Traumatic experiences , psychophysical consequences and needs of human trafficking victims

The global phenomenon of human trafficking involves wide social and economic implications, and its expansion is strengthened by globalization and the use of new technology. Victims can be anyone. The forms of exploitation differ, ranging from sexual, labor exploitation, criminal involvement, arrangement of marriages, organ donation, to forced military service, all implying violent exploitation and abuse of human beings and their rights. The causes of human trafficking include: poverty, unemployment, migrations, rule of law, gender inequality, region militarization, organized crime, corruption, violence in family, etc. In accordance with the “Palermo protocol”, human beings trafficking implies recruitment, transportation, transfer, harboring or receipt of persons, by use of force, threats or other forms of coercion, abduction, fraud, deceit, abuse of authority or position of the superior, for the purpose of sexual or economic abuse and achieving profit or benefit of the third parties, and/or groups (pimps, traffickers, brokers, brothel owners or other employers, clients and criminal groups) . It is often not possible to medically rebalance and enable victims to reach satisfactory level of physical and mental health.


Introduction
The global phenomenon of human trafficking involves wide social and economic implications, and its expansion is strengthened by globalization and the use of new technology.Victims can be anyone.The forms of exploitation differ, ranging from sexual, labor exploitation, criminal involvement, arrangement of marriages, organ donation, to forced military service, all implying violent exploitation and abuse of human beings and their rights.
The causes of human trafficking include: poverty, unemployment, migrations, rule of law, gender inequality, region militarization, organized crime, corruption, violence in family, etc.In accordance with the "Palermo protocol", human beings trafficking implies recruitment, transportation, transfer, harboring or receipt of persons, by use of force, threats or other forms of coercion, abduction, fraud, deceit, abuse of authority or position of the superior, for the purpose of sexual or economic abuse and achieving profit or benefit of the third parties, and/or groups (pimps, traffickers, brokers, brothel owners or other employers, clients and criminal groups) 1 .It is often not possible to medically rebalance and enable victims to reach satisfactory level of physical and mental health.

Human risks
Human trafficking has dire consequences in regards to the safety, welfare and human rights of the victims, who are forced to live in the conditions of physical and mental imprisonment.Numerous mechanisms are used during the exploitation phase, commonly involving: repayment obligations; isolation -confiscation of identification documents; use of violence and intimidation; psychological imprisonment and torture.
Victims are often beaten, raped, limited in movement, denied food or water, tortured or drugged, in order to provide absolute obedience.These methods may be a form of punishment for disobedience, but may also serve as prevention to warn the victims of the potential consequences in case of breaching the established rules.For instance, research conducted by the Counseling Centre for Alternative Prostitution in Portland, Oregon, USA, based on data and experience of women engaged in prostitution, reported that: a) 84% of women report that pimps force them into prostitution; b) 78% suffered rape while being prostitutes; c) 84% are victims of violence; d) 49% are victims of kidnapping: e) 53% are victims of sexual torture; f) 27% suffered physical impairment as a result of torture: and g) 73% considered suicide as a way to escape everything 2 .

