Transcultural Psychiatry

http://tps.sagepub.com Women Trafficked Into Prostitution: Determinants, Human Rights and Health Needs
Olga Gajic-Veljanoski and Donna E. Stewart TRANSCULT PSYCHIATRY 2007; 44; 338 DOI: 10.1177/1363461507081635 The online version of this article can be found at: http://tps.sagepub.com/cgi/content/abstract/44/3/338

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transcultural psychiatry
September 2007
ARTICLE

Women Trafcked Into Prostitution: Determinants, Human Rights and Health Needs
OLGA GAJIC-VELJANOSKI & DONNA E. STEWART
University of Toronto
Abstract Human trafcking is an international challenge that increasingly affects industrialized countries. It represents a gross violation of a persons right to liberty and freedom of movement, and is often accompanied by violence and degrading treatment which can have detrimental effects on health. In this article, we review the denition and extent of human trafcking, and focus on the human rights abuses and determinants of trafcking in women. Mental health and other health outcomes are reviewed, and differences between countries in organized activities for victim assistance and protection are assessed. Finally, we discuss the roles of mental health and other healthcare providers in identifying and helping trafcked women, and recommend a tailored multidisciplinary approach for victim assistance. Key words human trafcking mental health victim assistance women

Human trafcking is an international challenge that increasingly affects several highly developed countries including the USA, Canada and western Europe (Kangaspunta, 2003; Stewart & Gajic-Veljanoski, 2005; U.S. Department of State, 2003). This adverse sequel of globalization generates up to $9.5 billion per year (Morrison & Crosland, 2000; U.S. Department of State, 2005), and according to some reports, represents the third-largest source of prot for organized crime after drugs and guns (Orhant, 2002). Human
Vol 44(3): 338358 DOI: 10.1177/1363461507081635 www.sagepublications.com Copyright 2007 McGill University

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Gajic-Veljanoski & Stewart: Trafcking in Women

trafcking represents a denial of human rights, undermines governmental (legal) authority, and poses health risks for individuals. It embraces a wide range of subpopulations enslaved for substantially different purposes such as work, organ trafcking or sex (Loff & Sanghera, 2004). Human trafcking is a complex problem and is difcult to research. Studies on trafcked persons encounter serious methodological challenges that result in many limitations (Cwikel & Hoban, 2005; Laczko & Gozdziak, 2005). Some of these include the hidden nature of the population, confusion in dening trafcked individuals (e.g., trafcked vs. smuggled), descriptive and/or qualitative study designs, small samples, the diversity of trafcked people (country of origin), and the presence of selection, sampling and/or measurement bias. Therefore, any attempts to generalize, quantify or simplify this problem may lead to spurious conclusions. In this article, we review the current literature to describe and explore some determinants of the phenomenon of trafcking in women. We discuss sex trafcking in the context of a human rights violation, as an issue of violence against women, and as a health issue. This narrative literature review briey describes the denition and extent of human trafcking, and discusses the process and possible causes of sex trafcking. It specically explores whether cultural and psychosocial factors can affect differences in the degree of deceptiveness behind sex trafcking, and whether they could intensify a womans risk to be trafcked and/or represent barriers to escape prostitution. It also reviews the main health-related outcomes of sex trafcking. The authors further explore Australian, Canadian, German, Italian, Dutch, U.K. and U.S. government and non-government web sites and publications to analyze differences in destination-country policies for trafcking victim assistance. Finally, we assess the roles and challenges of healthcare providers when identifying and helping women trafcked for prostitution.

Human Trafcking: Denition and Extent

Human trafcking constitutes the denial of the persons rights to liberty, integrity, security and freedom of movement. This is often combined with violence, torture and degrading treatment. There is little or no consensus among researchers on a consistent theoretical framework for understanding human trafcking (Bruckert & Parent, 2002). Human trafcking can be studied in the context of migration, labor, prostitution, crime, human rights, health, child abuse or violence against women. Disagreements in dening human trafcking are also apparent (Bruckert & Parent, 2002), however, coercion is crucial to most denitions (Loff & Sanghera, 2004; Wijers & Lap-Chew, 1997).
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Transcultural Psychiatry 44(3)

The ofcial denition1 is given by the United Nations (UN) Protocol to Prevent, Suppress and Punish Trafcking in Persons, Especially Women and Children (hereafter the UN Protocol), which supplements the UN Convention Against Transnational Organized Crime (United Nations General Assembly, 2000). The UN Protocol also denotes the irrelevance of consent from trafcked victims (article 3b) and imposes the protection of all victims, not only those who can prove force (article 68). Reliable data on human trafcking are difcult to ascertain, mainly due to its clandestine nature (Cwikel & Hoban, 2005; Laczko & Gozdziak, 2005; Loff & Saghera, 2004; Makkai, 2003). Estimates differ among countries, and there is a lack of detail on the methodologies used to derive them (Makkai, 2003). Accordingly, estimates of human trafcking are imprecise, with wide ranges, and accurate cross-country comparisons are difcult to perform. The inability to adequately extract trafcking victim data from smuggled migrant data causes further misinterpretation and speculation (Aronowitz, 2001; Morrison & Crosland, 2000; OxmanMartinez & Hanley, 2004; Royal Canadian Mounted Police, 2004). Recent analyses also indicate changes in the magnitude and nature of trafcking whereby it appears to be declining but in fact, has become less visible as it has gone underground following large-scale government raids and changes in immigration/border policies (United Nations Population Fund, 2006). In some instances human trafcking data are classied as secret by law enforcement agencies (Oxman-Martinez, Hanley, & Gomez, 2005), further hindering unbiased estimations of the phenomenon. However, in general, the U.S. government estimates that annually, 600,000800,000 individuals are trafcked worldwide, of whom up to 3% are trafcked into the USA (U.S. Department of State, 2004). The majority of victims (80%) are women and girls, usually trafcked for sexual exploitation.

