Trafficking in persons: a health concern?


Tráfico de pessoas: uma preocupação da Saúde?



Cathy Zimmerman; Ligia Kiss; Mazeda Hossain; Charlotte Watts

Gender, Violence & Health Centre, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine. 36 Gordon Square. +44 2079588240 London UK. Cathy.E-mail: Zimmerman@




Human trafficking is a phenomenon that has now been documented in most regions in the world. Although trafficking of women and girls for sexual exploitation is the most commonly recognised form of trafficking, it is widely acknowledged that human trafficking also involves men, women and children who are trafficked for various forms of labour exploitation and into other abusive circumstances. Despite the violence and harm inherent in most trafficking situations, there remains extremely little evidence on the individual and public health implications of any form of human trafficking. The Brazilian government has recently launched a national plan to combat human trafficking. However, because the health risks associated with human trafficking have not been well-recognised or documented, there is extremely limited reliable data on the health needs of trafficked persons to inform policy and practices.. Brazilian policy-makers and service providers should be encouraged to learn about the likely range of health impacts of trafficking, and incorporate this into anti-trafficking protection and response strategies. As well as prevention activities, the government, international and local organisations should work together with the public health research community to study the health needs of trafficked persons and explore opportunities to provide safe and appropriate services to victims in need of care.

Key words: Traffic in women, Sexual exploitation, Labour exploitation, Violence, Health needs, Public health


O tráfico de pessoas é um fenômeno que foi registrado na maioria das regiões do mundo. Embora o tráfico de mulheres e meninas para exploração sexual seja a forma mais comumente reconhecida de tráfico, sabe-se que o comércio ilegal de pessoas envolve também homens, mulheres e crianças, em várias formas de exploração de trabalho e circunstâncias abusivas. Apesar da violência e danos inerentes à maioria das situações de tráfico, há ainda muito pouca evidência sobre as implicações do tráfico de pessoas para a saúde individual e pública. O governo brasileiro recentemente lançou um plano nacional de combate ao tráfico humano. Entretanto, dados confiáveis para informar políticas públicas e práticas ainda não foram produzidos, particularmente sobre a escala potencial e as implicações de saúde de diferentes formas de tráfico. Planejadores de políticas públicas e provedores de serviços no Brasil deveriam ser encorajados a reconhecer o alcançe do impacto do tráfico à saúde e incorporar essas informações às estratégias anti-tráfico. Governo, organizações locais e internacionais deveriam trabalhar conjuntamente com a comunidade de pesquisadores da Saúde no estudo das necessidades de saúde da população traficada e explorar oportunidades de oferecer serviços seguros e apropriados para vítimas com necessidades de saúde.

Palavras-chave: Tráfico de mulheres, Exploração sexual, Exploração do trabalho, Necessidades de saúde, Saúde pública



International picture

Human trafficking is a subject that now receives significant attention from international and non-governmental organizations and governments around the world1. It is a phenomenon that initially gained recognition because increasing numbers of migrant women and children were detected in situations of forced prostitution. More recently, the spotlight has broadened to include the plight of a much wider group of people trafficked for various forms of labour exploitation2, 3. For example, trafficked persons have been found in agricultural, construction, cleaning, nursing, manufacturing, textile, fishing and mining sectors4, 5. In many regions, people are trafficked for forced begging and petty theft6. Women and children are frequently trafficked for domestic service and childcare, and females, as brides5, 7.

The inclusion of these various forms of exploitation within the category of trafficking indicates that human trafficking is a large scale global problem. Yet, despite efforts by experts to obtain a sense of the scale of the problem, to date, reliable statistics on the numbers of persons who are trafficked remain elusive. Trafficking is a crime that, by its very nature, is difficult to detect.

Moreover, "trafficking in persons" is a concept that has been notoriously hard to define8, 9. Since 2000, the most commonly accepted definition of trafficking in persons is found in the UN Protocol: "Trafficking in persons" shall mean 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 organs10.

