ArticlePDF Available


In this Position Piece, I critically reflect upon some epistemological and political issues of interventions and intervention-oriented research in post-trafficking mental health care. I discuss three loci of friction within the framework of a critical global mental health approach to trafficking aftercare: ethnography, biomedical studies, and post-trafficking care. I address these loci through three case studies: two drawn from my own ethnographic fieldwork and one from a recent systematic review of biomedical studies on post-trafficking mental health. My discussion focuses on the limits of such activities when conducted as isolated interventions and highlights the need for radical interdisciplinary and participatory approaches.
Medicine Anthropology Theory 7 (2): 230246;
© Runa Lazzarino, 2020. Published under a Creative Commons Attribution 4.0 International license.
PTSD or lack of love?
For radical interdisciplinarity in global trafficking aftercare
Runa Lazzarino
In this Position Piece, I critically reflect upon some epistemological and political issues of
interventions and intervention-oriented research in post-trafficking mental health care. I
discuss three loci of friction within the framework of a critical global mental health approach
to trafficking aftercare: ethnography, biomedical studies, and post-trafficking care. I address
these loci through three case studies: two drawn from my own ethnographic fieldwork and
one from a recent systematic review of biomedical studies on post-trafficking mental health.
My discussion focuses on the limits of such activities when conducted as isolated interventions
and highlights the need for radical interdisciplinary and participatory approaches.
Trafficking aftercare, Critical global mental health, Ethnography, Interdisciplinarity, Brazil,
Medicine Anthropology Theory
A felicidade é muito injusta [Happiness is very unfair] (Marcelo).
The diagnosticians principal task is to evaluate the patients strengths rather than his
weaknesses (Devereux 1980, 321).
Ethnography, biomedical studies, and existing post-trafficking care are conceptualised, in this
article, as loci of friction between different interventions in trafficking aftercare. The central
argument is that, when these activities are conducted as isolated interventions, they tend to
produce knowledge-practice which is not survivor-centred, hence failing to produce positive
change in the lives of human trafficking survivors. The loci represent wider epistemological
positions (i.e., biomedical, anthropological, and humanitarian), and therefore they are also
ethical and political in nature. Whereas ethnography and biomedicine are more clearly located
in knowledge production, trafficking aftercare is here critically framed as an epistemological
locus as well, since it operates within regimes of humanitarian governance (Fassin and Pandolfi
2013). For this, trafficking aftercare also rests within regimes of truth that shape practices of
assistance. I depict ethnography, biomedicine, and trafficking aftercare with the metaphor of
loci of friction. The friction metaphor helps to shed light onto some key advantages-cum-
disadvantages; problematic knots; and internal and, mostly, external disconnections, collisions,
and collusions among these loci. The term friction here is not used with the goal of building
a holistic theory of interdisciplinarity (Callard and Fitzgerald 2015) or of worldly ethnography
(Tsing 2011). I look at frictions among epistemic and practical approaches to trafficking mental
aftercare mostly as the loci where these approaches meet and clash: at their boundaries and
limitations. From such frictions, I envision the production, not only dispersion, of new
energythat is, new understanding and knowledge production. It is this new, always different,
contextual, and situated knowledge that I ultimately invoke and point to in this article.
I illustrate these loci of friction with three case studies. Two case studies are drawn from
fieldwork I conducted within the framework of a multi-country ethnography around post-
trafficking life (Lazzarino 2015). One, taken from fieldwork conducted in Brazil in 2009 and
2012, explores the case of a Brazilian trafficking returnee assisted by a local organisation in
Goiânia (Goiás state). The other is based on fieldwork carried out in Vietnam in 2010, 2011,
and 2013, and focuses on a shelter for female trafficking returnees in Hanoi. A third case study
is represented by the most recent systematic review of biomedical studies on post-trafficking
The names of research participants have been changed to protect their identities. Conversations and
interviews conducted in a language other than English have been translated by the author.
PTSD or lack of love?
mental health that was available when I was developing this article.
These three case studies
are good to think with when it comes to considering the
disciplinary/epistemological/political milieus that they rest on, and how, in a radical
combination, the disciplinary/epistemological/political limitations of each could be
overcome. In the discussion below, I highlight the usefulness, but mostly the limits and the
frictions, of each locus when taken in isolation while depicting the benefits arising from their
radical integration. Each locuss shortcomings can turn into new knowledge production (i.e.,
new energy) and inform better practices via a deeper integration with the others, which in turn
promises an overcoming of their epistemological limits and political blindness. I here refer to
such deeper contamination as radical integration. Responding directly to the lack of
integration between critical medical anthropological and biomedical approaches in the field of
post-trafficking mental health, this article argues that more radical interdisciplinary research in
post-trafficking mental health looks promising in informing user-centred, more effective
interventions for survivors of human trafficking.
Locus 1. Ethnography: Marcelos case study
The ethnographers point of view
I never dared to tape-record any conversations I had with Marcelo. The real reasonas I now
see itwas that Marcelo had what I describe in my field diary as the soul of a child. In other
words, I perceived him as a very delicate, spontaneous, and candid person. Therefore, it did
not feel right to put a voice recorder between myself and his genuine desire to befriend me,
and to lessen the feeling of solitude in which he was struggling along (Desjarlais 1997).
In the discourse of human trafficking, dominated by the stereotype of the female prostitute,
Marcelo was a peculiar case. On the one hand, he was male, homosexual, had been forced into
prostitution in Italy as a travesti (transvestite), and had mental health issues. Thus, his position
of vulnerability was intensified by his sexuality and his mental condition. On the other hand,
Marcelo followed a route typical of many trafficked Brazilian male homosexuals (Teixeira
2008). Coming from the poorer areas of the north-eastern states of the country, he went
Claims made in this article are bounded to the period in time in which data were collected. Similarly, the
secondary data used as my third case study refer to studies carried out prior to 2016. However, it is worth
mentioning that the fieldboth of studies and interventions in trafficking aftercarehas not
dramatically advanced, with ongoing work in the biomedical field only (Viergever et al. 2019) and no
ethnography-based or interdisciplinary research. This affirmation is based on available evidence, recent
research I co-conducted (Wright et al. 2020), and on ongoing informal contacts with my field sites.