Trafcking in Women: Process and Causes

The process of human trafcking begins in source countries from which recruited women are legally or illegally transported to destination countries (Busza, Castle, & Diarra, 2004; Busza & Schunter, 2001; Gushulak & MacPherson, 2000; Macklin, 2003; McDonald, Moore, & Timoshkina, 2000; Morrison & Crosland, 2000; Okonofua, Ogbomwan, Alutu, Kufre, & Eghosa, 2004; Oxman-Martinez, Martinez, & Hanley, 2001). Women usually enter destination countries as visitors, refugees, family-class immigrants or temporary-work migrants, for example, as exotic dancers or strippers to Canada, Japan or Australia (International Labour Organization, 2005; Stewart & Gajic-Veljanoski, 2005). Some women are smuggled across the borders (illegal entry), most likely due to the restrictive immigration policies of destination countries (International
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Gajic-Veljanoski & Stewart: Trafcking in Women

Labour Organization, 2005; United Nations Population Fund, 2006). A German study found that 42% of all registered victims of sex trafcking crossed the border illegally in 2003 (Cyrus, 2005). At the nal destination, womens passports were conscated by the agents (trafckers), and women were subjected to travel visa debts, required to be repaid through prostitution (Aghatise, 2004; Busza et al., 2004; Cwikel, Chudakov, Paikin, Agmon, & Belmaker, 2004; Macklin, 2003; McDonald et al., 2000; Raymond & Hughes, 2001; Watts & Zimmerman, 2002; Zimmerman et al., 2003). Over time, womens nancial burdens increased, including other costs such as monthly rents, medications and clothing (e.g., one Italian study found trafcking womens debts of 62,000124,000; Aghatise, 2004). In general, human trafcking is a demand-driven, expanding market facilitated on one side, by push factors related to source countries (Aronowitz, 2001; Haynes, 2004; Kangaspunta, 2003; Okonofua et al., 2004; U.S. Department of State, 2004). These include poverty, unemployment, country economic and/or political instability, government corruption, ignorance or lack of awareness of exploitation and domestic abuse or other family problems. On the other side, it is endorsed by pull factors, related to destination countries, such as an increasing demand for commercial sex and cheap labor, restrictive immigration policies, existence of legal avenues (e.g., exotic dancers, domestic work), corruption of government servants and growth in organized crime.

Cultural and Psychosocial Determinants of Women Involved In Sex Trafcking

Economic deprivation and the desire for a better future motivate most women to voluntarily participate in some stages of trafcking. As noted by the UN Protocol, obtaining consent from a trafcked woman is irrelevant for at least three reasons: rst, consent is a requirement of a continuous nature; second, most cases of trafcking are cases of vulnerable victims; and third, it is impossible to consent to exploitation. In the recruitment stage, many women are deceived as to the nature of the work. Evidence suggests that motivation and the degree of deceptiveness behind sex trafcking depend on the social and cultural milieu in which trafcked women grow up (Aghatise, 2004; Limanowska, 2005; Okonofua et al., 2004). Both the degree of deception (by trafckers) and the level of self-deception vary from partial to complete, and depend on womens vulnerability and factors such as young age, poor education, history of abuse or violence, patriarchal society, single-parenting or desperate socioeconomic/war circumstances. The feminization of poverty results in many African and Asian women being sold or encouraged by their families to seek a better life in more developed countries (Aghatise, 2004; Beyrer, 2001; Busza & Schunter,
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Transcultural Psychiatry 44(3)

2001; Busza et al., 2004). These women are often young and poorly educated, easily emotionally and mentally controlled (e.g., by black magic rites) (Aghatise, 2004; Beyrer, 2001; Busza et al., 2004; Family Violence Prevention Fund, 2005; Haynes, 2004). They usually come from patriarchal societies, and initially, may not be capable of recognizing emotional abuse, exploitation or coercion by their intermediaries (i.e., aunts or friends who transport them to destinations) (Aghatise, 2004; Family Violence Prevention Fund, 2005). They also may be accustomed to respecting older and authoritative people, or be embarrassed to break their contracts and fail to help their large poor families, or they may even be haunted by fears related to magical initiation rites (Aghatise, 2004; Beyrer, 2001). One study on Nigerian girls, frequently trafcked into Italy, showed that those women, who belonged to the Edo Benin ethnic group, were obliged with black magic rites and had a strong sense of duty to their intermediaries (trafckers). This later developed into a fear of a curse or misfortune to themselves or their families if the orders were not obeyed (Aghatise, 2004). The fears may continue even after repaying the debts, inducing paranoid states in some women. Studies have also described trafcking cases of young, educated and emancipated women, divorced women, single mothers or married women (Aghatise, 2004; Bruckert & Parent, 2004; Cwikel et al., 2004; Orhant, 2002; Zimmerman et al., 2003). Research has revealed that over 70% of trafcked women with children are single mothers (ILO, 2005; United Nations Population Fund, 2006; Zimmerman et al., 2003). In the former Soviet Union republics (e.g., Ukraine), homeless girls and orphans represent an extremely vulnerable and largely trafcked population for prostitution (Hughes & Denisova, 2001). A population-based survey on 1189 Ukraine women and girls, aged 1535, living in 10 urban regions showed the eagerness of young women to travel abroad to seek jobs (Hughes & Denisova, 2001). All of the respondents viewed prostitution as unacceptable. None of the women aged 1735 viewed dancer or stripper jobs as acceptable jobs abroad but all of the girls aged 1517 thought they were. Sixty-four percent of women trafcked from east/south-east Europe were acquainted with the recruiters (United Nations Population Fund, 2006). Recruitment is conducted through newspaper and Internet ads, agencies offering work opportunities, immigration agencies, religious groups and/or via personal recruitment (Hughes & Denisova, 2001; Makkai, 2003; Oxman-Martinez, Lacroix, & Hanley, 2005; United Nations Population Fund, 2006). Organized crime groups may also establish databases with potential victims photographs, height, weight and personality traits by using applications for beauty contests or marriage agencies (Hughes & Denisova, 2001). During the recruitment process, some women are promised substantial earnings and bogus jobs as nannies and waitresses, but some are recruited
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Gajic-Veljanoski & Stewart: Trafcking in Women

