- Human trafficking victimisation may cause a variety of health implications for adult survivors, which leads to trauma.
- Adopting the principles of trauma-informed care (TIC) combined with a person-centred approach can provide effective support for adult trafficking survivors.
- A person-centred, trauma-informed approach can benefit organisations, as well as service users.
- The National Referral Mechanism (NRM) is a framework used across the UK to refer and support potential trafficking victims. Evidence suggests that the support offered through the NRM tends to be short in duration and not tailored to each victim’s needs.
- Scottish practice aligns the NRM framework more closely to the principles of TIC and a person-centred approach. Care contract-holding organisations should continue to extend the NRM support offered.
- Practitioners require more trafficking awareness and training.
Focusing on adult victims (over-18s), this Insight will discuss the trauma caused by human trafficking victimisation and the principles for effective support for survivors. It will also explore the National Referral Mechanism (NRM) which is a UK support framework, in the context of Scottish practice in non-governmental organisations (NGOs) that hold the governmental care contract for trafficking victims (Trafficking Awareness Raising Alliance (TARA) and Migrant Help).
It discusses findings from 12 interviews conducted for the author’s PhD in Law, How is human trafficking regulated in the UK? A critical examination of the UK’s anti-trafficking response, undertaken at the University of Edinburgh between 2017–2021. The interviews were conducted with six support workers and managers coming from TARA and Migrant Help; a manager of a Scottish NGO advocating for trafficking victims; a legal director of a UK NGO; two support workers from another two UK NGOs advocating for trafficking victims in England; a female British survivor trafficked for sexual exploitation in England for whom the alias ‘Eve’ is used; and a qualitative questionnaire with a Scottish Government official. Anonymity and confidentiality were guaranteed with the use of vague descriptions for interviewees based on their positions/occupations, which had been agreed in advance (Kvale and Brinkmann, 2009).
The evidence suggests that combining the principles of trauma-informed care (TIC) with a person-centred approach can improve services. Despite the NRM’s UK-wide remit, Scottish practice tends to align the framework more closely to the principles of TIC and a person-centred approach, when compared to English practice.
What is human trafficking?
Based on the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organised Crime, human trafficking of adult victims consists of three elements: the criminal act (eg recruitment, transportation, transfer, harbouring or receipt of persons); the means (eg threats, violence, abduction, fraud, deception, abuse of power or victims’ vulnerabilities); and the intention of exploitation. Exploitation can take several forms, such as sexual exploitation (prostitution), forced labour, servitude or organ harvesting.
The UK’s Modern Slavery Act 2015 defines human trafficking as an offence where the perpetrator arranges or facilitates the travel of another person with a view to that other person being exploited. Section one of the Human Trafficking and Exploitation (Scotland) Act 2015 states that a human trafficking offence is committed if the offender takes a relevant action (recruitment, transportation/transfer, harbouring, receiving, exchanging or transferring control of another person or arranging/facilitating the above), with a view to another person being exploited. Modern slavery is the broader term encompassing human trafficking, along with slavery, servitude and forced/compulsory labour (Home Office, 2016).
Human trafficking – trauma and needs
According to the literature and irrespective of the context where the phenomenon is taking place, the human trafficking experience has been described as a ‘multi-staged process of cumulative harm’ (Zimmerman, Hossain and Watts, 2011, p327), that leads to ‘complex layers of trauma’ for survivors (Marburger and Pickover, 2020, p14). The health implications caused by trafficking victimisation vary from physical to psychological (Davy, 2015; Pascual-Leone, Kim and Morrison, 2017). The maltreatment to which victims are frequently subjected by traffickers can include violence, rape, food deprivation, emotional abuse, manipulation, torture and/or slavery-like bondage conditions (Davy, 2015). Trafficking survivors may experience injuries (eg occupational injuries), diseases (eg sexually transmitted diseases-STDs) and/or post-traumatic stress disorder (PTSD) (Richards, 2014; Oram and colleagues, 2016). Anxiety and depression are frequently reported in women trafficked for prostitution. Despite our limited understanding of trafficked men’s mental health, PTSD is commonly reported among them too, due to their frequent exposure to abuse and deprivation (Zimmerman and Pocock, 2013). The difficulty experienced by many male victims in coming forward and accessing mental health services further impedes their identification, perpetuating their psychological issues (Zimmerman and Pocock, 2013).