Medicine Anthropology Theory
through an initiatory phase where he was exploited in São Paulo before being subsequently
trafficked transnationally and ending up in Italy.
Marcelo was born in Olinda, a colonial boutique town north of Recife, the capital city of
Pernambuco state. He had grown up as an abused street child in a very deprived family. When
Marcelo was a teenager, his mother, a domestic helper, died due to complications related to a
miscarriage. According to Marcelo, his mother did not love him, and his father only
acknowledged paternity when Marcelo was 12 years old, and often beat him. His brother
now a military policemanalso did not care about him.
The psychoanalysts point of view
One day, I was sitting in front of Viola, the young psychoanalyst who was taking care of
Marcelo at the Centro POP, a shelter for the homeless in Aparecida de Goiânia, Brazil.
Marcelo had found a part-time job as a kitchen assistant. Viola described the past events of
Marcelos life, adding technical references to his mental aetiopathogenesis and treatments. She
shared her observations of Marcelo from their first sessions of psychotherapy several months
before: he had been extremely tearful, robotised, and lethargic, and had suffered from suicidal
mania and hypersalivation due to the heavy pharmacological therapy he was subject to.
However, Viola recalled that, over time, Marcelo started to look into peoples eyes again, to
tell less fragmentary stories, and to talk about different things, many of which were sad and
negative. At the beginning, he was asking me to make him forget, Viola explained, whereas
now, after almost a year of psychotherapy, he seemed able to talk about his traumas as
experiences that he went through. Viola reported that he had always been treated as
schizophrenic, and that he was traumatised when he came back from Italy.
Marcelos point of view
However, when Marcelo talked about his life, the return to his homeland after more than three
years in Italy seemed just the last in a series of disturbing events that had begun in his infancy.
Marcelo did not place emphasis on his Italian enslavement; on the contrary, at least in the
period I was seeing him, he focused on his childhood, which he characterised as consisting of
a lot of poverty and a lot of punches. He also viewed his life as replete with discrimination
Aparecida de Goiânia is a suburban district of Goiânia, the capital of the state of Goiás in Central West
Brazil. Centro POP stands for Centro de Referência Especializado para População em Situação de Rua
(Specialised Reference Centre for Homeless People). In these centres, the homeless receive food, clothes,
and other kinds of assistance.
PTSD or lack of love?
but lacking in love. Love was what Marcelo missed the most, and falta de amor (the lack of
love) was what he viewed as the main cause of his sadness in the present. I do not feel the
trauma now anymore, but I was never happy, he once expressed to me, adding that: Morreu
dentro de mim a sensação de amar . . . sonhar (It has died inside me, the sensation of [being able
to] love . . . to dream).
Locus 2. Biomedical approach: the case of a systematic review
The systematic review by Ottisova and colleagues (2016) considers the prevalence and risk of
physical, mental, and sexual health problems among survivors of human trafficking. The
review is based on 31 studies, 15 of which report on the mental health of trafficking survivors,
mainly using female study participants. The studies reviewed are, for the most part, either
cross-sectional or case-control in design, and employ biomedical screening scales, such as the
Hopkins Symptoms Checklist (HSC-25) and Harvard Trauma Questionnaire (HTQ).
Regarding the mental health of trafficked women specifically, the results of these studies
considerably vary. The percentage of trafficked women afflicted by depression, for example,
ranges from a maximum of 86 percent among trafficking returnees to Nepal (Tsutsumi et al.
2008) to a minimum of 12.5 percent among returnees to Moldova (Abas et al. 2013). Anxiety
disorder is also reported to be high in some studies (Hossain et al. 2010; Kiss et al. 2015;
Tsutsumi et al. 2008) while relatively low in others (Abas et al. 2013; Turner-Moss et al. 2014).
Similar variations could be observed in relation to post-traumatic stress disorder (PTSD). The
two studies making use of the HTQ report the highest prevalence of PTSD among trafficked
women (77 percent in Hossain et al. 2010; 44 percent in Kiss et al. 2015), whereas other studies
give ranges between 36 percent (Abas et al. 2013) and 13 percent (Tsutsumi et al. 2008).
With respect to pre-trafficking histories of mental health or abuse and adverse childhood
experiences (ACEs), these are merely considered in terms of the sociodemographic and clinical
characteristics of the sample (Le 2014; Oram et al. 2015; Varma et al. 2015).
investigated, instances of childhood and pre-trafficking abuse are significant. In one study, 43
percent of trafficked adults suffered physical and sexual abuse in their childhood and 60
percent suffered abuse in their adulthood (Oram et al. 2015). In another study, compared to a
group of age-matched sexually abused/assaulted adolescents, the group of trafficked children
In situations of multiple traumas, individuating a clean nexus between pre-trafficking history, trafficking-
related trauma, and post-trafficking health can be complex work. Abas et al. (2013, 78), for instance,
framed their study within the larger biomedical literature on trauma and PTSD, covering trauma pre-,
during, and post-trafficking. Post-migration environmental stressors, such as stigmatisation,
socioeconomic conditions, and family pressures also have a tremendous importance in delaying recovery
and triggering mental disorders, particularly PTSD and depression (e.g., Alemi et al. 2016).
Medicine Anthropology Theory
for sexual exploitation presented significantly higher rates of physical abuse (44 percent),
sexual violence (31 percent), and drug use (50 percent) (Varma et al. 2015).
Overall, these studies use different diagnostic and screening tools; adopt different recruitment
criteria; present considerable definitional differences in trafficking exposure; are conducted in
different kinds of settings, with mono- or multi-cultural samples; and stress different factors
(e.g., kind of work the victims were forced into and kind of violence and abuse suffered).