as exotic dancers or sex-workers. In a small study of 28 east/south-east European trafcked women, 17 women stated money as a reason to migrate, more than half of them (9) had children and 80% of these were single parents (Zimmerman et al., 2003). The rest were abducted, eeing danger/abuse, enticed by promises of love/marriage, wanted to study abroad or sought an interesting experience (Zimmerman et al., 2003). All but one woman reported being tricked as to the nature of employment (e.g., housekeeping, restaurant work). Thus, the roots of deception are different and the degree varies from extreme (e.g., being recruited for a totally different job) to partial (e.g., recruited as exotic dancers with no customer contact). Even those women completely aware of the job description (sex-workers) were deceived as to the slavery-like working conditions, nancial abuse, and the level of violence (Aghatise, 2004; Bruckert & Parent, 2004; Busza et al., 2004; Cwikel et al., 2004; Limanowska, 2005; Macklin, 2003; McDonald et al., 2000; Raymond & Hughes, 2001; Zimmerman et al., 2003). Few studies have examined awareness of possible sex trafcking, especially in countries where anti-trafcking campaigns are in place. Changes in perceptions or the degree of deception as to sex trafcking have been recognized. Aghatise (2004) found that sending Nigerian girls to Italy has become a status symbol for some families, and that many families (including husbands) accepted the idea of prostitution as a solution to poverty. Okonofua et al. (2004) examined knowledge and attitudes of 1456 Nigerian young women at high risk for sex trafcking and found that 97% had some knowledge of sex trafcking, while one in ve women supported it as an option for economic gain and prosperity. A recent analysis of human trafcking in south-east Europe indicated that many people do not believe in anti-trafcking programs, interpret them as anti-migration messages, and declare no changes in their migration plans despite the dangers (Limanowska, 2005).

Barriers to Escape from Sex Trafcking

Research suggests that barriers to womens escape from sex trafcking can be external or internal. External barriers are related to the trafckers and destination countries. Hughes and Denisova (2001) found that trafcked women perceive only three ways to escape the trafcking ring: rst, to become unprotable due to trauma, emotional breakdown or advanced pregnancy; second, to be helped by a client; or third, to die. Trafcked women are usually psychologically abused, intimidated, emotionally manipulated, and marginalized (Aghatise, 2004; Beyrer, 2001; Busza & Schunter, 2001; Cwikel et al., 2004; Limanowska, 2005; McDonald et al., 2000; Raymond & Hughes, 2001). Some experience the Stockholm
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Transcultural Psychiatry 44(3)

syndrome, the psychological coercion that trafckers use to encourage a false sense of love and empathy from the women. They are physically isolated, frequently relocated and may be dependent on drugs. Women coming from the former European socialist countries are also accustomed to keeping quiet about their personal and citizen rights (stay still/put up with and shut up method). Living in a corrupt society has instituted a belief that criminals are protected and that a crime against them is impossible to prove (Hughes & Denisova, 2001). This further helps trafckers to succeed in both coercion and intimidation. Threats to harm their children/families also work effectively to pacify and prevent womens escape. Women may also be photographed or videotaped in compromising or illegal situations, and then threatened with exposure to friends, family, or the police (Hughes & Denisova, 2001). Thus, fears of exposure, involvement in illegal activities (such as prostitution), criminal prosecution, deportation and/or retribution may prevent women from leaving. These, together with lack of knowledge of language and culture, as well as lack of identication documents impede many women from escaping sex trafcking and prostitution. Internal barriers may be related to the cognitive dissonance and hopelessness some women feel or to inveterate living standards/cultural norms of their countries of origin, which if not followed could result in violence, retribution, disrespect, shame and stigma. Some trafcked women accept prostitution until they repay their debts to reconcile the dissonance they feel, as they had actively participated in the trafcking process, had been aware of possible abuse but did nothing, and saw no other viable alternative (Cyrus, 2005; McDonald et al., 2000). A sex-worker trafcked to Canada from Hungary reported: I knew something was going on . . . I didnt do anything . . . you know this is the re, its going to burn you . . . but you keep on going. (McDonald, 2000, p. 45). Women may also present themselves as entrepreneurial and self-reliant to avoid cognitive dissonance (Cyrus, 2005). Some women trafcked from Estonia to Sweden and Finland accepted prostitution and low pay (10% of the earned money), as in one week, they could make the equivalent of half a years average wages in Estonia (Alalehto, 2002). Some women feel responsible for the victimization (Family Violence Prevention Fund, 2005) and this mixed with feelings of hopelessness, low self-worth, dissociation and apathy decreases their ability to escape prostitution. Another barrier may come from womens families. Thus, the families of Nigerian girls, who sell them to trafckers for prostitution in Italy, forbid their return or encourage them to remain with their exploiters and pay off the debts (Aghatise, 2004). Women trafcked from a patriarchal culture in Albania are dishonored, with spoiled reputations and thus, considered unacceptable to their families (Aghatise, 2004). Also, more violent cases have been
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Gajic-Veljanoski & Stewart: Trafcking in Women

described, such as that of Burmese Shan trafcked women who are considered criminals in their country, are sexually and physically abused, incarcerated in barbed wire enclosed camps or leprosy colonies or sold back into prostitution by local police (Beyrer, 2001).

Mental Health and Other Health Outcomes

In addition to the violation of their basic human rights, trafcking in women is also a health issue (Beyrer, 2004; Family Violence Prevention Fund, 2005; Gushulak & MacPherson, 2000; Schinina, 2004; Zimmerman & Watts, 2004). In general, health outcomes of sex trafcking result from physical violence, mental illness including psychological and substance abuse, violent and unsafe sex practices, inhumane working and living conditions and lack of access to healthcare services. Physical and sexual abuses may start early in the travel/transit stage of trafcking with pacication and brainwashing of victims through repeated raping, physical assaults and food and sleep deprivation (Royal Canadian Mounted Police, 2004; Zimmerman et al., 2003). Trafckers may rape girls who are virgins at the time of abduction or sale to ensure their collaboration (Zimmerman et al., 2003). Physical attacks and torture continue throughout the process, resulting in injuries such as broken bones, cuts, mouth and teeth injuries, cigarette- or iron-burns (Cwikel et al., 2004; Raymond & Hughes, 2001; Zimmerman et al., 2003). Women may be forced to sexually serve men for as many as 12 hours per day, seven days a week until they repay their travel visa debts (Beyrer, 2001; Busza et al., 2004; Cwikel et al., 2004; McDonald et al., 2000; Raymond & Hughes, 2001; Zimmerman et al., 2003). A German study reports the use of both physical and mental violence to force women to proceed with work in prostitution in 83% of trafcking cases in 2003, noting an increase of 11.5% compared with 2002 (Cyrus, 2005). Physical and sexual abuse, social restriction and marginalization overlap with psychological abuse, further jeopardizing womens mental health (Zimmerman et al., 2003). Women may be intimidated by blackmail and threats, emotionally manipulated, isolated and relocated or sold many times (Cwikel et al., 2004; Zimmerman et al., 2003). Virgins are in highest demand in some countries, being sold (as a virgin) 20 to 30 times when they rst begin their work (Beyrer, 2001). Several studies have demonstrated high rates of depression, post-traumatic stress disorder (PTSD) or somatic symptoms (e.g., headache, backache, dizziness), suicidal thoughts or attempts and drug or alcohol abuse (Cwikel et al., 2004; Raymond & Hughes, 2001; Zimmerman et al., 2003). A U.S. survey of 159 service providers assessing needs of trafcking victims found that, compared with other victims of crime, trafcked women were less stable, were more
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Transcultural Psychiatry 44(3)

