Human trafficking takes place transnationally across borders and internally within and across regions of countries. It is regarded as a crime [1] but also a human rights violation. Human trafficking can take many forms including forced labour, sexual exploitation, organ trafficking, forced marriage, forced criminality including exploitative begging and shopping alongside a new phenomenon recognised in the UK as County Lines Exploitation [2]. Despite there being some academic discussion on what an ideal victim of crime looks like, there is no agreed definition or consensus of what the specific patterns of behaviours are which trafficked victims act out. This is because exploiters can often disguise the coercive and controlling behaviours over their victims [3]. However, the victims involved possess a degree of innate vulnerability [4] which is attractive to traffickers who are opportunist in nature and seek to deceive, manipulate and coerce vulnerable individuals for the purpose of exploitation. It is a widely profitable crime for offenders to be engaged in and one which requires a robust response from law enforcement [5]. This short article examines some of the challenge’s victims have in failing to recognise themselves as victims of trafficking because of their mental health conditions which affect their ability to be correctly identified. It argues that practitioners working in mental health by supporting victims of modern slavery and human trafficking will need to play a greater pivotal role as the true impact of the pandemic on their mental health. This issue is even more pertinent given it has been four years since the social restrictions were lifted in many countries after the pandemic, and it remains to be seen the true extent of how the mental health of victims has been affected during this period.

Present research advocates a public health approach as well as a crime control approach to combatting trafficking [6]. This involves prioritising the coordination of various agencies to work together to provide a framework on prevention, At the expense of investing in the treatment of victims of their mental and physical health.

Having said this, there is research on the types of mental health conditions victims experience because of being a victim of trafficking. Most recent research on the mental health considerations which impact identifying victims of modern slavery of human trafficking focus on the mental health conditions of trafficked victims, specifically Post Traumatic Stress Disorder (PTSD) [7]. Other research looks at the broader availability of mental health services across the world [8]. There is an acknowledgment that the delivery of evidence-based support remains a gap which requires attention through a robust global response to anti-slavery practices [9]. Notable research involves studies to uncover the exploitative experiences of British nationals and how survivors are often failed by the current support system in place designed to protect victims from re-trafficking [10]. There has been specific research from the US where participants share their trafficking experiences, their struggles living with the effects of trafficking on their mental health, how they cope, and their recommendations for supporting other sex trafficking survivors [11]. However, the existing research is disjointed in terms of the adoption of a consistent narrative advocating towards the importance of addressing the specific mental health needs of victims, post exploitation. This is evidenced from research illustrating at present that there is no consensus on the outcomes needed for the recovery and reintegration of survivors of modern slavery and human trafficking [12]. To better inform what is required to meet the needs of trafficked victims from a health perspective, it is essential to consider the experiences of victims so that professionals can plan an effective health service provision. To do this, this article takes the following approach.

In response to the above, this short article builds on knowledge from the recent book publication entitled, ‘The Legal Issues, Barriers and Challenges Associated with Identifying Victims of Human Trafficking’ [13] which highlights how victims encounter many problems in becoming identified either by the State or through self-identification. Victims self-identifying can often be difficult because in some cases individuals find it challenging recognising their victim status due to the coercive and control methods carried out by their exploiters.

The existing research overlooks the intrinsic challenges victims have in recovering from their exploitative experiences and how addressing their mental health can play a crucial role in their recovery. The purpose of this article to specifically highlight the issues, barriers and challenges victims of trafficking have in becoming identified, preventing them from being able to access the required services and support to enable them start recovering from their traumatic exploitative experiences.

Having said this however, there are limitations to this article. It is still relatively unclear as to what extent survivors of trafficking were impacted by the pandemic in terms of access of services and support. Much of the research comes from reports carried out without participants direct involvement in the research. Consequently, survivors were unable to be co-creators of the research.

Moreover, a future research directional opportunity would be to collate data and research from survivors of trafficking and consider their lived experience during the pandemic. This would be extremely useful to inform academics and policymakers of the difficulties and barriers victims faced to ensure that recommendations including the continuity of health services is a priority which should continue in the event of similar events occurring in the future. Survivors of trafficking could also be encouraged to participate in becoming co-creators of research and have their voices heard to create change in social policy and if required changes to legislation to better protect vulnerable people.

Consequently, the issues raised in this article requires further examination in the future. Nevertheless, the aim of this article is to create greater awareness amongst health professionals to encourage more identification to take place in health settings when individuals encounter vulnerable patients. The following sections examine the challenges associated with the identification of trafficked persons and the impact of the pandemic on this issue. They are crucial to understand as they build an understanding of how health professionals can effectively treat the conditions brought on from their experiences of trauma and abuse.