Therefore, the heterogeneity in results can be partly attributed to the different study designs,
which can, in turn, be taken as a sign of the level of complexity of the subject matter.
Methodological problems and the disparateness of results are so significant, the authors of
the review maintain, as to limit both the comparability of studies and reliability of findings
(Ottisova et al. 2016, 338).
Locus 3: Post-trafficking care: the Peace House Shelters case study
The Peace House Shelter (Ngôi Nhà Bình Yên) was opened in Hanoi in March 2007 to support the
recovery and reintegration of survivors of human trafficking. The shelter, a pilot model, was
supported by aid from the Spanish Agency for International Development Cooperation, the
house was set up and operated by the Centre for Womens Development (a branch of the
Vietnam Womens Union) as part of a pilot project, and had an almost entirely Vietnamese
staff. Mrs. Thuy, the projects vice-director at the time, told me that during the first few years
the shelter did not take off. The major difficulty was that almost nobody was coming to the
shelter; it was not until a massive communication campaign was delivered, Mrs. Thuy recalled,
that the first residents arrived. By 2011, the shelter still had not reached its capacity. The lack
of beneficiaries was only one of the difficulties being experienced by the project. Mrs. Thuy
also lamented the lack of expertise in the management; appropriately trained social workers;
funds necessary for long-term, comprehensive support; and knowledge and personnel for the
provision of psychological assistance.
It is in this context that Pierre, a French psychoanalyst, was contacted. The provision of
psychological care in the shelter was missing in 2010, and it seemed wise to hire a Western
psychologist who could train and lead the shelters social workers while also taking care of the
residents. When I interviewed Pierre, we discussed the presence of trauma among the
residents, and he was absolutely convinced that On ny a aucune trace (there is no sign). He
continued: Inside the work that was conducted [with the shelters residents] there was no sign
of traumatism . . . rien [emphasis mine]. The only sign is’—here, he paused to find the right
word—’the exclusion, he finally uttered. The traumatism is the social rejection they live upon
return. Pierre was referring to the fact that, in Vietnam, like in many other countries, survivors
are stigmatised because they are associated with sex work, forced marriage, and HIV/AIDS,
PTSD or lack of love?
which all ultimately stand for an illicit loss of virginity outside the marriage and for a
polluted/polluting female body (Lazzarino 2014; Vijeyarasa 2013).
Marcelos case illuminates the complexity of understanding post-trafficking mental health
through ethnography. As has often been argued, ethnography is characterised by the
establishment of a relationship with research participants, a multivocal approach, and an
attention to micro and macro contextual factors of power inequalities, among other things
(Snajdr 2013). Yet, multivocality and emic concepts can be problematic when taken out of
interdisciplinary, impact-oriented, applied research. Consider the case of Marcelo: Viola
regarded him as a traumatised survivor; the psychiatric institution had diagnosed him as
schizophrenic, to use Marcelo and Violas word, and he remained under
psychopharmaceutical treatment; and the anthropologist (myself) was employing a critical lens,
attentive to how anti-trafficking constructs life along multiple modalities and expressions
(Molland 2019), such as the discourse of psychiatry, human trafficking, and humanitarianism.
I was also meeting Marcelo in person and formulating views of him in a reflexive effort to
build an ethical relationship with him as a whole person. Marcelos self-perception appeared
different from these three readings and paid attention to his pre-trafficked life (i.e., childhood,
kinship relations, and an affective dimension).
Where and what are the needsmental health or otherwiseof Marcelo amid such a
multiplicity of voices? With this case, I aim to stress that the polyphony of a multi-stakeholder
approach, when not framed within a participatory design for evaluation and intervention, can
lead to losing sight of what is at stake in impact-oriented researchthat is, a better
understanding and meeting of trafficking survivors mental health needs. Furthermore,
experience-near categories (Geertz 1974) collected during fieldwork may prove
inappropriate, when taken alone, in formulating useful diagnoses that lead to necessary mental
health care. Soul of a child and lack of love are instances of emic and what I suggest to be
unpathologising conceptsones formulated by the researcher or her interlocutors which may
miss mental suffering that is in need of support.
In an impactful multidisciplinary project that includes ethnography, Marcelos point of view
becomes not only politically necessary, but scientifically relevant (Biehl 2016, 130) among
other stakeholders viewpoints and across diverse disciplinary approaches, including the
biomedical one. Ethnographys empirical lantern (Biehl 2016, 131) is meant to function as an
echo chamber of the noise of context and of beneficiaries savoir faire and knowledge, which
should radically contribute to the intervention along all its phases. Biomedicine and
interventions tend to disregard the impact of structural injustice, ideological agendas, and the
Medicine Anthropology Theory
political arena of projects on survivors lives (Olivier de Sardan 1998). Conversely,
ethnography is radically ethical and political (Biehl and McKay 2012) because it locates
participants experiences within micro and macro power configurations. In fact, the mental
health sequelae of human trafficking can be particularly severe because the trafficking
experience often culminates in life stories of different forms of violence, from personal to
structural, which are then perpetuated in post-trafficking care and conditions of discrimination
and marginality (Lazzarino 2017a, 2017b).
As my second locus aimed to illustrate, despite findings not being robust, global mental health
sciences have made important steps towards understanding and addressing the consequences
of human-to-human exploitation on the mental health of the victims, which can be potentially
devastating. Global health is craving an evidence base in its effort to quantify even the most
unquantifiable social experiences (Adams 2016, 189). Emphasis here is on two lines of
problems: life story and screening and diagnostic tools. In relation to life story, going back to
Marcelos words, the experience of trafficking may be better understood as a consequence of
existing disadvantaged positions rather than the trauma at the root of mental suffering.
Biomedical studies have corroborated, as seen, the importance of ACEs, and how pre-
trafficking vulnerability can significantly contribute to vulnerability to trafficking (Oram et al.