In practice, trafficking generally involves vulnerable individuals who are recruitedo—ften by someone known to them or their family—with promises of profitable employment. They are frequently informed that travel and other upfront costs can be repayable from future wages—although, in some cases, individuals are asked to make advanced payments11. Ultimately, hopeful and trusting individuals find themselves in situations that are exploitative, dangerous, abusive—and commonly inescapable.

Trafficking is not solely an "international" occurrence where individuals are taken from their home and moved to a foreign country. Traffickers and their agents, such as those who recruit or transport victims, move and exploit people within their own country, as well. In fact, although internal trafficking receives much less attention, in many countries, in-country trafficking outnumbers cross-border trafficking11.

For those who are trafficked across international borders, most seem to be transported within their own region. For example, South Asians are generally trafficked within South Asia (e.g., Nepalese to India12), Central Americans are often moved to another Latin American country (e.g., Dominicans to Argentina13), Eastern Europeans are trafficked either within central or eastern Europe (e.g., Ukraine to Kosovo14) or to Western Europe (e.g., Moldova to United Kingdom15) and Africans are generally moved within their originating region (e.g., West Africans may be moved between Benin, Gabon and Togo16,17).

Anti-trafficking activities are generally categorised as: "prevention", "protection" or "prosecution". Prevention efforts have involved, for example, public awareness campaigns through television and radio (e.g., MTV EXIT (End Exploitation & Trafficking) Campaign in Europe17 and the USAID campaigns in Africa18). Protection activities commonly encompass assistance resources, such as hotlines, shelters and counselling services3. "Prosecution" includes the law enforcement activities of anti-trafficking programmes. Policing and immigration control are areas that are very often an international and governmental priority2.

One of the major reasons that human trafficking has received such significant attention, particularly by human rights groups, is because of the egregious abuses reported to be perpetrated on victims19.Those who are trafficked for forced sex work are frequently raped by one or more males as a form of "initiation" and/or intimidation20. They are often made to engage in high-risk sex, such as intercourse without condoms, anal sex and gang rape. It is not unusual for women and girls to be held captive under lock and key, brought to and from the work venue, when not forced to live and work at the same location and work long hours with significant numbers of men to service each day21.

One of the few studies on trafficking that has focussed on health was conducted in Europe22,23. This research documented the physical and psychological health risks and consequences of 192 women attending post-trafficking assistance services. Among the key findings from this research were that 59% of women had been physically or sexually abused prior to leaving home, with 15% reporting that they were sexually abused before the age of 15. Within the first 14 days of arriving at a service centre, women were most likely to report the following physical health symptoms: headaches (82%); fatigue (81%); dizzy spells (70%); back pain (69%) and gynaecological symptoms (vaginal discharge, 70%; pelvic pain, 59%; infection, 58%)22,23.

Psychological trauma is an extremely common and predictable aftermath of interpersonal violence, particularly sexual violence24, 25. Poor mental health symptoms were widely reported by women in the European study, with 57% of those interviewed scoring above the 2.5 cut-off point for post-traumatic stress disorder (PTSD). Similarly, extremely high levels of symptoms associated with depression, anxiety and hostility were also recorded22, 23.

To date, research on the health of persons trafficked for forced labour or exploited labourers appears to be extremely limited. In the absence of this type of data, if one wanted to get a sense of the health implications of trafficking into different labour sections, it seems reasonable to consider the occupational hazards associated with various forms of labour and from there, to speculate how these exposures might be greater for trafficked persons. For example, individuals who are trafficked into agricultural work are frequently treated as slave-labourers and/or are debt-bonded26, 27. In farming work, trafficked persons may, for instance, be exposed to toxic chemical or pesticides, repetitive activities, heat or cold exposure, sharp tools or heavy machinery and long work hours. Exploited farm labourers are rarely provided protective gear (e.g., gloves, masks against chemicals, water, heat or cold) or adequate safety training to prepare them for the work they are made to do. Living conditions may be overcrowded, have poor sanitation and offer little opportunity for sufficient rest or sleep. Compensation may make it difficult, if not impossible, to seek medical services or necessary basic care products. Job-related risks can lead to musculoskeletal disorders, pesticide poisoning, skin diseases, dehydration or frostbite and exhaustion. Physical abuse and punishment may be perpetrated by owners or managers to elicit obedience or greater productivity. Females may be subjected to sexual violence. Other industries, such as textiles, fisheries and mining are likely to have similarly long work hours and exposures to deleterious circumstances.

