD)	Range
Age when trafficked (years)	16.8 (5.8)	8–32
Duration of trafficking (months)	33.6 (28.8)	1–96
Length of workday during trafficking (hours)	11.8 (4.4)	2–20
	n	%
Area where trafficked from
Kathmandu	23	35.9
Hetauda	9	14.1
Nuwakot	5	7.8
Sindhupalchowk	4	6.3
Bhaktapur	2	3.1
Chitwan	2	3.1
Kailali	2	3.1
Narayanghat	2	3.1
Rautahat	2	3.1
Sindhuli	2	3.1
Others (all n = 1)	11	17.2
Key person who lured them into trafficking
Local broker	42	65.6
Outside broker	4	6.3
Close relative	12	18.8
Other	6	9.4
Promises made to lure victims
Employment	36	56.3
Escape from poverty	8	12.5
Love	6	9.4
Drugs	8	12.5
Other	6	9.4
Rescuer
Escaped on their own	11	17.2
Escaped with other(s)	8	12.5
NGO	26	40.6
Police	17	26.6
Relatives	1	1.6
Kicked out	1	1.6

NGO: non-governmental organisation.

Anxiety, depression and PTSD

The mean HSCL scores for anxiety and depression were 2.5 (n = 62, SD = .6, range = 1.4–3.5) and 2.41 (n = 62, SD = .6, range = 1.4–3.5), respectively. In all, 87% (n = 54; 95% confidence intervals = 78.6%–95.4%) and 85.5% (n = 53; 95% confidence intervals = 76.7%–94.3%) of the sample scored above the 1.75 cut-off for anxiety and depression, respectively. The mean PCL PTSD score was 44.7 (SD = 12.7, range = 23–70), while 19 (29.7%) women scored above the applied cut-off threshold of 50 (95% confidence intervals = 18.5%–40.9%).

As can be seen in Table 3, strong significant positive correlations were found between the three outcome measures. A number of significant relationships were identified between the three outcome measures variables and background variables. For the HSCL anxiety outcome measure, significance was identified for number of hours worked per day (p < .01), duration of trafficking period (p < .01), and HIV status (p < .01). No significant differences between the two main ethnicities (Janajati and Khas) were identified across any of the outcome measures. The anxiety score difference between Hindus and Buddhists was close to significance (U = 322; sig. = .066).

Table 3.

Statistical relationships between background variables and outcome measures.

	HSCL anxiety (n = 62)	HSCL depression (n = 62)	PCL-C (n = 64)
	MR	MR	MR
Ethnicity
Janajati (n = 35)	23.7	24.4	24
Khas (n = 12)	24.8	22.9	28.1
U	201	196.5	185
Education
No education (n = 15)	40.1	37.9	41.1
Primary level (n = 28)	27.8	29.9	29.9
Secondary level (n = 20)	30.7	29.3	29.7
H	4.4	2.3	4.2
Religion
Hindu (n = 33)	26.8	26	29.1
Buddhist (n = 29)	35.1	36	34.3
U	322	297*	398.5
Religiosity
Somewhat religious (n = 16)	35.9	35.1	35.2
Very or fairly religious (n = 48)	29.9	30.2	31.6
U	297	310	341
Marital status
Single (n = 44)	29.8	29.5	31.6
Married (n = 14)	24.5	25.6	23
U	238	253	218
Area where trafficked from
Kathmandu (n = 23)	32.4	33.9	31.2
Any other location (n = 41)	30.9	30.1	33
U	427.5	394	441.5
Key person who lured victim
Close relative (n = 12)	39.3	39.8	44.6
Any other (n = 52)	29.8	29.7	29.7
U	194.5	189.5	166.5
HIV status
Positive (n = 20)	47.6	46.2	47.3
Negative (n = 44)	23.8	24.5	24.9
U	98*	125.5*	125*
	Rho	rho	rho
Age (n = 64)	.109	.200	.117
Age when trafficked (n = 64)	−.126	−.045	−.178
Length of workday during trafficking (n = 64)	.449*	.368*	.434*
Duration of trafficked period (n = 64)	.241	.258	.226
HSCL anxiety (n = 62)	–	.928*	.866*
HSCL depression (n = 62)	.928*	–	.791*
PCL-C (n = 64)	.866*	.791*	–

HSCL: Hopkins Symptoms Checklist; MR: Mean Rank; H: Kruskal Wallis H-test statistic; U: Mann–Whitney U-test statistic; rho: Spearman’s rho-test statistic; PCL-C: PTSD Checklist–Civilian Version.

p < .01.