2015, 1090) and act as pre-departure stressors impacting the formulation of the desire to leave
home (Zimmerman et al., 2006). The life course perspective of biomedical studies, which
maintains that early life health exposures can critically shape current health status (Cwikel et
al. 2004, 244), is, however, dramatically insufficient for grasping the complexity of survivors
life experiencemostly because it leaves out micro and macro contextual elements, the
narratives of study participants, and also the narratives of ecosystems (i.e., the stories of our
technologies, our bodies, or our metrics and objects, [Adams 2016, 192]). The second
problematic line is the well-known issue of the validation of both screening and diagnostic
tools in cultural contexts outside the West. These biomedical studies are easily subject to
criticism concerning the universal validity of psychiatric nosology and diagnostic categories
and the Western cultural underpinnings behind them (Hinton and Good 2016).
In sum, as biomedical scholarship also suggests, there is a critical need to develop validated
instruments for use with trafficked populations (Ottisova et al. 2016, 339) that are able to
more accurately grasp the culturally different ways in which traumas can be experienced and
expressed (Zimmerman et al. 2008, 58) and in which experiences come to count as traumatic
(Pupavac 2001; Fassin and Rechtman 2009). Biomedical studies also assimilate survivors to
other categories of people who have supposedly suffered similar traumas (e.g., refugees;
PTSD or lack of love?
survivors of torture, wars, and natural catastrophes; victims of domestic and sexual violence).
However, such assimilation has not been ascertained (Doherty et al. 2016, 469). A good
starting point to assess this is to understand how survivors are recruited and how the definition
of trafficking victim works during identification and assistance.
The third locus is the case study of the Peace House Shelter, and highlights issues with how
beneficiaries are recruited in anti-trafficking interventions. Recruitment, in turn, affects the
representativeness of study participants in both biomedical and ethnographic work. Most
research is conducted with women in contact with post-trafficking service providers.
However, it is not determined whether survivors accessing assistance represent the most
severe cases, or, on the contrary, are healthier, more resourceful, and more capable of seeking
assistance. Ethnographic studies have shown that, in the perfect anti-trafficking business,
projects are launched before needs assessments are conducted (Molland 2012) in areas a priori
identified as trafficking hotspots (Zhang 2012). Therefore, as in the case of the shelter in
Hanoi, projects from the onset may be missing beneficiaries who must subsequently be found,
which is sometimes achieved by broadening selection criteria (e.g., to include people at risk).
Overall, the Peace House Shelter case study is not necessarily indicative of a lack of need for
mental health support, but rather a failure to follow good practice protocols and conduct
grounded needs assessments before establishing interventions. In this way, the case presented
in this article illuminates how anti-trafficking interventions are subject to national and
international political agendas while failing to attend to cultural differences, among other
things. The involvement of Pierre in the shelter was indeed based neither on his previous
experience with survivors, nor on his long-term knowledge of conducting psychotherapy in
the northern Vietnamese context, where, as expected, different notions of mental health are
in place.
To reinforce the issue of the relevance of global (health) politics in post-trafficking
interventions, at last we must consider the definition of human trafficking and how it is
operationalised. As mentioned, most researchers access their study participants as post-
trafficking service users. Many studies, including mine (Lazzarino 2015), also work according
to the international definition of human trafficking given by the United Nations Office of
The HTQ was designed by the Harvard Programme in Refugee Trauma to investigate different traumatic
events and associated emotional symptoms. It has been validated in different groups of refugees and
survivors of natural disasters and wars in Asia and Eastern Europe (Doherty et al. 2016, 469). Similarly,
the HSCL-25 was designed in the 1950s to measure symptoms of anxiety and depression. It has been
translated into six languages and validated in a population of Tibetan refugees exposed to torture and
human rights abuse.
Medicine Anthropology Theory
Drugs and Crimes.
Prior to its approval, the definition of human trafficking went through a
long process of negotiation and confrontation, which was heavily influenced by neo-
abolitionist, anti-prostitution, and anti-migration agendas (e.g., Doezema 2010; Brennan
2014). This comprehensive definition has not been able to dispel terminological ambiguities
and practical misuses. The categories human trafficking and survivor are not unambiguous,
nor are the identification criteria free from prejudice (OConnell Davidson 2010). Studies
recruiting their research population among the beneficiaries of service providers de facto rely
on what the international definition becomes when operationalised by governmental and non-
governmental officers. As a result, scholarship is at risk of reflecting the ideological, neo-
colonial underpinnings of the human trafficking discourse, which is dominated by an anti-
prostitution stance (Kempadoo, Sanghera, and Pattanaik 2012) and by governments anti-
migration securitarian agendas (Anderson 2012). It does so by fuelling the very existence of
the category of the trafficking survivor, with which the anti-trafficking movement at large is
fixated (Molland 2019).
My aim in this article has been to make a case for the need to overcome comfortable
disciplinary silos and reject the division between those who know the world and those who
must simply struggle to survive it (Biehl 2016, 130, 135). There are promising and growing
examples in this sense, all of them working to overcome the post-positivist paradigm where
increasing numbers of rapid qualitative analysis serve as add-ons in randomised studies
(Mannell and Davis 2019). There are also qualitative investigations devoted to understanding
key local conceptions of mental distress, which then help to inform interventions (e.g., Bolton
et al. 2007). In some cases, scholars sharing the same cultural milieu as their study participants
adopt mixed-method approaches to investigating mental health (Le 2014). Other cases are
going beyond mixed-method techniques to combine critical medical anthropology with
biocultural insights from global health (Mendenhall and Weaver 2014). From the participatory
paradigm (Palmer et al. 2018) to structural competency in mental healthcare (Hansen and
Metzl 2019) and attention to power relations which get under the skin (Leatherman and
Goodman 2011), growing scholarship suggests that there cannot be easily scalable, cost-
There, human trafficking is defined as the recruitment, transportation, transfer, harbouring 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 benefits 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 of the prostitution of
others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to
slavery, servitude or the removal of organs (UNODC 2004, 42).
PTSD or lack of love?
effective interventions without accounting for users experiences and micro/macro contexts
of power configurations.
The first part of this articles title is evidently provocative. There is no clear-cut answer to the
question of whether people who have come to be identified, studied, and assisted as survivors
of human trafficking suffer more from PTSD than from a lack of love. Or, to put it better,
there is no mono-disciplinary answer to that question (either biomedical or ethnographic), just
as there cannot be effective survivor-centred intervention in post-trafficking global care
without radical interdisciplinary, participatory research informing it. Ethnography,
biomedicine, and trafficking aftercare taken in a vacuum risk imploding within their own limits,
failing to ultimately produce effective change in the lives of survivors. Indeed, all frictions
discussed could be subsumed under a single overarching one: the mismatch between how we
come to know and meet peoples needs and, too often, what their actual needs are. Radical
interdisciplinary and participatory research in post-trafficking mental health, at a political and
epistemological level, looks promising in generating fresh understanding that moves away
from hierarchical power/knowledge production and towards more effective interventions.
I have argued that critical global mental health interventions in trafficking aftercare must
proceed from polyphonic ethnographies integrated with global mental health to co-design and
implement interventions together with service users. The three case studies presented have
helped us think about the disciplinary/epistemological/political milieus that they rest on, and
how in a radical integrationwhich is simultaneously disciplinary, epistemological, and
politicaleach locuss limitations could be overcome. In such multidisciplinary efforts, critical
anthropological ethnography helps to convey survivors voices, better enabling the
development of ethically, politically, and scientifically relevant interventions. As seen in
trafficking aftercare, this means embedding survivors life stories, and structural and cultural
factors, into new biomedical screening and diagnostic toolsstarting, crucially, by de-
Westernising the discourse of victimhood and trauma (Lazzarino 2019; Jordan et al. 2020). In
relation to post-trafficking interventions, ethnography can help to identify survivors needs
while remaining wary of the implications and effects of the international discourse of human
trafficking and its categories of subjects (Lazzarino 2019, 2015). On the other hand,
ethnographys polyphony and experience-closeness can bend to and blend into biomedicine
and humanitarian impactfulness, and in so doing facilitate the practical goal of better
understanding and meeting survivors mental health needs.
Medicine Anthropology Theory
My PhD study was funded by the Italian Government and University of Milano-Bicocca. I
would like to deeply thank all of my research participants, particularly those mentioned in this
article. Earlier drafts of this text were shared at the Institute of Advanced Studies at University
College London, and an important thanks goes to my former colleagues for their insightful
comments. I am particularly grateful to Professor Tamar Garb for her useful
recommendations and encouraging remarks and Dr. Katayoun Shafiee for her thoughtful
observations and detailed linguistic reading. Many thanks also go to the two discussants of my
talk, Dr. Philippa Hetherington and Dr. Lionel Bailly, for their helpful comments. Finally, I
am grateful to all the anonymous reviewers whose comments helped to greatly improve the
clarity of the article.
About the author
Runa Lazzarino is a medical anthropologist, currently based at the Research Centre for
Transcultural Studies in Health at Middlesex University. For her doctoral project, Runa
conducted a multi-country ethnography on the recovery and reintegration of human
trafficking survivors (Lazzarino 2015). In her postdoctoral research, at University College
London, University of Nottingham, and St Marys University, her focus has been on post-
exploitation support needs in relation to the consequences of violence on the mental, sexual,
and parental wellbeing of vulnerable migrants. Her current research revolves around
transcultural health; (global) mental health; social and cultural norms and determinants of
health; and mixed-method, participatory, and impact-oriented research.
Abas, Melanie, Nicolae V. Ostrovschi, Martin Prince, Viorel I. Gorceag, Carolina Trigub, and
Siân Oram. 2013. Risk Factors for Mental Disorders in Women Survivors of Human
Trafficking: A Historical Cohort Study. BMC Psychiatry 13 (1): 204.
Adams, Vincanne. 2016. What Is Critical Global Health?. Medicine Anthropology Theory 3 (2):
Alemi, Qais, Carl Stempel, Kelly Baek, Lisa Lares, Patricia Villa, Didem Danis, and Susanne
Montgomery. 2016. Impact of Postmigration Living Difficulties on the Mental
Health of Afghan Migrants Residing in Istanbul. International Journal of Population
Research 7690697: 18.
PTSD or lack of love?
Anderson, Bridget. 2012. Wheres the Harm in That? Immigration Enforcement, Trafficking,
and the Protection of Migrants Rights. American Behavioral Scientist 56 (9): 12411257.
Biehl, João. 2016. Theorizing Global Health. Medicine Anthropology Theory 3 (2): 127142.
Biehl, João, and Ramah McKay. 2012. Ethnography as Political Critique. Anthropological
Quarterly 85 (4): 12091227.
Bolton, Paul, Judith Bass, Theresa Betancourt, Liesbeth Speelman, Grace Onyango, Kathleen
F. Clougherty, Richard Neugebauer, Laura Murray, and Helen Verdeli. 2007.
Interventions for Depression Symptoms among Adolescent Survivors of War and
Displacement in Northern Uganda: A Randomized Controlled Trial. JAMA 298 (5):
Brennan, Denise. 2014. Life Interrupted: Trafficking into Forced Labor in the United States. Durham,
NC: Duke University Press.
Callard, Felicity, and Des Fitzgerald. 2015. Rethinking Interdisciplinarity across the Social Sciences and
Neurosciences. London: Palgrave Macmillan.
Cwikel, Julie, Bella Chudakov, Michael Paikin, Keith Agmon, and Robert Belmaker. 2004.
Trafficked Female Sex Workers Awaiting Deportation: Comparison with Brothel
Workers. Archives of Womens Mental Health 7 (4): 243249.