isolated and had higher levels of fears, more severe trauma and greater mental health needs (Clawson, Small, Go, & Myles, 2003). Studies have also suggested that many women had violent or difcult childhoods (abuse, rape, homelessness, neglect, poverty and food deprivation) (Cwikel et al., 2004; Zimmerman et al., 2003), predisposing their vulnerability to trafcking (Limanowska, 2005; Zimmerman et al., 2003). Violence and trauma experienced in trafcking may further cripple their ability to recuperate mentally and physically and reintegrate into society (Zimmerman et al., 2003). Sex trafcking is also listed as one of the factors inuencing the pandemic heterosexual spread of HIV/AIDS around the world (Beyrer, 2000). Violence against women is considered a separate risk factor for HIV/AIDS or other sexually transmitted infections (World Health Organization, 2000). A U.S. study of 40 trafcked women indicated that frequent unsafe sex practices resulted in at least one self-reported sexually transmitted infection (e.g., gonorrhea, syphilis, trichomoniasis, HIV/AIDS, human papilloma virus (HPV) infection, genital herpes, hepatitis) or unwanted pregnancy (Raymond & Hughes, 2001). An Israeli study of 47 migrant sex-workers trafcked from the former Soviet republics revealed that women were allowed to use condoms for vaginal but not for oral sex (Cwikel et al., 2004). Beyrer et al. (2001) found a high prevalence of HIV of 5070% in Burmese Shan women and young girls trafcked to Thailands brothels. The majority of these women were aged 1216 years, being biologically at increased risk for HPV and HIV infection due to increased vascularity of the immature cervix. On top of this physiologic susceptibility, social circumstances (e.g., fear of deportation, no power to negotiate safe sex, isolation, language barriers, poor education including illiteracy and innumeracy and limited understanding of the infectious nature of disease) increased their high vulnerability to HIV or other infections (Beyrer, 2001). Other studies have also found that trafcked women had limited access to healthcare and social services, forced and unsafe abortions and absence of gynecological care and HIV testing (Busza et al., 2004; Cwikel et al., 2004; McDonald et al., 2000; Zimmerman et al., 2003).

Protection and Assistance to Trafcking Victims

In 2003, 117 countries signed the UN Protocol (United Nations General Assembly, 2000) that obliged them to prosecute trafckers, protect and assist trafcking victims (e.g., law enforcement, witness protection, social benets and repatriation) and prevent human trafcking (e.g., international cooperation, strict security and border controls and secure travel documents). Annually, the U.S. government examines and reports compliance of world countries with the U.S. Trafcking Victims Protection Act
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(TVPA) of 2000 and Trafcking Victims Protection Reauthorization Act (TVPRA) of 2003/05 that have the same objectives as the UN Protocol (i.e., prosecution of trafckers, prevention of human trafcking and protection of victims) (U.S. Department of State, 2005). Within this assessment, the countries are classied to one of four tiers (1, 2, 2a-watch list and 3), where the Tier 1 represents fully compliant countries, whilst the Tier 3 includes least compliant countries making no efforts against human trafcking (U.S. Department of State, 2006). The authors (Stewart & Gajic-Veljanoski, 2005) and other human trafcking researchers found that most destination countries enacted antitrafcking laws to protect their borders and security, prevent illegal migration, criminalize the act of trafcking and punish the trafckers (Future Group, 2006; Laczko & Gozdziak, 2005; Oxman-Martinez, Hanley, & Gomez, 2005; Stewart & Gajic-Veljanoski, 2005; U.S. Department of State, 2005). Canada treats human trafcking as a national security problem and prohibits trafcking-related conduct via three laws: the Criminal Code of Canada, the Immigration and Refugee Protection Act (2001) IRPA (sections 118 and 25), and most recently, the act as to trafcking in persons amending the Criminal Code (the former Bill C-49) (Department of Justice and Foreign Affairs, 2004). A maximum penalty is life imprisonment, a ne of C$1 million dollars or both (IRPA). Bill C-49 adds the following criminal offences: it prohibits receiving a nancial or material benet knowing that it results from human trafcking (with a penalty of 10 or more years imprisonment) and forbids withholding or destroying travel/identity documents to commit or facilitate the trafcking of persons (a maximum penalty of 5 years imprisonment). Thus far, under the IRPA, 17 of 40 prosecuted trafckers were sentenced from one to seven years imprisonment. In other Tier 1 countries, trafcking sentences range from 3 months to 23 years imprisonment, and the number of convicted trafckers vary from 20 in the UK, around 70 in Italy and the USA (of 110120 prosecuted) to over 130 in the Netherlands (of 260 prosecuted) (U.S. Department of State, 2006). In terms of human trafcking prevention in source countries, western countries including Canada, in partnership with the International Organization for Migration or on their own (e.g., USAID, CIDA, AusAID, La Strada-Netherlands), provide nancial and logistical support for educational programs to raise knowledge and awareness of the dangers of human trafcking in vulnerable populations. However, legal policies and programs specic to trafcking victim assistance (TVA) for immediate help, visa/residence assistance, housing, counseling, medical and psychological services, nancial help, protection of privacy, identity and physical safety of victims differ among destination countries (Table 1). Although, it might be a policy dilemma as to what
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TABLE 1 Trafcking victim assistance (TVA) programs in destination countries (Tier 1 and USA)

Tier 1 destination countries Permanent residence A? AG A Yes Yes 30 days Yes Bridge-F-Visa (55 issued)