Challenges associated with identification of victims of trafficking

Despite the increased numbers of referrals being made to agencies who make decisions as to whether someone is a victim of modern slavery, the number of positive decisions confirming victim status is decreasing [14]. Individuals subjected to exploitation and abuse may encounter many challenges, barriers and issues in either becoming identified as a victim of trafficking. There may be many hundreds, even thousands of people who have not been referred or identified as potential victims of trafficking and continuing to be exploited within society [15].

Victims of trafficking are often forced under duress to commit criminal offences as part of their exploitation by traffickers. Consequently, if they meet the Police, the criminal justice system will regard the individual as an offender, at the expense of being a victim of crime. In some cases, the vulnerable individual may be experiencing mental health conditions which require treatment by health professionals [16]. It has been seen how some victims who have been misidentified are often arrested, charged by police, prosecuted and found guilty of offences and receive custodial sentences [17].

Individuals may have issues recognising that they are being exploited while being subjected to abuse. In situations where victims present themselves as victims, they may have difficulties verbally disclosing their experiences because they have not yet processed them in a way which makes discussing their experiences coherent and without distress.

Victims of human trafficking often experience a range of severe mental health conditions due to their prolonged trauma, abuse, and exploitation. Some of the most common mental health issues associated with victims of modern slavery include:

1. Post-traumatic stress disorder (PTSD): This can include the re-experiencing of traumatic events, flashbacks, nightmares, hypervigilance, and severe anxiety which can be extremely intrusive for the victim [18].
2. Depression: Feelings of hopelessness, worthlessness, and persistent sadness, which can sometimes lead to suicidal thoughts and/or self-harm.
3. Anxiety disorders: Generalised anxiety, panic attacks, and social anxiety due to prolonged fear and stress which may be extremely difficult to treat.
4. Dissociative disorders: Feelings of detachment from reality or self, often seen as a coping mechanism to endure trauma. This may also lead to the person becoming depressed.
5. Substance use disorders: Many victims turn to drugs or alcohol as a method to cope with their distress.
6. Self-harm and suicidal ideation: Self-harm and suicide attempts may occur due to the overwhelming psychological pain.
7. Stockholm syndrome (Trauma Bonding): This is the emotional attachment to traffickers, often seen as a survival mechanism from victims [19].
8. Complex trauma (C-PTSD): Emotional dysregulation, the difficulty of forming healthy relationships, and the extreme distrust of people brought on by the experiences associated with prolonged abuse. This is increasingly prevalent when treating child victims, who have been subjected to abuse and trauma in their early years of childhood.
9. Psychotic symptoms: In extreme cases, victims may experience hallucinations or delusions related to their trauma.

The above section has highlighted the main mental health conditions which many trafficked victims will experience as part of their exploitation. These will be different in nature depending upon the environmental factors associated with the exploitation, namely the type of exploitation, the length of the abuse and the characteristics of the offender. It has been evidenced that modern slavery continued during the pandemic [20]. The COVID-19 pandemic exacerbated the difficulties in identifying victims of human trafficking due to several interconnected factors including restricted movement and isolation, social distancing measures which reduced contact between potential victims and people who might identify and help them. These include social workers, healthcare providers, and law enforcement. Subsequently, this led to a limited access of services being available, leaving more vulnerable people in riskier situations with fewer resources. The COVID-19 pandemic had a significant impact on the exploitation of trafficked victims, aggravating vulnerabilities and creating new risks.

In situations where exploitation was happening, the mental health of victims negatively worsened because of the environmental factors including the imposed lockdown during the pandemic by governments. The next section examines how COVID-19 affected trafficked victims to be identified because of the social restrictions imposed by the government, which enabled the mental health conditions of victims to at best not improve or at worst negatively deteriorate.

The impact of COVID-19

The impact of the COVID-19 pandemic left a transformative legacy on individuals, communities and regions across the UK as well as the rest of the world. In one previous piece if research it was argued that the pandemic has considerably exacerbated existing social inequalities, elevating the risk of multiple harms to individuals from vulnerable groups [21].

Many vulnerable individuals from various social groups were detrimentally impacted from the social restrictions imposed by government. These groups included refugees, undocumented migrants, asylum seekers awaiting decisions on their refugee applications, and children and adults relying on safeguarding services alongside other support provision. A further vulnerable group who was directly impacted during this time were trafficked victims. They were especially impacted by the social restrictions during the pandemic. Accordingly, victims were enclosed in exploitative situations with less chance of being rescued or having the opportunity to escape whilst simultaneously being exploited by traffickers. This was occurring within shadows of a society where large sections were locked down, preventing them from being potentially seen by authorities who have the possibility of identifying them as victims.