Psychological trauma, therefore, is a key concept in human trafficking. Levenson (2017, p105), citing the American Psychiatric Association (2013), defines trauma as ‘an exposure to an extraordinary experience that presents a physical or psychological threat to oneself or others and generates a reaction of helplessness and fear’. Trauma is experienced and expressed differently between people or between different incidents related to the same person (NHS Education for Scotland, 2017). Resilience – the ability to cope with a post-traumatic situation – often depends on ‘personality traits linked to extraversion, high self-esteem, assertiveness, hardiness, internal locus of control, and cognitive feedback’ (Agaibi and Wilson, 2005, p196). Past experiences related to parenting/family, financial situation, health problems, social development and interactions are crucial too (Johnson and Wiechelt, 2004). Luthar and Brown (2007) conclude that resilience is related to the person’s environment and that environment’s ‘capacity to facilitate growth’ for the individual (Ungar, 2013, p262), while also being a matter of biology. Recent literature illustrates the role of an individual’s genetic processes in how well they can cope and recover from stress or trauma (Bowes and Jaffee, 2013).
Other key needs of trafficking survivors include accommodation, legal assistance, employability, education, and repatriation (Davy, 2015; Munro-Kramer and colleagues, 2020).
Creating an effective support context for trafficking victims
Addressing the complex needs of trafficking victims poses a challenge for practitioners. Frequently encountered obstacles include: survivors’ fear of traffickers; prior involvement in criminal activities; reduced trust towards authorities; language/cultural barriers; and shame or inability to self-identify as victims (Chaffee and English, 2015; Munro-Kramer and colleagues, 2020). Simultaneously, involvement with the criminal justice system creates the risk of re-traumatisation (Zimmerman, Hossain and Watts, 2011; Gerassi, 2015), as some criminal justice systems neglect victims’ needs and/or view them mainly as ‘sources of information’ (Adams, 2011, p202). Victims who are unable or unwilling to assist with prosecutions often face criminal proceedings, deportation and cuts to support, which can increase the risk of re-trafficking (Adams, 2011). Consequently, a growing body of literature argues that using TIC combined with a person-centred approach may foster effective support for survivors.
TIC views an individual’s problems in the context of their pre-existing trauma (Levenson, 2017). Centred around the principles of safety, choice, empowerment, trust and cooperation, TIC encourages support workers to recognise the individual’s background of trauma, and adjust the provided services around this to minimise the chances of triggering or re-traumatising the service user (NHS Education for Scotland, 2017). TIC can be combined with a person-centred approach. The latter instructs the need to further shift the focus on the individual, identifying their specific needs, preferences, interests, abilities and identity characteristics (age, gender, culture, beliefs) to tailor services and ultimately maximise choice, self-determination and empowerment (The Health Foundation, 2016). Thus, practice should aim to increase ‘the client’s power resources rather than the client’s conformity to prescribed behaviours’ (Hasenfeld, 1987, p480).
Establishing a case management programme that follows TIC principles centres on each victim’s needs and allows them the time and space to establish trust with their support workers. This has been found helpful in avoiding re-traumatisation and promoting empowerment (Heffernan and Blythe, 2014). Respecting the service user’s cultural background and progressing at their pace should also be key elements of an effective service framework (Hopper, 2017). Ladd and Neufeld Weaver (2018) summarise the principles of TIC for trafficking survivors: inter-agency cooperation; understanding the causes of trafficking; understanding the individual’s trauma and vulnerabilities; avoiding placing blame on the survivor; and prioritising their individual strengths, choices and goals. The aim is to achieve empowerment and recovery (Pascual-Leone, Kim and Morrison, 2017).