Extent

Laws specic to TVA

Temporary Residence Visa Reection Yes/No Available period a per year/ before issued deportation AUS $20 million

National 24/7 Permanent toll-free TVA Providers residence & phone line: (A) Housing training: government (A) Specic: (B) Social services (A) Specic: assistance Funds trafcking (C) Legal services trafcking conditional allocated victims (D) Health care victims on the for TVA (B) General: (E) Financial help (B) General: willingness Witness programs in victims of (F) Education victims of to cooperate protection destination violence (G) Employment violence and testify programs countries

Funds allocated for repatriation/ reintegration programs in countries of origin Yes (AusAID)

Australia

< 100 (ofcial) Yes 1000 (NGO)

Yes Jan 2004

?/0 Witness Protection Trafcking Visas 120 days Short-term TRPsc Yes Asylum Compassionate grounds B AG; Sporadicd 911 & 1.866.789.4636 B Yes *(A) RCMP and Immigration Ofcers are getting training A Yes

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28 days Yes Asylum B AG 3045 days Yes Italian Immigration Law 1998 A AG A

Canada

1400 600:sex 800:labor via Canada to USA: 15002000

No Under IRPAb

Yes ?/? May 2006c Long-term TRPs

Yes

CDN ?e Yes $2 million (CIDA) for Victims Fund (general fund, can include TVA) Yes US $700,000 ?e Yes aimed for TVA

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Germany

1200

Yes Victims Rights Reform Law 2004

Yes

?/103 (in 2004)

Italy

2500

Yes Yes Law on Measures Against Human Trafcking 2003

?/922 (in 2004)

No

Yes

US $3.5 million aimed for TVA

?e Yes

TABLE 1 Continued

Tier 1 destination countries Permanent residence Yes A AG A Yes Yes

Extent

Laws specic to TVA

Temporary Residence Visa Reection Yes/No Available period a per year/ before issued deportation Yes 100,000 Euros

National 24/7 Permanent toll-free TVA Providers residence & phone line: (A) Housing training: government (A) Specic: (B) Social services (A) Specic: assistance Funds trafcking (C) Legal services trafcking conditional allocated victims (D) Health care victims on the for TVA (B) General: (E) Financial help (B) General: willingness Witness programs in victims of (F) Education victims of to cooperate protection destination violence (G) Employment violence and testify programs countries

Funds allocated for repatriation/ reintegration programs in countries of origin Yes La Strada projects in Eastern and Central Europe

Netherlands 20,000

Yes

Yes

?/45 90 days (2004) B-9 residence permit

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0 No? B AG; Sporadicc ? Yes precertication period (? days) Yes A AG 1.888.3737.888. A

UK

4000

Nof

No

NA

Yes (general law) Yes Yes

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USA

14,50017,500 Yes TVPAg TVPRAg

Yes T-Visa TVA U-Visa victims of crime

T-Visa: 5000/700 (20002006) U-Visa: 10,000/0?

US $200 million aimed for TVA

Yes (USAID; Department of State; Department of Labor)

Note. AusAID, the Australian governments overseas aid program; RCMP, Royal Canadian Mounted Police; CIDA, the Canadian International Development Agency; USAID, The U.S. Agency for International Development; NA, Not applicable; ?, Unknown. a Reection period is a period before deportation during which women recover and decide whether to collaborate with police; housing, medical and legal assistance is provided. b Immigration and Refugee Protection Act (IRPA). c Temporary Residence Permit (TRP). d Sporadic NGO projects, no nationwide strategy/program. e Difcult to distinguish funds allocated specically for TVA reintegration programs in countries of origin (summed into funds for prevention, awareness and education programs). f The UK did not sign the Council of Europe Convention on trafcking. g Trafcking Victims Protection Act (TVPA) of 2000, Trafcking Victims Protection Reauthorization Act (TVPRA) of 2003/05.

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government should be responsible for victims treatment and rehabilitation, some Tier 1 countries (e.g., Australia, Germany, Italy, Netherlands) and the USA have enacted legal frameworks specic to TVA, and allowed a reection period from 30120 days (Table 1). During this period (before deportation), women can decide whether to collaborate with police and they have immediate access to housing, medical and legal services (Table 1). After the reection period, most countries allow temporary residence visas (with a possibility of immigration and permanent residence) and access to TVA programs including employment and education services, welfare and witness-protection programs; however, this is conditional on womens willingness to cooperate with the authorities to testify against the trafckers. One could argue that tolerant immigration or residency laws, and unconditional help or permanent residence could be misused by organized crime groups and trafckers. Nonetheless, refusal of residency rights goes against victims needs for social protection. Pearson (2002) warned that the women who decide to testify are rewarded, whereas the others are punished, and deported. And, among those deported, many decide not to testify because of fears for the health and safety of their families. Also, Table 1 illustrates that a small number of temporary residence visas have been provided in most countries compared to the estimated extent of sex trafcking and number of visas available per year (e.g., USA, 20002006, issued 700 of 5000 T-visas available per year). This may be caused by restrictive policies, although some research suggests that women lack trust in the system and fear corruption of ofcials and their connections with trafckers (Clawson et al., 2003). However, some women genuinely wish to return home, and countries such as Australia or the USA invest some funds for repatriation and reintegration TVA programs. Little is known about the effectiveness of these programs and about the fate of women who return to their countries of origin. Are they stigmatized? How well do they reintegrate into society? Do they self-isolate and disassociate to prevent re-trafcking? How often are they retrafcked? These questions are yet to be answered. In Canada, organized and government-guided TVA programs are still in development. Human trafcking policy research has consistently found that assistance to trafcking victims has been limited, sporadic and not organized or coordinated (Future Group, 2006; Oxman-Martinez, Hanley, & Gomez, 2005; Oxman-Martinez, Lacroix, & Hanley, 2005; Stewart & Gajic-Veljanoski, 2005). In 2003, the U.S. Trafcking in Persons assessment downgraded Canada to a Tier 2 country due limited anti-trafcking and TVA efforts (U.S. Department of State, 2003). Since then, the government has worked to improve the prosecution of trafckers and public awareness of trafcking. The Interdepartmental Working Group on Trafcking (IWGT) has been established including 17 federal departments and
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Gajic-Veljanoski & Stewart: Trafcking in Women