Exposure of human trafficking victims to AIDS and other sexually transmitted diseases
Human trafficking is closely related to AIDS, as many involved in prostitution are unable to negotiate the use of condoms.Evaluations of the access to effective treatment, protection and support could improve the programs focused on victims' aid 3 .A number of relevant studies indicate that AIDS and other deadly diseases may be easily transmitted through condoms, as well.During the late 80s, the Center for Prevention and Disease Control in the US published a report "HIV is not isolated from blood, tears, urine, saliva, cerebrospinal liquid, mothers' milk, and tissues of infected people… Skin, particularly if scratched, taxed or pealed, infected or otherwise Banović B, Bjelajac Ž. Vojnosanit Pregl 2012; 69(1): 94-97.damaged, as well as mucosa of the eyes, nose, mouth, and breathing area, should be considered as potential paths of virus entry" 4 .A campaign message therefore appears completely reasonable: 'You pay for a night -She pays for a lifetime' 5 .
Utilization of condoms provides false safety regarding AIDS transmission, and leads to other sexually transmitted diseases and viruses such as: Chlamydia infection, condilomi (genital warts), genital herpes as well as urinarz tract infections, scabies (Sarcoptes scabies), lice (Pediculosis pubis), gonorrhea, syphilis, hepatitis A, B, and C. Condilomi is caused by the human papilloma virus (HPV).ΗΡV condiloma causes cervical cancer in women and treatment must be initiated straight after detection.ΗΡV is commonly transmitted through sexual contact, regardless of regular contact, anal or oral sex.It can also appear even if the condom is used, as a partner could be a carrier of the virus, without any visible symptoms.The touch of infected skin or contact of body liquids during sexual contact is sufficient to get infected.Statistics provided by the US Centers for Prevention and Disease Control, state that at least 20 million people in the US suffer from HPV. Estimations indicate that around 80% of sexually active population has some form of this virus.In Croatia, it is estimated that about 60% of sexually active women is infected.In Serbia, there are no valid statistics but it is expected that the numbers do not significantly differ 6 .

Trauma and needs of victims
Human trafficking victims suffer from chronic, long-term trauma.Traumatic events represent a threat to life or physical integrity or close contact with violence and death.Commonly, human response to danger causes increased flow of adrenalin alarming the state of alert.Individuals in such crisis situation may choose to 'fight or flight', exhibiting strong emotions (fear or anger) that can mobilize or paralyze them.
Normal human reactions to abnormal events, such as traumatic experience of human trafficking involve 7 : 1) physical reactions: headache and stomach pain; sudden sweating and heart disturbance; changes in sleep and appetite; weakened immune system; alcohol or drug misuse; and 2) psychological reactions: shock and fear; disorientation and confusion; oversensitivity and distress; rumination of trauma; nightmares and flashbacks; minimization of the experience; isolation and detachment; problems with trust and/or feelings of betrayal; feelings of helplessness, panic and loss of control; decreased interest for daily activities; lack of sense of order or justice in the world; and fear of the future.

Psychological status of trauma survivor victims
The intensity of acute reactions of the victims depends on the experienced trauma and emotional pain, and is often combined with maltreatment and abuse during childhood, which is important in the domain of clinical consequences caused by enslavement and sexual abuse.
The victims assisted by the International Organization for Migration (IOM) Kosovo as part of the Program against human trafficking (Counter Trafficking -CT Program) during psychological counseling in the shelter, exhibited the following reactions as consequences of trauma: 1) acute stress reaction; 2) post-traumatic stress disorder (PTSD): flashbacks, nightmares appearing on a base of 'numbness', disregard of environment, emotional flatness, isolation from others, anhedonia; 3) depression; 4) adjustment disorder: difficulties to adjust and function regularly, overcome daily problems and plan ahead; 5) dissociation and self-harm: split consciousness is an instinctive response of the victims to allow themselves to avoid painful and unwanted memories; actions may include: heavy cuts, extinguishing cigarettes on skin, self-hitting, abuse of various sedatives or substances.

Needs of victims of human trafficking
The circle of violence and exploitation may be terminated only when a victim is identified and subsequently resocialized and reintegrated through the institutionalized support system.The term reintegration has been replaced by the term social inclusion 8 .Prosecution-oriented approach has been abandoned, adopting a victim-oriented approach that views human trafficking primarily as an issue of human rights [9][10][11] , and subsequently procedural matter.Comprehensive programs should also satisfy the standards of processorientation (emotional healing and overcoming trauma), effect-orientation (emotional stabilization and social inclusion), as well as the change of policies and measuresorientation (upgrading victims' protection framework).Victim-oriented approach implies development of a program scheme and performance of specific activities in each single case of support (case-by-case) 8 .
The diversified needs of human trafficking victims may be satisfied only through coordinated actions of state institutions, non-governmental organization (NGOs) and international organizations 11 .Usually, housing appears as a basic need, involving help to obtain food, clothing, hygiene and other basic resources for life.Victims often need medical assistance for acute health issues, sexually transmitted diseases and drug addiction.Concurrently, psychological support and assistance is considered crucial.Legal aid through regulating civil status of the victim, provision of all relevant documents and with adequate security measures is needed for access to health and social support as well as administrative and court proceedings, where victims may appear as witnesses 12 .The need for education and employment represent prerequisites for sustainable reintegration of the victim.Some victims have specific personal needs to re-establish contact with family, interpersonal and intimate relationships.These needs can be satisfied only through comprehensive and institutionalized programs including: detection and identification, rehabilitation, short-term reintegration, and sustainable social inclusion.