The scant literature on the health of trafficked persons is partly a result of the relatively recent emergence of trafficking as a subject of research, as well as the difficulty in detecting and reaching individuals who have been trafficked and the considerable attention that has been given the legal and human rights aspects of the problem.

Conceptually, health, in the context of trafficking, has been viewed within a migration framework22,28. Individual health risks and characteristics are seen within the phases of an individual's journey. Factors affecting a person's health status begin prior to her or his departure from home and continue throughout the trafficking cycle. For some migrants—particularly those undertaking illegal forms of migration—risk exposures may emerge while they travel to their destination, such as during treks through malarial jungles or sea crossings on unsafe vessels. Numerous serious health risk are likely to occur at the point of destination, which may include occupational hazards, exposure to new infections, violence and deprivation, problems associated with being socially or economically marginalised or difficulties accessing medical care.


Trafficking in Brazil: What is the evidence?

In Brazil, human trafficking is a problem that has been recognised by both the NGO sector and the government. In 2006, the Brazilian government approved a national policy (Decree n. 2948/06 of 26/10/2006) and, in 2008, a national plan addressing trafficking in persons29. These initiatives intended to tackle the problem from three strategic axes: prevention, repression of perpetrators, and assistance to victims29. Yet, to date, there is extremely limited research on trafficking patterns, dynamics and victims. One of the most comprehensive studies describing trafficking in Brazil is the research conducted by Leal and Leal30. In their report on trafficking in women, children and adolescents, the authors have identified 110 internal trafficking routes and 131 international routes30. This report states that trafficking within national borders involves primarily adolescents, whereas those trafficked internationally are mainly adult women.

Internationally, Brazilian women are trafficked to Spain, Netherlands, Venezuela, Italy, Portugal, Paraguay, Switzerland, United States, Germany and Suriname. Adult victims are generally black or mixed race young women (less than 24-years old), and come from low-income and educational backgrounds. It is not uncommon for women to be single mothers and live in the outskirts of cities with other family members31.

Adolescents are most commonly transited between Brazilian municipalities and federal states, with some crossing borders into other South American countries, specifically Suriname, Venezuela, French Guiana, Paraguay, Bolivia, Peru, Argentina and Chile. Young women and girls appear to come from poor municipalities in the Brazilian countryside or from impoverished urban areas31. The participation or agreement of family members in the recruitment of girls, has been noted, as a child's work can represent an important additional source of income for impoverished families32. A common theme identified among trafficked women is a "history of violence", such as domestic violence and child sexual abuse, and institutional violence, such as in orphanages. These experiences of abuse are perceived to make individuals vulnerable to dubious employment offers that might lead them to be trafficked or into exploitative labour situations23.

Slave labour is not new to Brazil. Trafficking for forced labour in the Amazon dates to the 1960s, where it primarily involved male workers33, 34. Today, slave-like practices have been documented in the Amazon and other remote regions in Brazil. Forced labour is also reported to extend to urban areas such as Sao Paulo, where, for example, cases have been noted of migrants recruited from Bolivia to work for Korean-owned sewing businesses in debt-bondage situations34. According to one report on slavery and forced labour in Brazil, victims can be found in ranching, "deforestation", agriculture, logging and charcoal mining communities34. Where male labour migration is prevalent, migratory sex work and trafficking for forced prostitution may also be common.

Numerous analyses on trafficking and migration propose that increasing disparities in wealth between urban and rural areas and between nations, combined with expansion of illicit trade networks, have intensified migration flows20, 31, 35, 36.

There is some evidence to suggest that women from the north and northeast regions of Brazil are more vulnerable to being trafficked than those coming from other parts of the country31. These regions represent areas with lower average indicators for income, educational level and employment in the country. Furthermore, the growth of sex tourism, especially from Europe to the northeast coast of Brazil, has fostered an increase in trafficking opportunities through connections with common destination countries14, 36.