agencies to combat human trafcking at the national level (Department of Justice and Foreign Affairs, 2004). A poster and booklets have been prepared and translated into 14 languages explaining potential dangers of human trafcking. Across Canada, the Royal Canadian Mounted Police (RCMP) provides human trafcking-specic training to immigration, law and police ofcers and to some NGOs to improve victim identication (human trafcking vs. smuggling) and victim protection and assistance (Lowe, 2006). There is a plan for telephone numbers where specialized RCMP ofcers will be available 24/7 to provide direct assistance to law enforcement agencies on questions about human trafcking. In May 2006, the immigration and passport program developed Canadas rst Human Trafcking National Coordination Centre to address national and international components of human trafcking investigations (Lowe, 2006). At the same time, the Minister of Citizenship and Immigration (CIC) introduced guidelines to assist immigration ofcers in issuing short-term temporary resident permits (TRPs) to trafcking victims for a period of up to 120 days with an option for obtaining long-term residence visas conditional on the willingness to testify against trafckers (Citizenship and Immigration Canada, 2006). However, the legal protocol, which ensures TVA, is specied for the rst 120 days of the reection period. During this period, TVA and medical services are under the federal jurisdiction provided via the Interim Federal Health program. After the reection period, funding and organization of TVA transfer to the provincial governments, and their accessibility and completeness may vary substantially from province to province. Therefore, social services for health care, legal, housing and welfare assistance depend on where trafcked women are located. In the CIC TRP guidelines (2006), the federal government suggests that holders of temporary visas obtain private health and dental care coverage. This may pose another burden to trafcked women who are less likely to be employed and to support themselves during the recovery period. In addition, healthcare services are not likely to be covered by the Canada Health Act as trafcked women should obtain permanent residence status to be eligible for provincial health insurance. Therefore, if the federal government does not take jurisdiction over TVA, the needs of trafcked women as to social, healthcare, education and employment services will be unmet and provided only sporadically. A study on perspectives from the Canadian community sector also suggests a lack of coordination and funding for basic TVA needs (OxmanMartinez, Lacroix, & Hanley, 2005). Our analysis also found that the funding of TVA programs is not transparent, is ad hoc and delivered from a general victim of violence fund. It is not clear whether the current TVA programs are effective and culturally sensitive to the needs of trafcked women, specically to those trafcked for sexual purposes. In addition to
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Transcultural Psychiatry 44(3)

this, there is a need for better identication of trafcked women. Therefore, civil society involvement, culturally sensitive community outreach and public awareness should be encouraged in major ethnic communities in Canada, as part of TVA programs. It is necessary that the federal government and IWGT establish and coordinate a nationwide network of all NGOs and organizations funded for TVA programs. This will help in assessing their accountability and effectiveness. Furthermore, this will ensure more credible estimates of the extent of sex and human trafcking in Canada as well as rational allocation of resources, and realistic evaluations of human trafcking policy initiatives and TVA programs.

Conclusion: Helping Victims of Sex Trafcking

Women and girls trafcked for sexual purposes represent a specic group of victims of violence. Their experiences, physical and mental abuses and related illnesses are unique and often require tailored multidisciplinary approaches in TVA programs (Clawson et al., 2003; Oxman-Martinez, Lacroix, & Hanley, 2005; Zimmerman et al., 2003). However, programs developed for other marginalized populations such as migrant women, women experiencing sexual abuse, rape, domestic violence or torture victims, women sex-workers or exploited women laborers may also be helpful in treating trafcked women (Zimmerman et al., 2003). Compared with other victims of violence/crime, trafcking victims cases are often more difcult: Clawson et al. (2003) found that one trafcking case require as much work as 20 domestic violence cases. Long-term repeated physical and psychosocial trauma and torture are common features of sex trafcking. Traumas trafcked women suffer are often more extreme than those in women who are battered, sexually assaulted and raped (Clawson et al., 2003). These may cause medical (e.g., injuries, sexual or reproductive consequences, somatic stress-related symptoms such as headache, backache, sleep or digestive system problems), behavioral (e.g., self-harm and suicide attempts, risk-taking, sexual aversion or promiscuity) and psychological effects (e.g., PTSD, anxiety, chronic depression, dissociative disorders, difculty in forming trusting relationships, feelings of anger, helplessness, hopelessness, stigma or guilt, low self-esteem and self-blame) on health which may be difcult to treat (Stewart & Robinson, 1996). Female victims of domestic abuse disproportionately utilize healthcare services compared with other women (Plichta, 1992) and frontline healthcare providers are vital in victim identication and treatment. Similarly, healthcare providers may be the rst to identify and help victims of sex trafcking (Family Violence Prevention Fund, 2005; U.S. Department of Health and Human Services, 2006). Although research suggests that trafcked women have limited access to the healthcare system (Busza et al.,
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Gajic-Veljanoski & Stewart: Trafcking in Women

2004; Cwikel et al., 2004; McDonald et al., 2000; Zimmerman et al., 2003), violence may be so severe that women are forced to seek professional help, often chaperoned by their trafckers. Thus, a recent qualitative study indicated that the opportunity for intervention was missed in 28% of trafcking victims who encountered healthcare providers during their time in captivity (Family Violence Prevention Fund, 2005). Healthcare providers play important roles in emergent medical and mental health assistance, which represent major components of TVA programs. The US Department of Health and Human Services has recently released an online toolkit that may be used to train healthcare providers to help victims of human trafcking (US Department of Health and Human Services, 2006). This toolkit describes approaches to identify a victim of sex trafcking, ensure safe and condential communication, and assess and provide specic emergent and long-term mental health and other medical services to victims. However, in practice, service providers encounter difculties in meeting all the needs of trafcked women (Clawson et al., 2003). This specically holds for sexual assault and prostitution recovery services. Some recommendations are to improve coordination among service providers, to design specic case-management protocols (e.g., condentiality and consent protocols, safety protocols, crisis intervention plans, health protocols for medical, dental, mental health, sexual trauma, substance abuse services) and to establish a trafcking experts database including consultants with hands-on experience in areas of victim services (Clawson et al., 2003). Therefore, experts including psychiatrists and other mental health providers, need to be integrally involved in both the education of trainees who provide health services and the development of TVA framework and policies, sensitive to the needs of victims of sex trafcking. In conclusion, trafcking of women and girls into prostitution is an egregious example of violence against women and a gross violation of human rights. Causes of sex trafcking are well researched but the cultural and psychosocial determinants of women trafcked for sexual purposes have received less study. This review suggests that entrenched cultural norms may intensify womens vulnerability and the risk of sex trafcking, and may further hinder their escape from prostitution. Compared with other victims of violence, many trafcked women suffer more extreme sex and mental health traumas. Therefore, mental health services especially sexual assault, prostitution, detoxication and addiction recovery services should be culturally sensitive and tailored to the victims of sex trafcking. Future research should examine the effectiveness of TVA programs in women who decide to help authorities to prosecute the trafckers and who in return, obtain permanent resident status in destination countries. Also, future research should ll the gap in understanding the quality of life of
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Transcultural Psychiatry 44(3)

women who return to their countries of origin and their reintegration into society.

Notes
1. The UN Protocol (article 3a) denes trafcking in persons as: . . . the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benets to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.

References
Aghatise, E. (2004). Trafcking for prostitution in Italy. Violence Against Women, 10, 11261155. Alalehto, T. (2002). Eastern prostitution from Russia to Sweden and Finland. Journal of Scandinavian Studies in Criminology and Crime Prevention, 3, 96111. Aronowitz, A. (2001). Smuggling and trafcking in human beings: The phenomenon, the markets that drive it and the organisations that promote it. European Journal on Criminal Policy and Research, 9, 163195. Beyrer, C. (2000). Accelerating and disseminating across Asia. The Washington Quarterly, 24, 211225. Beyrer, C. (2001). Shan women and girls and the sex industry in Southeast Asia: Political causes and human rights implications. Social Science & Medicine, 53, 543550. Beyrer, C. (2004). Is trafcking a health issue? The Lancet, 363, 564. Bruckert, C., & Parent, C. (2002). Trafcking in human beings and organised crime: A literature review. Ottawa, ON: Royal Canadian Mounted Police. Bruckert, C., & Parent, C. (2004). Organized crime and human trafcking in Canada: Tracing perceptions and discourses. Ottawa, ON: Royal Canadian Mounted Police. Busza, J., Castle, S., & Diarra, A. (2004). Trafcking and health. British Medical Journal, 328, 13691371. Busza, J., & Schunter, B. T. (2001). From competition to community: Participatory learning and action among young, debt-bonded Vietnamese sex-workers in Cambodia. Reproductive Health Matters, 9, 7281. Citizenship and Immigration Canada. (2006). IP 1 Temporary resident permits. Retrieved December 5, 2006, from http://www.cic.gc.ca/manuals-guides/ english/ip/ip01e.pdf Clawson, H. J., Small, K. M., Go, E. S., & Myles, B. W. (2003). Needs assessment for service providers and trafcking victims. Fairfax, VA: Caliber. 354
Downloaded from http://tps.sagepub.com by Agnes Villegas on October 1, 2008

Gajic-Veljanoski & Stewart: Trafcking in Women Cwikel, J., Chudakov, B., Paikin, M., Agmon, K., & Belmaker, R. H. (2004). Trafcked female sex-workers awaiting deportation: Comparison with brothel workers. Archives of Womens Mental Health, 7, 243249. Cwikel, J., & Hoban, E. (2005). Contentious issues in research on trafcked women working in the sex industry. Journal of Sex Research, 42, 306316. Cyrus, N. (2005). Trafcking for labour and sexual exploitation in Germany. Geneva: International Labour Organization (ILO). Department of Justice and Foreign Affairs. (2004). Interdepartmental Working Group on Trafcking in Persons (IWGTIP). Retrieved December 5, 2006, from http://www.canada.justice.gc.ca/en/fs/ht/iwgtip.html Family Violence Prevention Fund. (2005). Turning pain into power: Trafcking survivors perspectives on early intervention strategies. San Francisco, CA: Family Violence Prevention Fund. Future Group. (2006). Falling short of the mark: An international study on the treatment of human trafcking victims. Calgary: The Future Group Publications Division. Gushulak, B. D., & MacPherson, D. W. (2000). Health issues associated with the smuggling and trafcking of migrants. Journal of Immigrant Health, 2, 6778. Haynes, D. F. (2004). Used, abused, arrested and deported: Extending immigration benets to protect the victims of trafcking and to secure the prosecution of trafckers. Human Rights Quarterly, 26, 221272. Hughes, D. M., & Denisova, T. A. (2001). The transnational political criminal nexus of trafcking in women from Ukraine. Trends in Organized Crime, 6, 221. Immigration and Refugee Protection Act. R.S.C. (2001). International Labour Organization. (2005). Forced labour, migration and human trafcking. In A global alliance against forced labour. Global report under the follow-up to the ILO Declaration on fundamental principles and rights at work, report I(B). International Labour Conference, 93rd Session 2005 (pp. 4662). Geneva: International Labour Organization. Kangaspunta, K. (2003). Mapping the inhuman trade: Preliminary ndings of the database on trafcking in human beings. Forum on Crime and Society, 3, 81103. Laczko, F., & Gozdziak, E. M. (2005). Data and research on human trafcking: A global survey. Geneva: International Organization for Migration. Limanowska, B. (2005). Trafcking in human beings in Southeastern Europe: 2004 focus on prevention in: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, the former Yugoslav Republic of Macedonia, Moldova, Romania, Serbia and Montenegro, and the UN Administered Province of Kosovo. Geneva: UNICEF, UNOHCHR and OSCE/ODIHR. Loff, B., & Sanghera, J. (2004). Distortions and difculties in data for trafcking. Lancet, 363, 566. Lowe, L. (2006). 39th Parliament, 1st Session: Standing Committee on the Status of Women, October 3, 2006. Retrieved December 5, 2006, from http:// cmte.parl.gc.ca/Content/HOC/committee/391/fewo/evidence/ev2382924/ fewoev14-e.htm#T1110 355
Downloaded from http://tps.sagepub.com by Agnes Villegas on October 1, 2008