The pandemic in 2020 severely impacted different groups of people significantly in the UK in different ways, with “evidence showing that the pandemic has increased vulnerability to modern slavery all over the world, as many of the underlying drivers of modern slavery have worsened across many countries during the pandemic, such as poverty, inequality and unemployment” [22]. This provided an opportunity for traffickers to profit from illegal forms of migration via lockdowns and to take advantage of restrictions on internal travel within borders and across regions. This resulted in many victims being trapped in exploitation. Social restrictions also had a negative impact on the number of trafficked victims being identified. It was found that “the number of detected victims fell for the first time in 20 years as the pandemic limited the opportunities and potentially pushed trafficking underground, while constraining law enforcement capacity to target the crime” [23]. Globally, it has been estimated that there was a drop of 11% in the number of victims identified as trafficked in 2020 compared to 2019 with sexual exploitation and cross border trafficking dropping by 24% and 21% respectively [24]. These findings can be explained by the hidden nature of sexual exploitation and driven even further underground during the pandemic alongside the border security issues States were addressing where they would enforce the prohibition on international travel and the restrictions on social movement within regions. Whilst there was an increase of 3% in the number of male victims identified during the pandemic, there was a drop of 11% in the number of females identified [25].

One of the main issues associated with the increased vulnerability and new risks the pandemic created was the disruption of support services. Consequently, the impact of the lockdowns and social distancing measures limited victims’ access to shelters, counselling, and law enforcement services. The effect on victims has been leaving victims more at risk of becoming isolated and vulnerable.

Many people required health provision during the pandemic placing services under significant pressure [26]. Some health centres either closed or severely reduced their access and availability due to social restrictions. It has been acknowledged that “the barriers faced in closed settings in accessing services and finding their way in society highlight that some approaches to victim protection may serve to isolate and marginalise people rather than effectively reintegrate them into society” [27].

The mental health of victims with past trafficking experiences or those navigating the NRM deteriorated as "lockdowns and isolation from friends and family heightened anxiety, triggering memories of exploitative situations" [28]. This situation has been referred to as an ‘immigration lockdown’ where victims are awaiting decisions from the NRM as to whether the UK has recognised their status as a trafficked victim or not [28]. Citizens were encouraged to avoid hospitals, which further marginalised individuals in need of medical care who would have otherwise received attention. A direct consequence may have been that more victims faced repeated and intensified abuse from traffickers during this period, as they were at greater risk of being in public, increasing the chance that someone might notice they were being exploited.

The previous section explored the impact of COVID-19 on existing trafficking victims. This section focuses on how the pandemic affected trafficked individuals facing difficult circumstances, particularly those struggling with decisions to withdraw from the NRM. Ending support services would leave victims vulnerable to re-trafficking.

In the case of NN & LP v SoS HD 2019 [29] it highlighted the necessity of ongoing needs-based assessments for victims. The case concerned applications for asylum made by two victims of human trafficking. One victim was from Albania who was trafficked to the UK, was held captive and repeatedly raped before being rescued in March 2017. The second victim was from Vietnam who was trafficked into the UK and was made to work on a cannabis farm. The UK Government had promised to remove the amount of time victims would have access to services and support, often known as the 45-day rule originating from the EU Trafficking Directive. Article 11 of the EU Trafficking Directive [30] requires States to provide support and assistance to victims of trafficking. Furthermore, Article 12(1) the Council of Europe Convention on Action against Trafficking states that:

1. standards of living capable of ensuring their subsistence, through such measures as: appropriate and secure accommodation, psychological and material assistance.
2. access to emergency medical treatment.
3. translation and interpretation services, when appropriate.
4. counselling and information, in particular as regards their legal rights and the services available to them, in a language that they can understand.
5. assistance to enable their rights and interests to be presented and considered at appropriate stages of criminal proceedings against offenders.
6. access to education for children” [31].

In the UK, under the National Referral Mechanism (NRM), victims are entitled to receive £65 per week, accommodation (typically provided by the Salvation Army), and support from a dedicated worker. In 2017, the Home Office introduced the 45-day rule, extending the support period from 14 days to 45 days following a positive Conclusive Grounds Decision (CGD), which confirms that the Home Office recognises an individual as a victim of modern slavery or human trafficking. Charities and professionals working with victims had expressed concerns that the previous 14-day period was insufficient and could increase the risk of individuals being re-trafficked. These concerns ultimately influenced the policy change.