In certain locations in Brazil, various organized crime networks have profited from the weakness of state structures and poor law enforcement32. These networks have established transit routes and destination points for illicit trade, both locally and internationally37. The report by Leal30 suggests, for example, that international criminal organizations like the Russian Mafia, the Italian Camorra and the Japanese Yakusa may be involved in the trafficking of women (along with other illicit activities) in Brazil and Latin America. It has been noted that the trafficking of women appears to follow similar patterns as those used to traffic drug and weapons, such as transit routes and police corruption schemes14, 31.

Case studies by non-governmental organisations and news articles by journalists offer striking examples of the vulnerability of Brazilian girls from poverty-stricken families to being trafficked. These pieces have described, for example, the situations of girls sold in local sex markets, trafficked into Amazonian brothels, and those traded in virgin auctions in mining fields37.


Research gaps in Brazil

In Brazil, most published work on human trafficking has focussed on trafficking of women for forced sex work or child trafficking, often focusing on trafficking in the north and northeast. Yet, it has been noted that few, if any, offer critical appraisal, reliable sources of information or conclusions based on verified data37. Also lacking in research on trafficking is information on individuals who are trafficked for other forms of exploitation, such as forced labour14.

Because of the limited amount of published literature on trafficking in Brazil, what is available tends to generalise about the cases of trafficking, suggesting that most trafficked persons fit neatly into a singular profile of a poverty-stricken, uneducated and/or orphaned female who was sold by her family. However, this characterization is likely to be an over-generalisation. Numerous reports from around the world suggest that trafficked persons are likely to be a much more diverse group12, 13, 22, 38.

Moreover, sometimes women who may be seen as fitting the category of "trafficked" may not view themselves under this label. Piscitelli, who conducted research that included women working in prostitution in Spain, noted that women she interviewed did not perceive that they were trafficked, despite what could be considered financially and otherwise exploitative circumstances39. Similarly, reports have shown that men who are trafficked for exploitative labour may also have difficulty accepting a "victim" label40. Many individuals who are trafficked come from disempowered political and social positions, which may prevent them from recognising the exploitative nature of these situations or from reporting them as criminal.

The range of circumstances and characteristics of trafficked persons seems to be poorly represented, with existing literature highlighting the most extreme cases or those that have made it into the legal system41.

Finally, despite the documented health effects associated with trafficking in other settings32, to date, little to no data exist on the health of trafficked populations in Brazil.



The Brazilian government is to be congratulated for its clear recognition of the problem of trafficking in persons through its new plan of action on trafficking29. However, it is difficult to plan activities or services without reasonable estimates of the extent, range and dynamics of trafficking in persons in Brazil. In order to develop appropriate responses to prevent and respond to trafficking, more in-depth and systematic research is needed. Information on the mechanisms used to introduce men and women into trafficking, and potential risk factors for being trafficked are needed. Effective laws and national referral strategies are needed to ensure that victims who are detected are provided with appropriate care and security. Components of a National Referral Mechanism in Europe, for example, recognise that persons who have been trafficked will have a wide range of needs, including security, health, legal counsel, and support to integrate or return home42. States implementing the NRM (National Referral Mechanisms for the assistance and protection of trafficked persons) are trying to identify ways in which these services can be provided in a timely and sensitive manner.

Health has been a neglected subject in many countries' anti-trafficking programs. It is common for representatives from the health sector to be left out of discussions at both policy and practice levels. Instead, attention is often given to law enforcement and immigration services, while overlooking the assistance required for adequate victim support. Brazil has clearly made important steps in recognising the problem of human trafficking. It can now be among the international leaders in considering trafficking in persons a serious health concern and ensuring that the health needs of trafficked persons are clearly prioritised in research, policies and services.



C Zimmerman, L Kiss, M Hossain and C Watts have equally participated in the conception and writing of the text.



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Artigo apresentado em 19/11/2008
Aprovado em 18/02/09
Versão final apresentada em 16/04/2009

ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil