Introduction

A felicidade é muito injusta [Happiness is very unfair] (Marcelo).[1]

The diagnostician’s principal task is to evaluate the patient’s 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 energy—that 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 mental health that was available when I was developing this article.[2] 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 locus’s 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: Marcelo’s case study

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).[4] Where 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 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 Shelter’s 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 Women’s Development (a branch of the Vietnam Women’s Union) as part of a pilot project, and had an almost entirely Vietnamese staff. Mrs. Thuy, the project’s 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 shelter’s 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 n’y a aucune trace’ (‘there is no sign’). He continued: ‘Inside the work that was conducted [with the shelter’s 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, which all ultimately stand for an ‘illicit’ loss of virginity outside the marriage and for a polluted/polluting female body (Lazzarino 2014; Vijeyarasa 2013).

Discussion

Marcelo’s 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 Viola’s 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. Marcelo’s 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 needs—mental health or otherwise—of 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 research—that 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 concepts—ones 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, Marcelo’s 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. Ethnography’s ‘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 ‘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 Marcelo’s 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 experience—mostly 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; survivors of torture, wars, and natural catastrophes; victims of domestic and sexual violence).[5] 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 Drugs and Crimes.[6] 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 (O’Connell 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-effective interventions without accounting for users’ experiences and micro/macro contexts of power configurations.

Conclusion

The first part of this article’s 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 people’s 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 integration—which is simultaneously disciplinary, epistemological, and political—each locus’s 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 tools—starting, 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, ethnography’s 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.

Acknowledgements

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 Mary’s 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.

Footnotes

1. 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.↩︎

2. 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 field—both of studies and interventions in trafficking aftercare—has 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.↩︎

3. 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.↩︎

4. 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, 7–8), 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).↩︎

5. 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.↩︎

6. 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).↩︎

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