The complexity of addressing survivors’ needs corroborates the necessity for governments and organisations to work in tandem to provide an effective and tailored support context (Davy, 2015). Doherty and Morley (2016) also emphasise the need for a holistic, multi-agency approach to foster an environment of trust and safety, one that supports healing and reintegration. Johnson (2012) explains that aftercare services should first try to satisfy basic needs, such as clothing and accommodation. This is before moving on to address complex needs in a tailored way, such as medical and psychological help, legal services, protection from prosecutions, financial assistance, education, vocational training and repatriation. Johnson’s proposal reflects Maslow’s (1943) hierarchy of needs, which suggests that for an individual to reach their full potential, they must first satisfy their basic ‘physiological needs’ (air, water, food, home, clothing), before moving to higher ‘self-actualisation’ needs.
The National Referral Mechanism
The NRM is the UK-wide framework for identifying and referring potential human trafficking and modern slavery victims for support (Home Office and UK Visas and Immigration [UKVI], 2022a). It is based on the model designed by the Organisation for Security and Co-operation in Europe (OSCE) (2004). Human trafficking is a reserved issue due to its ties with immigration and borders, making the NRM a UK-wide framework. Still, human trafficking and the NRM’s operation also relate to victims’ rights and needs, the criminal justice system and health, which are devolved to Scotland (Scotland Act 1998). Human trafficking for the UK becomes an issue where both reserved and devolved powers are exercised together.
When a person is identified as a potential victim, they are referred to the NRM by a first responder – a specific professional who has first contact with victims (Home Office and UKVI, 2022a). The Single Competent Authority (SCA) will aim to make a reasonable grounds decision based on the ‘suspect but cannot prove’ threshold on the status of the person as a victim within the first five days (Home Office, 2022; Home Office and UKVI, 2022a). If this is positive, support lasts for at least 45 days until their case is considered in England, Wales and Northern Ireland, and for 90 days or until a conclusive grounds decision is made (whichever comes sooner) in Scotland (Home Office and UKVI, 2022a; 2022b).
The SCA’s conclusive decision on the status of the person as a victim is based on the ‘balance of probabilities’ (Home Office, 2022). These provisions slightly extend the minimum 30-day recovery and reflection period instructed in art.13 of the Convention on Action against Trafficking in Human Beings (ECAT). Support is offered in England and Wales by the Salvation Army and their subcontractors by Migrant Helpline or Women’s Aid in Northern Ireland, and by TARA or Migrant Helpline (care contract-holding NGOs) in Scotland (Home Office and UKVI, 2022a; 2022b).
Commentators have critiqued the NRM for its alleged inability to address victims’ needs in an effective and tailored way; the lack of inter-agency cooperation (Independent Anti-Slavery Commissioner, 2017); the short duration and low quality of support (The Human Trafficking Foundation and colleagues, 2017); and the precarious immigration status of non-UK/non-European victims which impedes access to accommodation, employment and welfare (Williams-Woods and Mellon, 2018). This questions whether the UK NRM achieves the key target of the OSCE’s NRM, to secure victims’ rights and needs (OSCE, 2004). The NRM has been undergoing reforms, among which is the extension of the support period (Home Office, 2019).
Interviews with stakeholders
A key theme that emerged during the research interviews was the short duration of support, which impacts on the achievement of long-term recovery goals. A support worker from a Scottish care contract-holding NGO stated that the NRM gives survivors the opportunity just to say, ‘OK we are here for three months, nothing bad’s gonna happen, we are gonna get a payment, we are gonna get sorted in terms of accommodation’. Discussing the UK’s extension of ECAT’s minimum 30-day support period, the Legal Director of a UK NGO in England stated that the UK ‘have interpreted that [the support period] is the only specialist support required for victims’. They argued that the support offered is ‘not long en0ugh’, but instead needs ‘to be actually tailored to the specific needs of an individual and [be] more focused around that’. According to an English support worker from another NGO, the NRM support in England is impeded by ‘austerity’, offering ‘short-term benefits’ mostly around ‘safety’, with few positive long-term outcomes for service users.