Desjarlais, Robert R. 1997. Shelter Blues: Sanity and Selfhood Among the Homeless. Philadelphia, PA:
University of Pennsylvania Press.
Devereux, George. 1980. Basic Problems of Ethnopsychiatry. Chicago, IL: University of Chicago
Doezema, Jo. 2010. Sex Slaves and Discourse Masters: The Construction of Trafficking. London: Zed
Doherty, Shannon, Siân Oram, Chesmal Kamaneetha Siriwardhana, and Melanie Amna Abas.
2016. Suitability of Measurements Assessing Mental Health Outcomes in Men and
Women Trafficked for Sexual and Labour Exploitation: A Systematic Review. The
Lancet Psychiatry 3 (5): 464471.
Fassin, Didier, and Mariella Pandolfi, eds. 2013. Contemporary States of Emergency: The Politics of
Military and Humanitarian Interventions. Cambridge, MA: MIT Press.
Fassin, Didier, and Richard Rechtman. 2009. The Empire of Trauma: An Inquiry into the Condition
of Victimhood, translated by Rachel Gomme. Princeton, NJ: Princeton University Press.
Geertz, Clifford. 1974. ‘“From the Natives Point of View: On the Nature of Anthropological
Understanding. Bulletin of the American Academy of Arts and Sciences 28 (1): 2645.
Medicine Anthropology Theory
Hansen, Helena, and Jonathan M. Metzl. 2019. Structural Competency in Mental Health and
Medicine: A Case-Based Approach to Treating the Social Determinants of Health. Cham:
Hinton, Devon E., and Byron J. Good. 2016. Culture and PTSD: Trauma in Global and Historical
Perspective. Philadelphia, PA: University of Pennsylvania Press.
Hossain, Mazeda, Cathy Zimmerman, Melanie Abas, Miriam Light, and Charlotte Watts. 2010.
The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually
Exploited Girls and Women. American Journal of Public Health 100 (12): 24422449.
Jordan, Melanie, Nicola Wright, Edward J. Wright, and Runa Lazzarino. 2018. Biopower and
the Promise of Parrhesia: A Critical Analysis of the Global Mental Healthcare
Response to Modern Slavery Survival, with the Work of Foucault and Bourdieu.
Sociology of Health & Illness. Unpublished/under review.
Kempadoo, Kamala, Jyoti Sanghera, and Bandana Pattanaik, eds. 2012. Trafficking and
Prostitution Reconsidered: New Perspectives on Migration, Sex Work, and Human Rights, second
edition. Boulder, CO: Paradigm Publishers.
Kiss, Ligia, Nicola Pocock, Varaporn Naisanguansr, Soksreymom Suos, Brett Dickson, and
Doan Thuy. 2015. Health of Men, Women, and Children in Post-Trafficking Services
in Cambodia, Thailand, and Vietnam: An Observational Cross-Sectional Study. Lancet
Global Health 3 (March): e154161.
Lazzarino, Runa. 2014. Between Shame and Lack of Responsibility: The Articulation of
Emotions among Female Returnees of Human Trafficking in Northern Vietnam.
Antropologia 1 (1): 155167.
Lazzarino, Runa. 2015. Who Is the Subject of Human Trafficking? A Multi-Sited and
Polyphonic Ethnography. PhD thesis, University of Milano-Bicocca.
Lazzarino, Runa. 2017a. After the Shelter: The Nuances of Reintegrating Human Trafficking
Returnees in Northern Vietnam. In Dreams of Prosperity. Inequality and Integration in
Southeast Asia, edited by Silvia Vignato, 167202. Chiang Mai: Silkworm Books.
Lazzarino, Runa. 2017b. Freeloaders, Blackmailers and Lost Souls: Rescued Sex Trafficking
Survivors in the Hands of the Assistance. OpenDemocracy, 29 November.
Lazzarino, Runa. 2019. Fixing the Disjuncture, Inverting the Drift: Decolonizing Human
Trafficking and Modern Slavery. Journal of Modern Slavery 5 (1): 131.
Le, PhuongThao Dinh. 2014. Human Trafficking and Psychosocial Well-Being: A Mixed-
Methods Study of Returned Survivors of Trafficking in Vietnam. PhD thesis,
University of California, Los Angeles.
PTSD or lack of love?
Leatherman, Tom, and Alan H. Goodman. 2011. Critical Biocultural Approaches in Medical
Anthropology. In A Companion to Medical Anthropology, edited by Merrill Singer and
Pamela I. Erickson, 2948. Oxford: Wiley-Blackwell.
Mannell, Jenevieve, and Katy Davis. 2019. Evaluating Complex Health Interventions with
Randomized Controlled Trials: How Do We Improve the Use of Qualitative
Methods?. Qualitative Health Research 29 (5): 623631.
Mendenhall, Emily, and Lesley Jo Weaver. 2014. Reorienting Womens Health in Low- and
Middle-Income Countries: The Case of Depression and Type 2 Diabetes. Global
Health Action 7: 22803.
Molland, Sverre. 2012. The Perfect Business? Traffickers, Victims and Anti-Traffickers Along the
Mekong. Honolulu: Hawaii University Press.
Molland, Sverre. 2019. On Trafficking Survivors: Biolegitimacy and Multiplications of Life.
Dialectical Anthropology 43 (3): 279293.
OConnell Davidson, Julia. 2010. New Slavery, Old Binaries: Human Trafficking and the
Borders of Freedom”‘. Global Networks 10 (2): 244261.
Olivier de Sardan, Jean-Pierre. 1998. Anthropologie et Développement: Essai en socio-anthropologie du
changement social. Paris: Karthala.
Oram, Siân, Mizanur Khondoker, Melanie Abas, Matthew Broadbent, and Louise M. Howard.
2015. Characteristics of Trafficked Adults and Children with Severe Mental Illness:
A Historical Cohort Study. The Lancet Psychiatry 2 (12): 10841091.
