Exploitation, Violence, and Suicide Risk Among Child and Adolescent Survivors of Human Trafficking in the Greater Mekong Subregion | Adolescent Medicine | JAMA Pediatrics | JAMA Network
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United Nations.  Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children. New York, NY: United Nations; 2003.
United Nations Office on Drugs and Crime. United Nations Convention Against Transnational Organized Crime and the Protocols Thereto. http://www.unodc.org/documents/treaties/UNTOC/Publications/TOC%20Convention/TOCebook-e.pdf. 2004. Accessed February 2, 2015.
International Labour Organization.  Global Estimate of Forced Labour: Results and Methodology. Geneva, Switzerland: International Labour Organization; 2012.
US Department of State. Trafficking in persons report June 2007. http://www.state.gov/g/tip/rls/tiprpt/2007. Accessed August 1, 2007.
Pinheiro  PS.  United Nations Secretary-General’s World Report on Violence against Children. New York, NY: United Nations; 2006.
United Nations Children’s Fund.  Africa’s Orphaned Generation. New York, NY: United Nations Children’s Fund; 2003.
International Programme on the Elimination of Child Labour, International Labour Organization.  Estimates on Child Labour. Geneva, Switzerland: International Programme on the Elimination of Child Labour, International Labour Organization; 2002.
Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258.PubMedGoogle ScholarCrossref
Krug  EG, Mercy  JA, Dahlberg  LL, Zwi  AB.  The world report on violence and health.  Lancet. 2002;360(9339):1083-1088.PubMedGoogle ScholarCrossref
Norman  RE, Byambaa  M, De  R, Butchart  A, Scott  J, Vos  T.  The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis.  PLoS Med. 2012;9(11):e1001349.PubMedGoogle ScholarCrossref
Parker  DL, Overby  M.  A discussion of hazardous child labor.  Public Health Rep. 2005;120(6):586-588.PubMedGoogle Scholar
Hesketh  T, Gamlin  J, Woodhead  M.  Policy in child labour.  Arch Dis Child. 2006;91(9):721-723.PubMedGoogle ScholarCrossref
Singer  MI, Anglin  TM, Song  LY, Lunghofer  L.  Adolescents’ exposure to violence and associated symptoms of psychological trauma.  JAMA. 1995;273(6):477-482.PubMedGoogle ScholarCrossref
Ouellet-Morin  I, Fisher  HL, York-Smith  M, Fincham-Campbell  S, Moffitt  TE, Arseneault  L.  Intimate partner violence and new-onset depression: a longitudinal study of women’s childhood and adult histories of abuse.  Depress Anxiety. 2015;32(5):316-324.PubMedGoogle ScholarCrossref
Rossiter  A, Byrne  F, Wota  AP,  et al.  Childhood trauma levels in individuals attending adult mental health services: an evaluation of clinical records and structured measurement of childhood trauma.  Child Abuse Negl. 2015;44:36-45.PubMedGoogle ScholarCrossref
Fliege  H, Lee  J-R, Grimm  A, Klapp  BF.  Risk factors and correlates of deliberate self-harm behavior: a systematic review.  J Psychosom Res. 2009;66(6):477-493.PubMedGoogle ScholarCrossref
Miller  AB, Esposito-Smythers  C, Weismoore  JT, Renshaw  KD.  The relation between child maltreatment and adolescent suicidal behavior: a systematic review and critical examination of the literature.  Clin Child Fam Psychol Rev. 2013;16(2):146-172.PubMedGoogle ScholarCrossref
Nock  MK.  Self-injury.  Annu Rev Clin Psychol. 2010;6:339-363.PubMedGoogle ScholarCrossref
van der Kolk  BA, Perry  JC, Herman  JL.  Childhood origins of self-destructive behavior.  Am J Psychiatry. 1991;148(12):1665-1671.PubMedGoogle ScholarCrossref
Abas  M, Ostrovschi  NV, Prince  M, Gorceag  VI, Trigub  C, Oram  S.  Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study.  BMC Psychiatry. 2013;13:204.PubMedGoogle ScholarCrossref
United Nations Office on Drugs and Crime. Global report on trafficking in persons. http://www.unodc.org/documents/data-and-analysis/glotip/Trafficking_in_Persons_2012_web.pdf. 2012. Accessed March 15, 2015.
Bélanger  D.  Labor migration and trafficking among Vietnamese migrants in Asia.  Ann Am Acad Pol Soc Sci. 2014;653(1):87-106. doi:10.1177/0002716213517066.Google ScholarCrossref
Rafferty  Y.  Children for sale: child trafficking in Southeast Asia.  Child Abuse Rev. 2007;16(6):401-422. doi:10.1002/car.1009.Google ScholarCrossref
United Nations Office on Drugs and Crime.  Trafficking in persons: global patterns.http://www.unodc.org/pdf/traffickinginpersons_report_2006ver2.pdf. 2006. Accessed July 24, 2015.
Kiss  L, Pocock  NS, Naisanguansri  V,  et al.  Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study.  Lancet Glob Health. 2015;3(3):e154-e161.PubMedGoogle ScholarCrossref