Background variables significantly associated with HSCL depression outcome scores included religion (Hindus compared to Buddhists) (p < .05), number of hours worked per day (p < .01), duration of trafficking period (p < .01) and HIV status (p < .01).

Significant relationships between the PCL-C outcome scores and background variables included number of hours worked per day (p < .01), duration of trafficking period (p < .01), and HIV status (p < .01).No significant relationships were identified between the outcome measures and the variables age, educational level, religiosity, area they were trafficked from, key person who lured victim, marital status and age when trafficked.

Discussion

This study’s findings on the prevalence of poor mental health outcomes are similar to those reported in previous literature (Abas et al., 2013; Hossain, Zimmerman, Abas, Light, & Watts, 2010; Zimmerman et al., 2008), including the study by Tsutsumi et al. (2008) which identified, among a sample of 44 sex trafficking survivors, that 97.7% and 100% of participants scored above anxiety and depression HSCL-25 thresholds, respectively. Also similar were identified rates of PTSD symptoms, with both studies identifying just below 30% of participants exceeding the PCL-C threshold. However, this rate is substantially lower than the rates of trauma symptomatology identified among both torture survivors in rural Nepal (59%; Tol et al., 2007) and internally displaced women as a consequence of armed conflicts (59.3%; Thapa & Hauff, 2005). In the latter study, the participants were continuing to directly experience displacement as opposed to the current study’s participants who had been rescued and housed by an NGO. This may partially help to explain the substantial difference in trauma rates.

Kiss et al.’s (2015) recent large study of health patterns among trafficking survivors in Cambodia, Thailand and Vietnam also measured depression and anxiety using the Hopkins Symptoms Checklist, as well as PTSD (using the Harvard Trauma Questionnaire). Among their sample (n = 1015), which consisted of men, women and children who had been trafficked for various forms of forced labour and sexual exploitation, 66.6% and 48.1% of female participants (n = 288) scored above thresholds for depression and anxiety, respectively, while 43.9% scored above the threshold for trauma symptoms. The differences in rates between Kiss et al.’s study and both Tsutsumi et al. (2008) and the current study are likely attributed to contextual differences.

This study, together with the results of Oram et al.’s (2012) systematic review and the aforementioned studies, clearly evidences how harmful the impact of sex trafficking can be for survivors’ mental health, particularly in terms of depression and anxiety for which the large majority of our sample scored above the applied thresholds. Such high rates of psychological distress are most likely a direct result of being forced to perform sex work, and the experience of physical, mental and sexual violence and abuse during the trafficked period (Abas et al., 2013; Ostrovschi et al., 2011; Zimmerman et al., 2008), including being forced into social and emotional isolation, having threats made against loved ones, being intimidated from help-seeking and living unsafe and unpredictable environments (Zimmerman et al., 2011).

The study also identified several background factors that significantly associated with higher rates of psychological distress. The two most consistent risk factors of poor outcomes were longer workdays and HIV-positive status, both of which were significantly associated with higher rates of depression, anxiety and trauma symptomatology. These risk factors have been previously documented to be powerful moderators of depression, anxiety and PTSD (e.g. Abas et al., 2013; Collins et al., 2013; Ozer, Best, Lipsey, & Weiss, 2003; Surratt, Kurtz, Chen, & Mooss, 2012; Tsutsumi et al., 2008). Approximately 31.3% (n = 20) of the sample were HIV-positive, a finding that is very similar to Tsutsumi et al.’s study (30%) and similar to other research which has examined HIV prevalence among victims of sex trafficking (Gupta, Raj, Decker, Reed, & Silverman, 2009; Oram et al., 2012; Silverman et al., 2006; Silverman et al., 2007). Poor quality of mental health among HIV-infected sex trafficking survivors is likely exacerbated by public stigma (Paudel & Baral, 2015), self-stigma (Katz et al., 2013; Paudel & Baral, 2015) and experiences of discrimination (Aberdein & Zimmerman, 2015; Neupane, Khanal, Sharma, & Aro, 2012). The issue is also cyclical given that poor mental health increases the likelihood of HIV vulnerability (Hong, Li, Fang, & Zhao, 2007; Surratt et al., 2012). It is also unsurprising that the longer the workday is, the more likely it is to increase vulnerability to poor mental health given that the social, physical and emotional burdens directly associated with forced sex work are inflated further.

According to Central Bureau of Statistics Nepal (2012), only 9% of the Nepali population subscribes to Buddhism. It may therefore be considered surprising that almost half of our sample subscribed to Buddhism. One explanation for this may be the historical significance of trafficking in the Buddhist religion across the Himalayan region (Tsomo, 2004). The analysis also revealed that participants who subscribed to Buddhism were significantly more likely to hold higher depression scores compared to participants subscribed to Hinduism. However, despite considerable previous research evidence that religiosity helps to protect against poor mental health among vulnerable populations (Akbari et al., 2015; Akrawi, Bartrop, Potter, & Touyz, 2015; Bonelli & Koenig, 2013; Caribé et al., 2015), no such association was identified in the current study.

The results of this study highlight how devastating the experience of sex trafficking can be for survivors’ mental health. Survivors are a very vulnerable population and thus require timely and effective support for their mental health. Our findings suggest that professionals need to be aware that survivors who are from particularly impoverished backgrounds, are HIV-positive and had worked particularly long hours during their trafficked period are at a particularly high risk of poor mental health. Oram et al. (2012) argue that longitudinal and intervention research studies are required to investigate and establish how best to foster recovery of trafficked persons. Another key challenge is the utilisation of health care services by survivors. As reported by Aberdein and Zimmerman (2015), public stigma prevents survivors from being willing to seek out and access services given the fear that disclosure may damage both the individual’s and the family’s reputation. To help reduce the effects of public stigma, services must find effective means towards ensuring confidentiality and then clearly disseminate this assurance to prospective patients. Future research that explores survivors’ views on how services could achieve this would therefore be useful. Additionally, community-level anti-stigma intervention research will be key in enabling survivors to re-integrate with their community. This is important since, as Mahendra, Bhattarai, Dahal, and Crowley (2001) have previously highlighted, survivors are often shunned by their families and entire community. NGOs are also likely to be well-positioned to help re-integration occur (Crawford & Kauffman, 2008) and should therefore be involved in the design of such future research. Public anti-stigma initiatives are also likely to increase public awareness of sex trafficking and its consequences which should help reduce the likelihood of trafficking from occurring (Kauffman & Crawford, 2011). Research that evidences this would also be welcome particularly since this would strengthen the case for government policies needing to include a focus upon public awareness initiatives.

This study has a number of limitations. Both the non-randomised sampling procedure and, in particular, the small number of participants recruited to the study substantially hamper statistical power and generalisability. As a consequence of the small sample size, the prevalence estimates lack precision (as highlighted by the considerably wide 95% confidence intervals). Therefore, interpretations of the study data can only reliably be applied internally, and assumptions of its applicability to the wider population should be treated with much caution. Additionally, the participants were only recruited from recognised organisations that offer support to them. Therefore, the mental health of trafficked workers who have not been rescued is likely to be more severe (alternatively such women may have less severe needs hence why they have not accessed such services). It is also possible that social desirability bias exists in the study since participants may have responded to the interviewer in what they felt were desired responses. Due to practical limitations of time and resource, we chose to exclude several independent variables previously shown to be associated with mental health outcomes such as pre-trafficking physical and sexual violence and trafficking physical and sexual violence (Abas et al., 2013; Hossain et al., 2010) in order to keep the questionnaire brief. In addition, we limited the focus of the study upon sex trafficking survivors only since we were aware that the majority of the women we could access through Maiti Nepal and Shakti Samuha were trafficked for sexual exploitation (similarly to other trafficking research including Kiss et al., 2015 and Abas et al., 2013). This focus, coupled with the brief questionnaire and data collection period, hampered the scope of the data.

Overall, this study highlights how destructive sex trafficking can be to victims’ mental health. While we established evidence of poor mental health, particularly in terms of depression and anxiety symptomatology, across the entire sample, the participants who had been forced to work longer hours during a longer trafficking period and who are HIV-positive were identified to be at an increased risk of poor mental health. There is therefore a clear need to continue efforts to prevent trafficking from occurring and to provide effective support to victims. Reducing public stigma and enabling community re-integration is likely to support the recovery of survivors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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