Ottisova, Livia, Stacey Hemmings, Louise M. Howard, Cathy Zimmerman, and Siân Oram.
2016. Prevalence and Risk of Violence and the Mental, Physical and Sexual Health
Problems Associated with Human Trafficking: An Updated Systematic Review.
Epidemiology & Psychiatric Sciences 25 (4): 317341.
Palmer, Victoria Jane, Wayne Weavell, Rosemary Callander, Donella Piper, Lauralie Richard,
Lynne Maher, Hilary Boyd, et al. 2018. The Participatory Zeitgeist: An Explanatory
Theoretical Model of Change in an Era of Coproduction and Codesign in Healthcare
Improvement. Medical Humanities 45 (3): 247257.
Pupavac, Vanessa. 2001. Therapeutic Governance: Psycho-Social Intervention and Trauma
Risk Management. Disasters 25 (4): 358372.
Snajdr, Edward. 2013. Beneath the Master Narrative: Human Trafficking, Myths of Sexual
Slavery and Ethnographic Realities. Dialectical Anthropology 37 (2): 229256.
Medicine Anthropology Theory
Teixeira, Flávia do Bonsucesso. 2008. LItalia Dei Divieti: In between the Dream of Being
European and the Babado of Prostituition. Cadernos Pagu 31: 275308.
Tsing, Anna Lowenhaupt. 2011. Friction: An Ethnography of Global Connection. Princeton, NJ:
Princeton University Press.
Tsutsumi, Atsuro, Takashi Izutsu, Amod K. Poudyal, Seika Kato, and Eiji Marui. 2008. Mental
Health of Female Survivors of Human Trafficking in Nepal. Social Science & Medicine
66 (8): 18411847.
Turner-Moss, Eleanor, Cathy Zimmerman, Louise M. Howard, and Siân Oram. 2014. Labour
Exploitation and Health: A Case Series of Men and Women Seeking Post-Trafficking
Services. Journal of Immigrant & Minority Health 16 (3): 473480.
UNODC (United Nations Office on Drugs and Crime). 2004. United Nations Convention against
Transnational Organized Crime and the Protocols Thereto. New York: United Nations.
Varma, Selina, Scott Gillespie, Courtney McCracken, and V. Jordan Greenbaum. 2015.
Characteristics of Child Commercial Sexual Exploitation and Sex Trafficking Victims
Presenting for Medical Care in the United States. Child Abuse & Neglect 44: 98105.
Viergever, Roderik F., Nicki Thorogood, Tamara van Driel, Judith R. L. M. Wolf, and Mary
Alison Durand. 2019. The Recovery Experience of People Who Were Sex Trafficked:
The Thwarted Journey towards Goal Pursuit. BMC International Health & Human
Rights 19 (1): 3.
Vijeyarasa, Ramona. 2013. Stigma, Stereotypes and Brazilian Soap Operas: Road-Blocks to
Ending Human Trafficking in Vietnam, Ghana and Ukraine. Gender, Place & Culture
20 (8): 10151032.
Wright, Nicola, Melanie Jordan, and Runa Lazzarino. 2020. Mental Healthcare for Survivors
of Modern Slavery and Human Trafficking: a Scoping Study of Service Provision.
Journal of Mental Health. Unpublished/under review.
Zhang, Juan. 2012. A Trafficking Not-Spot in a China-Vietnam Border Town. In Labour
Migration and Human Trafficking in Southeast Asia: Critical Perspectives, edited by Michele
Ford, Lenore Lyons, and Willem van Schendel, 95111. New York: Routledge.
Zimmerman, Cathy, Mazeda Hossain, Katherine Yun, Brenda Roche, Linda Morison, and
Charlotte Watts. 2006. Stolen Smiles: A Summary Report on the Physical and Psychological
Health Consequences of Women and Adolescents Trafficked in Europe. London: London
School of Hygiene & Tropical Medicine.
Zimmerman, Cathy, Mazeda Hossain, Katherine Yun, Vasil Gajdadziev, Natalia Guzun, Maria
Tchomarova, Rosa Angela Ciarrocchi, et al. 2008. The Health of Trafficked Women:
A Survey of Women Entering Posttrafficking Services in Europe. American Journal of
Public Health 98 (1): 5559.
... This complex and varied reality does not match the relatively unanimous Western biomedical scholarly knowledge base on what post-slavery mental healthcare should provide (Chisolm-Straker & Stoklosa, 2017). To fill this gap -which seems to be a "quality chasm" between what is known to be effective and practices (IOM, 2001) -more research integrating bio-psychiatric sciences, practitioners' and users' experience and perspective is needed (Lazzarino, 2020). ...
... This complex and varied reality does not match the relatively unanimous Western biomedical scholarly knowledge base on what post-slavery mental healthcare should provide (Chisolm-Straker & Stoklosa, 2017). To fill this gap -which seems to be a "quality chasm" between what is known to be effective and practices (IOM, 2001) -more research integrating bio-psychiatric sciences, practitioners' and users' experience and perspective is needed (Lazzarino, 2020). ...
Full-text available
Due to experiences of extreme violence and psychological abuse, survivors of Modern Slavery and Human Trafficking can suffer from complex mental health problems. Modern Slavery and Human Trafficking are public health issues and insights are lacking around service provision and its evidence base to better meet support needs. Aim of this study was to globally scope and analyze the mental health provision available to survivors of MSHT. A scoping review of online evidence sources was performed, guided by Levac and colleagues’ six-staged framework. Service providers meeting inclusion criteria were 325, and most are located in Asia and South America, cater for a female population, and are Christian faith-based. Thematic analysis identified two overarching categories (characteristics of provision and types of mental health support) and twenty sub-themes. Largely, mental healthcare is informed by different models and exists within a nexus of care offering several services, for different vulnerable populations. Little information of evidence-based interventions and monitoring and evaluation was found. More empirical, multidisciplinary, and multi-stakeholder research in post-slavery mental healthcare is required to improve understanding of survivor support needs and to inform policies and practices that are culturally competent, survivor-centered, gender-inclusive and empowering.