Regarding housing, non-British or European victims are usually placed in National Asylum Support Service (NASS) accommodation, since they often have a separate asylum claim besides their NRM referral. Most interviewees found NASS accommodation unsuitable, in accordance with asylum-related literature, which has pinpointed how housing issues impede the integration of asylum seekers (Bakker, Cheung and Phillimore, 2016).
A NGO support worker from England claimed that many houses are ‘dilapidated’, ‘crowded’, ‘inappropriate’ and ‘not fit for purpose’. Meanwhile, a support worker from a care contract-holding Scottish NGO added that ‘everything is falling to pieces, very shabby, you know?’. As shown above, trafficking survivors and asylum seekers are often not entirely distinct populations to one another. Nonetheless, some interviewees underlined how problematic the mixing of the two can be due to their different needs, while others saw it as positive as it enhances socialisation. Furthermore, the research indicated that housing for UK/EU victims was precarious in Scotland as TARA and Migrant Help have limited emergency accommodation. Meanwhile, in England and Wales the Salvation Army subcontracts organisations for accommodation.
In Scotland, support organisations are trying to extend the legislated support period through their practice. The manager of a care contract-holding NGO stated that the UK’s NRM ‘doesn’t feel like it’s focused on the individual recovery needs’, being more of a ‘one size fits all’ process that ‘doesn’t allow for flexibility to meet individual needs’. Recounting a case where ‘for the first six months’ the referred individual ‘couldn’t speak… couldn’t make eye contact… [was] hiding in a cupboard when we went to visit, couldn’t go out on [their] own’, the interviewee acknowledged that no progress could have been achieved had the organisation ‘applied the NRM timescales’. This informal extension of the recovery period to provide additional tailored support seems to be an integral part of Scottish practice. A support worker from the other care contract-holding Scottish NGO claimed that their organisation is adopting a similar approach. They noted that their organisation gets ‘permission [from the Scottish Government] to spend the funding on non-essentials… [that] make a huge difference’ to victims, such as bus passes.
However, Scottish practitioners, particularly those not directly working with trafficking victims, are lacking trafficking awareness, according to the manager of a Scottish NGO. They said ‘some have had training, but the majority of people haven’t had training and they would like training’. The interviewee added that while training on issues like gender-based violence is well-established and, therefore, ‘part of your DNA as a practitioner’, many practitioners lack equivalent training on human trafficking. ‘So, that’s where we need to get with human trafficking. It needs to be embedded in people’s consciousness, when they are speaking with a service user… At the moment, that’s not happening.’
Moving on to the post-NRM period, a support worker from a Scottish care contract-holding NGO reflected on the ‘support cliff edge at the end of it’, because ‘when you get a conclusive decision…the support is finished’, particularly if the decision is negative. Many interviewees agreed that people are often left vulnerable post-NRM, with long-term needs not addressed. These experiences contradict a Scottish Government official’s statement that ‘every time a survivor leaves direct support, they are offered an exit interview to reflect on their experiences, ensure they are ready to move on to other forms of support and gather learning to improve future provision’. All these shortcomings may increase the risk of ‘cliff-drops’ for victims, the UK NGO Legal Director explained. A Scottish care contract-holding NGO worker added that survivors ‘might end up homeless… then end up re-trafficked.’ In fact, another support worker from a Scottish care contract-holding NGO mentioned two cases where both individuals were re-trafficked post-NRM, despite one of them having a positive conclusive decision.
Eve is a domestic trafficking survivor as she was trafficked within her home country. Eve was positive about the support she received from the Salvation Army in England. However, she was highly critical of the medical service received, which she found ‘intrusive’, as doctors ‘kept asking… what had happened’. This made her not ‘really want to seek medical attention’.