Bolton  P.  Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard.  J Nerv Ment Dis. 2001;189(4):238-242.PubMedGoogle ScholarCrossref
Lee  B, Kaaya  SF, Mbwambo  JK, Smith-Fawzi  MC, Leshabari  MT.  Detecting depressive disorder with the Hopkins Symptom Checklist-25 in Tanzania.  Int J Soc Psychiatry. 2008;54(1):7-20.PubMedGoogle ScholarCrossref
Mollica  R, Caspi-Yarvin  Y, Lavelle  J,  et al.  Harvard Trauma Questionnaire (HTQ) Manual: Cambodian, Lao, and Vietnamese Versions. Boston, MA: Harvard Program in Refugee Trauma; 1991.
Hossain  M, Zimmerman  C, Abas  M, Light  M, Watts  C.  The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women.  Am J Public Health. 2010;100(12):2442-2449.PubMedGoogle ScholarCrossref
Mollica  RF, Wyshak  G, de Marneffe  D, Khuon  F, Lavelle  J.  Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees.  Am J Psychiatry. 1987;144(4):497-500.PubMedGoogle ScholarCrossref
Tsutsumi  A, Izutsu  T, Poudyal  AK, Kato  S, Marui  E.  Mental health of female survivors of human trafficking in Nepal.  Soc Sci Med. 2008;66(8):1841-1847. doi:10.1016/j.socscimed.2007.12.025.Google ScholarCrossref
Derogatis  LR.  BSI Brief Symptom Inventory: Administration, Scoring, and Procedure Manual.4th ed. Minneapolis, MN: National Computer Systems; 1993.
National Institute for Clinical Excellence; National Collaborating Centre for Mental Health.  Self-Harm: Longer Term Management. London, England: National Institute for Clinical Excellence; 2011.
Hawton  K, Saunders  KEA, O’Connor  RC.  Self-harm and suicide in adolescents.  Lancet. 2012;379(9834):2373-2382.PubMedGoogle ScholarCrossref
Garcia-Moreno  C, Jansen  HAFM, Ellsberg  M, Heise  L, Watts  C.  WHO Multi-Country Study on Women’s Health and Domestic Violence against Women. Geneva, Switzerland: World Health Organization; 2005.
Devries  KM, Mak  JYT, García-Moreno  C,  et al.  Global health: the global prevalence of intimate partner violence against women.  Science. 2013;340(6140):1527-1528.PubMedGoogle ScholarCrossref
Hossain  M, Zimmerman  C, Kiss  L,  et al.  Men’s and women’s experiences of violence and traumatic events in rural Cote d’Ivoire before, during and after a period of armed conflict.  BMJ Open. 2014;4(2):e003644.PubMedGoogle ScholarCrossref
International Labour Organization. C001 - Hours of Work (Industry) Convention, 1919 (No. 1). http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312146. 1919. Accessed September 15, 2014.
International Labour Organization. C030 - Hours of Work (Commerce and Offices) Convention, 1930 (No. 30). http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312175. 1930. Accessed September 15, 2014.
International Labour Organization. C047 - Forty-Hour Week Convention, 1935 (No. 47). http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312192. 1935. Accessed September 15, 2014.
International Labour Organization. R116 - Reduction of Hours of Work Recommendation, 1962 (No. 116). http://www.ilo.org/dyn/normlex/en/f?p=1000:12100:0::NO:12100:P12100_INSTRUMENT_ID:312454. 1962. Accessed September 15, 2014.
International Labour Organization. C106 - Weekly Rest (Commerce and Offices) Convention, 1957 (No. 106). http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312251. 1957. Accessed September 15, 2014.
International Labour Organization. C014 - Weekly Rest (Industry) Convention, 1921 (No. 14). http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312159. 1921. Accessed October 10, 2014.
Zimmerman  C, Watts  C.  WHO Ethical and Safety Recommendations for Interviewing Trafficked Women. Geneva, Switzerland: World Health Organization; 2003.
Herman  JL.  Trauma and Recovery. New York, NY: Basic Books; 1997.
Zimmerman  C, Hossain  M, Yun  K, Roche  B, Morison  L, Watts  C.  Stolen Smiles: A Summary Report on the Physical and Psychological Health Consequences of Women and Adolescents Trafficked in Europe. London, England: London School of Hygiene and Tropical Medicine; 2006.
Rigby  P, Whyte  B.  Children’s narrative within a multi-centred, dynamic ecological framework of assessment and planning for child trafficking.  Br J Soc Work. 2015;45(1):34-51. doi:10.1093/bjsw/bct105.Google ScholarCrossref
Schloenhardt  A, Loong  M.  Return and reintegration of human trafficking victims from Australia.  Int J Refug Law. 2011;23(2):143-173. doi:10.1093/ijrl/eer003.Google ScholarCrossref
Mollica  RF, Brooks  R, Tor  S, Lopes-Cardozo  B, Silove  D.  The enduring mental health impact of mass violence: a community comparison study of Cambodian civilians living in Cambodia and Thailand.  Int J Soc Psychiatry. 2014;60(1):6-20.PubMedGoogle ScholarCrossref
Original Investigation
September 8, 2015

Exploitation, Violence, and Suicide Risk Among Child and Adolescent Survivors of Human Trafficking in the Greater Mekong Subregion

Author Affiliations
  • 1Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England
  • 2PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Reader in Gender Violence and Health, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England
JAMA Pediatr. 2015;169(9):e152278. doi:10.1001/jamapediatrics.2015.2278

Importance  Human trafficking and exploitation of children have profound health consequences. To our knowledge, this study represents the largest survey on the health of child and adolescent survivors of human trafficking.

Objective  To describe experiences of abuse and exploitation, mental health outcomes, and suicidal behavior among children and adolescents in posttrafficking services. We also examine how exposures to violence, exploitation, and abuse affect the mental health and suicidal behavior of trafficked children.

Design, Setting, and Participants  A survey was conducted with 387 children and adolescents aged 10 to 17 years in posttrafficking services in Cambodia, Thailand, or Vietnam, which along with Laos, Myanmar, and Yunnan Province, China, compose the Greater Mekong Subregion. Participants were interviewed within 2 weeks of entering services from October 2011 through May 2013.

Main Outcomes and Measures  Depression, posttraumatic stress disorder, anxiety, suicidal ideation, self-injury, and suicide attempts.

Results  Among the 387 children and adolescent study participants, most (82%) were female. Twelve percent had tried to harm or kill themselves in the month before the interview. Fifty-six percent screened positive for depression, 33% for an anxiety disorder, and 26% for posttraumatic stress disorder. Abuse at home was reported by 20%. Physical violence while trafficked was reported by 41% of boys and 19% of girls. Twenty-three percent of girls and 1 boy reported sexual violence. Mental health symptoms were strongly associated with recent self-harm and suicide attempts. Severe physical violence was associated with depression (adjusted odds ratio [AOR], 3.55; 95% CI, 1.64-7.71), anxiety (AOR, 2.13; 95% CI, 1.12-4.05), and suicidal ideation (AOR, 3.68; 95% CI, 1.77-7.67). Sexual violence while trafficked was associated with depression (AOR, 2.27; 95% CI, 1.22-4.23) and suicidal ideation (AOR, 3.43; 95% CI, 1.80-6.54).

Conclusions and Relevance  Children and adolescents in posttrafficking care showed high symptom levels of depression, anxiety, and posttraumatic stress disorder, which are strongly associated with self-harm or suicidal behaviors. Mental health screening and reintegration risk assessments are critical components of posttrafficking services, especially in planning for family reunification and other social integration options.