Full-text available
During the past sixteen years, since the ‘Trafficking Protocol’ entered into force in 2003, a dramatic escalation of research, writing, debating, and practice in the realm of human trafficking and modern slavery has occurred. While human trafficking and modern slavery belong to two distinct genealogies (Allain, 2018; Lazzarino, 2015; O’Connell Davidson, 2017), they are nonetheless frequently used as synonyms to refer to an ample array of conditions of human-to-human exploitation and dependency. Significantly, around these two terminologies, complex local, national, and international apparatuses have evolved. These apparatuses - devoted to identifying, preventing, and ultimately eliminating exploitation - involve experts, stakeholders, and social actors. As a re-elaboration and reflection on the contributions to an international symposium on human trafficking , this article makes two consecutive steps in modern slavery studies. The first step is a snapshot compilation of the complexity of problems involved in the discourse of human trafficking and modern slavery. I concentrate this discourse under two pillars, disjuncture and drift, which offer images of the often detrimental effects, as well as the equally negative “ineffectiveness” (Bravo, 2017), of many anti-slavery apparatuses. Secondly, this article envisions a walkable avenue for a decolonization of the discourse of human trafficking and modern slavery inasmuch as this discourse has been monopolized by the center (referring to a few powerful countries of the global north). Journal Name: JOURNAL OF MODERN SLAVERY A Multidisciplinary Exploration of Human Trafficking Solutions,
Full-text available
Human trafficking has become a key site for intervention in global politics. Although anti-trafficking claims to mobilize resources for the combat against structural inequality within labour relations, anti-trafficking is intertwined with a fixation with the “trafficking survivor” resulting in notable individuated policy responses. Based on long-term ethnographic research of anti-trafficking interventions in the Mekong region, this essay suggest biolegitimacy is a fruitful heuristic device as it elucidates how anti-trafficking constructs “life” along multiple modalities and expressions. This in turn helps explain why anti-trafficking constitutes a mixed assemblage comprising actors with different ideological, moral and political positions. As such, anti-trafficking constitutes an important case study of how life legitimates and is legitimated within transitional networks of governance.
Full-text available
Background In 2010, a shelter programme was established in the Netherlands to provide social and health services for trafficked people. This article describes how service users in this programme conceptualized and experienced their own process of recovery. Methods In 2012, 14 people of non-Dutch nationality who had been trafficked for the purpose of sexual exploitation were interviewed at all three shelters of the programme. Data analysis followed a grounded theory approach. Results Participants felt a strong need to turn over a new leaf in life, leaving negative experiences of the past behind and moving towards a life with a job, a family and friends. In contrast with their willingness to work towards realizing that future, they experienced a lack of autonomy and a thwarted sense of agency in redressing their present situation. Together with the ostracized nature of their place in Dutch society this left them ‘in limbo’: a feeling of standing still, while wanting to move forward. This led participants to find it more difficult to deal with problems related to their pasts and futures. They particularly appreciated Dutch language training, vocational skills training and opportunities for volunteer work. Conclusions Participants exhibited a strong desire to fulfil the basic psychological needs of competence, relatedness and autonomy, but were thwarted in pursuing these goals. Seemingly against all odds, while faced with several external regulators that limited their agency to change their situation, participants found ways to pursue these goals, through their enthusiasm for activities that helped them get closer to their envisioned futures (language and skills training and volunteer work). Identifying pathways toward attaining their goals allowed them to hope for a better future. That hope and pursuing their goals helped them to cope with the problems of their past and their worries about the future. Therefore, to facilitate service users’ recovery in a post-trafficking setting, there is a need to provide them with opportunities to hope for, pursue and attain their personal goals within the structural boundaries of their situation. A future-orientated, strengths-based approach towards service provision and responsive and supportive environments help to do this. Electronic supplementary material The online version of this article (10.1186/s12914-019-0185-7) contains supplementary material, which is available to authorized users.
Full-text available
Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an ‘explanatory theoretical model of change’ that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities—narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. Trial registration number The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).
This book documents the ways that clinical practitioners and trainees have used the “structural competency” framework to reduce inequalities in health. The essays describe on-the-ground ways that clinicians, educators, and activists craft structural interventions to enhance health outcomes, student learning, and community organizing around issues of social justice in health and healthcare. Each chapter of the book begins with a case study that illuminates a competency in reorienting clinical and public health practice toward community, institutional and policy level intervention based on alliances with social agencies, community organizations and policy makers. Written by authors who are trained in both clinical and social sciences, the chapters cover pedagogy in classrooms and clinics, community collaboration, innovative health promotion approaches in non-health sectors and in public policies, offering a view of effective care as structural intervention and a road map toward its implementation. Structural Competency in Mental Health and Medicine is a cutting-edge resource for psychiatrists, primary care physicians, addiction medicine specialists, emergency medicine specialists, nurses, social workers, public health practitioners, and other clinicians working toward equality in health.
Qualitative methods are underutilized in health intervention evaluation, and overshadowed by the importance placed on randomized controlled trials (RCTs). This Commentary describes how innovative qualitative methods are being used as part of RCTs, drawing on articles included in a special issue of Qualitative Health Research on this topic. The articles' insights and a review of innovative qualitative methods described in trial protocols highlights a lack of attention to structural inequalities as a causal mechanism for understanding human behavior. We situate this gap within some well-known constraints of RCT methodologies, and a discussion of alternative RCT approaches that hold promise for bringing qualitative methods center stage in intervention evaluation, including adaptive designs, pragmatic trials, and realist RCTs. To address the power hierarchies of health evaluation research, however, we argue that a fundamental shift needs to take place away from a focus on RCTs and toward studies of health interventions.