Transcultural Psychiatry 44(3) Macklin, A. (2003). Dancing across borders: Exotic dancers, trafcking, and Canadian immigration policy. The International Migration Review, 37, 464500. Makkai, T. (2003, May 15). Thematic discussion on trafcking in human beings. Presented at the workshop on trafcking in human beings, especially women and children 12th Session of the Commission on Crime Prevention and Criminal Justice, Vienna. Retrieved December 5, 2006, from http://www. aic.gov.au/conferences/other/makkai_toni/200305-trafck.html McDonald, L., Moore, B., & Timoshkina, N. (2000). Migrant sex-workers from Eastern Europe and the Former Soviet Union: The Canadian case. Ottawa, ON: Status of Women Canada. Morrison, J. & Crosland, B. (2000). The trafcking and smuggling of refugees: The end game in European asylum policy? Geneva: UHNCR. Okonofua, F. E., Ogbomwan, S. M., Alutu, A. N., Kufre, O., & Eghosa, A. (2004). Knowledge, attitudes and experiences of sex trafcking by young women in Benin City, South-South Nigeria. Social Science & Medicine, 59, 13151327. Orhant, M. (2002). Human trafcking exposed. Population Today, 30, 14. Oxman-Martinez, J., & Hanley, J. (2004). A follow-up study of Canadian policy on human trafcking: Impacts of the Immigration and Refugee Protection Act. Retrieved December 5, 2006, from http://www.im.metropolis.net/ research-policy/research_content/doc/oxman-martinez%20trac.pdf Oxman-Martinez, J., Hanley, J., & Gomez, F. (2005). Canadian policy on human trafcking: A four-year analysis. International Migration, 43, 729. Oxman-Martinez, J., Lacroix, M., & Hanley, J. (2005). Victims of trafcking in persons: Perspectives from the Canadian community sector. Retrieved December 5, 2006, from http://www.justice.gc.ca/en/ps/rs/rep/2006/rr063/ index.html Oxman-Martinez, J., Martinez, A., & Hanley, J. (2001). Human trafcking: Canadian government policy and practice. Refuge, 19, 1423. Pearson, E. (2002). Half-hearted protection: What does victim protection really mean for victims of trafcking in Europe? Gender and Development, 10, 5659. Plichta, S. (1992). The effects of woman abuse on health care utilization and health status: A literature review. Womens Health Issues, 2, 154163. Raymond, J. G., & Hughes, D. M. (2001). Sex trafcking of women in the United States: International and domestic trends. Coalition Against Trafcking in Women. Royal Canadian Mounted Police. (2004). Feature focus: Human trafcking. In Royal Canadian Mounted Police (Ed.), Environmental scans. Ottawa, ON: Strategic Policy and Planning Branch, Royal Canadian Mounted Police. Schinina, G. (2004). Psychosocial support to groups of victims of human trafcking in transit situations. Geneva: International Organization for Migration. Stewart, D. E., & Gajic-Veljanoski, O. (2005). Trafcking in women: The Canadian perspective. CMAJ: Canadian Medical Association Journal, 173, 2526. Stewart, D. E., & Robinson, G. E. (1996). Violence and womens mental health. Harvard Review of Psychiatry, 4, 5457. 356
Downloaded from http://tps.sagepub.com by Agnes Villegas on October 1, 2008

Gajic-Veljanoski & Stewart: Trafcking in Women United Nations General Assembly. (2000). Protocol To prevent, suppress and punish trafcking in persons, especially women and children supplementing the United Nations Convention Against Transnational Organized Crime (UN Doc A/55/383). United Nations Population Fund. (2006). Selling hope and stealing dreams: Trafcking in women and the exploitation of domestic workers. In State of world population 2006 A passage to hope: Women and international migration (pp. 4355). New York: United Nations Population Fund. U.S. Department of Health and Human Services. (2006). Look beneath the surface: Role of health care providers in identifying and helping victims of human trafcking. The campaign to rescue and restore victims of human trafcking. Retrieved December 5, 2006, from http://www.acf.hhs.gov/trafcking/ U.S. Department of State. (2003). Trafcking in persons report 2003. Washington, DC: U.S. Department of State. U.S. Department of State (2004). Trafcking in persons report 2004. Washington, DC: U.S. Department of State. U.S. Department of State. (2005). Trafcking in persons report 2005. Washington, DC: U.S. Department of State, June 2005. U.S. Department of State (2006). Trafcking in persons report 2006. Washington, DC: U.S. Department of State. Watts, C., & Zimmerman, C. (2002). Violence against women: Global scope and magnitude. Lancet, 359, 12321237. Wijers, M., & Lap-Chew, L. (1997). Trafcking in women: Forced labour and slavery-like practices in marriage, domestic labour and prostitution. Utrecht, The Netherlands: Foundation against Trafcking. World Health Organization. (2000). Violence against women and HIV/AIDS: Setting the research agenda. Geneva: World Health Organization. Zimmerman, C., & Watts, C. (2004). Risks and responsibilities: Guidelines for interviewing trafcked women. The Lancet, 363, 565. Zimmerman, C., Yun, K., Shvab, I., Watts, C., Trappolin, L., Treppete, M. et al. (2003). The health risks and consequences of trafcking in women and adolescents: Findings from a European Study. London: London School of Hygiene and Tropical Medicine. Olga Gajic-Veljanoski, MD, MSc, received her MD and specialization in epidemiology from the University of Belgrade (Serbia). She received her MSc in clinical epidemiology and diploma in health services and policy research from the University of Toronto in 2005. She is currently a research associate in Womens Health and Osteoporosis Program at University Health Network (Toronto). Address: University Health Network, Womens Health Program, 200 Elizabeth St., EN7228A, Toronto, Ontario M5G 2C4, Canada. [E-mail: ogveljan@uhnres.utoronto.ca] Donna E. Stewart, MD, FRCPC, is the Lillian Love Chair in Womens Health at University Health Network and the University of Toronto, where she is responsible for research, education, policy and health service delivery for womens health. 357
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Transcultural Psychiatry 44(3) She is a University Professor at University of Toronto and is appointed in the Faculty of Medicine in the Departments of Psychiatry, Obstetrics/Gynecology, Medicine, Anesthesia, Family and Community Medicine, and Surgery. She is Director of the University Health Network Womens Health Program. Dr Stewarts research interests are in womens health, womens health education, womens mental health, interpersonal violence, psychological aspects of reproductive health, psychological reaction to physical illness and international health. Address: University Health Network, Womens Health Program, 200 Elizabeth St., EN7229, Toronto, Ontario M5G 2C4, Canada. [E-mail: donna.stewart@uhn.on.ca]

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