Further, Eve was only offered ‘six counselling sessions’, where ‘as soon as you finished your session, another girl would be waiting for her session… and then if you’re upset… there was no [time], yeah’. She experienced neglect by the Salvation Army’s subcontracted care organisation who wanted to ‘move [her] on very quickly’ due to her domestic victim status.
Eve stated that based on her UK NRM experience, domestic survivors ‘weren’t seen as in need… as the others’. This is because as a domestic individual ‘you’ve got entitlements… you’ve got benefits… and you’ve your National Insurance Number’. As a result, ‘British survivors are sometimes overlooked’. After receiving a positive conclusive decision, Eve stated that ‘[her organisation] said I need to go’ despite her needing ‘treatment for… STDs [and] for the surgeries’ she had undergone to her genitals. Eve ended up staying with another organisation ‘run by people that wanted to do good, but they didn’t really understand what they were doing’. As Eve added, ‘we all needed support, but it wasn’t there’.
The organisation ‘within a year… closed down because of funding’, while Eve recounted how she could not access a specific service she needed, as it was not offered where she had been referred (‘all the services are disjointed’, ‘it’s almost like a postcode lottery’). Finally, the lack of a robust support framework and moving-on period made it ‘really easy to go back to the traffickers’, with Eve saying that she briefly returned to her traffickers post-NRM, without elaborating further.
Discussion and implications for practice
As the UK NRM tends to apply short support timeframes, it neither responds sufficiently to survivors’ individual needs, nor increases their power resources and autonomy. This ultimately does not assist people towards long-term recovery. The rigidness and time-limited character of the support may impede empowerment for service users, maintaining a power imbalance, rather than power being shared between the NRM and clients (Levenson, 2017). Choices offered to victims are limited, generic and prosaic. Based on Johnson’s (2012) aforementioned support context, as inspired by Maslow (1943), arguably, the UK’s NRM satisfies basic needs but fails to address the more complex, self-actualisation needs of service users.
The findings indicate that NRM services differ across Britain, creating a highly fragmented approach. It reinforces a postcode lottery, where support largely depends on the area in which the survivor was identified. Within this, Scottish practice seems to deviate from the prescribed NRM framework, often extending support in terms of time and provisions and tailoring services to individuals, thus aligning more closely with the principles of TIC and a person-centred approach. However, further research is needed on Scottish and English practice by way of interviews with English practitioners and victims referred to the NRM in Scotland. It will be important to replicate this research over time especially given the ongoing reforms that aim to improve several of the NRM’s inadequacies (Home Office, 2022).
Improving human trafficking training and education offered to Scottish practitioners is paramount to increase trafficking awareness among services. This could be achieved by a combination of in-house training offered by each NGO individually and central training organised and offered by the Scottish Government.
Scottish care-contract holding organisations should continue to extend the NRM support offered in practice, aligning with the principles of the person-centred, trauma-informed approach. This approach can benefit care providers too. By supporting individuals to make choices that suit their personal preferences rather than those instructed by ‘the convenience of providers’, organisations will spend less time and resources on actions and services that are out of line with service users’ needs (The Health Foundation, 2016, pp13, 30).
Further consultation and potentially official extension of the NRM and post-NRM support offered in Scotland could be a welcome move, in line with art.9 of the Human Trafficking and Exploitation (Scotland) Act.
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About the author
Konstantinos Kosmas Gaitis has completed his PhD in Law (Criminology pathway) at the University of Edinburgh, offering a critical examination of the human trafficking regulatory framework across Britain. He is a Scottish Justice Fellow, a Tutor with the University of Edinburgh and has also worked as a Research Assistant for the Edinburgh Study of Youth Transitions and Crime.
This Insight was reviewed by Dr Helen Allbutt and Dr Sandra Ferguson (NHS Education for Scotland); Scottish Government policy colleagues; and subject specialists including Jillian McBride (Scottish Refugee Council); Dr Paul Rigby, (University of Stirling), and Ruth Weston (City of Edinburgh Social Work).
Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and comment on this publication.
The author thanks the Alexander S. Onassis Public Benefit Foundation in Athens for their support of this work.
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