Health-related needs of human trafficking victims
In order to perform initial medical evaluation of the victims, it is necessary to evaluate their psychological and physical state, including assessment of: general state of health; presence of heavy and light bodily injuries, acute and chronic organic diseases, based on a general medical assessment; elements of crisis reaction, implying evaluation of Banović B, Bjelajac Ž. Vojnosanit Pregl 2012; 69(1): 94-97.
self-perception of danger, physical and mental exhauster, intensity of acute, prolonged or chronic stress reaction, intensity and prevalence of dominant emotional way of reacting over the rational one, confusion and inability to make decisions; general and specific intellectual abilities, including psychological assessment of general, verbal and nonverbal intellectual abilities by employing adequate instruments (WISC, WB-II, Kohs, PURDUE, Raven's progressive matrix for children and adults, DAT -series of specific intellectual abilities); personality structure and emotional state of the victim, including psychological assessment by utilization of personality tests (MMPI-201, CORNELL INDEX, PROFIL INDEX EMOCIJA, BDI, Frederik's maturity test); presence and intensity of traumatic reactions and symptoms of posttraumatic stress disorder, employing diagnostic procedure of PTSD according to the DSM-IV criteria; international classification of mental disorders, evaluation of stress intensity by appropriate scales and inventories (Horowitz' scale, Harvard checklist); the presence of psychiatric disorders, implying diagnostic procedure in accordance with the DSM-IV, and in particular assessment of the potential presence of depressive disorders, suicidal ideation or attempts, personality disorders, psychotic disturbances and addiction disorders 13 .
Assessment of psychophysical state and psychological treatment is performed on the basis of hierarchy of needs.Primary, organic health is addressed, and then physical safety, daily routine and physiological functions of sleep and alimentation are established, a trusting relationship between a victim and professionals is developed, and an in-depth psychological assessment is performed.

Clinical forensics in cases of human trafficking
Health state assessment of a victim may be used in criminal proceedings, in case medical facts are established and documented.Clinical forensic examination implies collection of anamnestic data, followed by an in-depth comprehensive body examination 14 .All changes must be described in accordance with specific principles (localization, shape, size and characteristics of the change).Findings must be documented both verbally and schematically, on a body sketch, whereas photos of the injuries are also recommended, primarily due to temporary character of the majority of body injuries 15,16 .Photos made during examination represent an excellent supplement to the developed reports and allow for objective evaluation of the examination report and related conclusions" 15,16 .Based on the findings of clinical forensic expertise, it is possible to evaluate reliability of anamnestic data provided by the victim, particularly in terms of time, method and means of harming, resisting, etc.Therefore, "specific aims of clinical forensic examination of human trafficking victims may be: determination of elements of sexual violence, determination of signs of a recent abortion, provision of material for toxicological analysis, determination -evaluation of age and provision of material for screening blood and sexually transmitted infections" 17 .

Conclusion
Human trafficking victims require medical treatment as well as psychological support and assistance.Mental state examination and psychological treatment are performed on the basis of needs' hierarchy.Each victim requires individualized treatment.Health status examination of a victim may also be used in the criminal proceedings.In this context, it is particularly important to establish a protocol of clinical forensic examination, as probative value of medical documentation in criminal proceedings will depend on its quality.