The case of R (on the application of NN & LP) v Secretary of State for the Home Department [29] was a significant legal challenge concerning the 45-day rule in the UK’s support framework for victims of trafficking. It was argued by the claimants that the removal of the 45-day rule was in breach of the Trafficking Directive and the Council of Europe Trafficking Convention. More time was needed to recover, and 45 days was not enough. In rebuttal, the Government advocated that there is a process of requesting an extension to the 45-day rule. However, during proceedings the Court found no evidence of a policy assessing what the criteria is to judge such extension, and one is not forthcoming from the defendant, leading that the Court unsure of what the result would be for the claimants if they were to apply for such an extension [29]. The claimants responded by referencing evidence from support workers who outlined the benefits of continued support:

“The 45-day deadline is very daunting for victims. Having built a relationship with their key worker, having felt safe and secure. Having received support to access the care that is needed, the prospect of that support no longer being there is a blow” [32].

The court ruled in favour of the claimants, concluding that the 45-day rule was unlawful because it failed to ensure that victims received the ongoing support necessary for their recovery and protection from re-trafficking. The judgment emphasised that support should be provided based on the individual needs of the victim rather than a rigid time limit. This case played a key role in highlighting the need for a more flexible and victim-centred approach to post-CGD support in the UK's trafficking response framework.

The impact on the victim’s progress to their mental recovery was also cited for justification of support to be continuous and consistent because victims experienced anxiety and ‘complex trauma’ meaning that progress does not always happen alongside a specific timeframe. There were important financial and practical considerations which must be considered if provision of support and services would continue, including the availability of support workers and the provision of accommodation. Additionally, these would include the cost to the taxpayer of continuing financial resources to consistently providing care after the 45 days, balanced with the risk of harm against the victim if support were to cease.

Nevertheless, it was held that removing help support after 45 days would be prejudicial to victims and is incompatible with Article 12 of the Council of Europe Convention on the basis that it would cause “a serious risk of irreparable harm to victims of human trafficking who received positive Conclusive Grounds determinations” [32] if support ended after this time. As a result, the Government was compelled to remove the 45-day limit on support for trafficking victims. This decision reassured victims that care would continue beyond this period, offering a positive outcome by ensuring ongoing access to support and service providers. This continuity of care would help victims maintain their recovery from past exploitation and reduce the risk of re-trafficking or exposure to unsafe environments where exploitation could happen again.

The implications of the judgment meant that the present system would be replaced with a needs-based assessment [33] detailing what services and support are required for the victim for them to start their recovery. The consequences resulting from this change meant that victims were entitled to specific services but may not have access to them because of the COVID-19 lockdown restrictions. Now that COVID has receded, focus needs to re-apply to the individual needs assessments and then followed up with practical support for victims. This is challenging due to the increased pressures on social care and the NHS since the reopening of society, compounded by the effects of Brexit, which has led to a reduction in labour within low-wage sectors like healthcare and social care.

Revisiting the issue of social distancing, the United Nations Office on Drugs and Crime (UNODC) expressed concern that travel restrictions during the pandemic lockdowns would "push crime further underground and force traffickers to adapt their business models" [34]. As highlighted earlier, social distancing directly affected victims, as "there is a risk they may not be identified by first responders and could find it more difficult to access support" [34]. As a direct response to social isolation, there was a reduced chance and less opportunities for victims to be rescued and identified by First Responders. Police to social workers had fewer opportunities to identify and engage with possible victims, as time and resources were diverted to the COVID-19 response. Furthermore, there was a distinct lack of legal enforcement and criminal proceedings during the pandemic. This impacted the number of prosecutions being brought. Victims were wanting to obtain accountability from the offenders of traffickers via the criminal justice system were prevented from doing so as there were significant delays in the number of trials due to the closure of courts during the pandemic. This led to a backlog of trials which need to be heard by courts after covid social restriction measures had been relaxed.

This article has explored the challenges of identifying victims of human trafficking and how the pandemic worsened these difficulties. As a result of the pandemic, victims have faced two main obstacles: first, the inability to escape their exploitation due to lack of identification, and second, the lack of access to specialised mental health support services necessary to begin their recovery.

The mental health challenges victims face can impact the credibility and reliability of their disclosures about their experiences. In some cases, it has been recognised that victims may not be fully truthful for various reasons related to their trauma as trafficking victims [35].

As a result, victims may struggle to provide a clear and detailed account of their experiences. When victims are cooperating with law enforcement in investigations and prosecutions against traffickers, it is crucial that their testimony is credible. If victims' mental health issues have not been addressed, prosecutors may be less confident in using their evidence in criminal trials, potentially leading to unsuccessful prosecutions. A jury may be less likely to trust testimony that does not withstand cross-examination by the defence during trial proceedings.

Early intervention, trauma-informed care, and long-term mental health support are crucial for victims' recovery from exploitation. These elements are essential for helping victims heal from their experiences. Professionals in this field play a key role in this process, supporting the victim's well-being and indirectly contributing to criminal justice efforts. Essentially, the pandemic has heightened the exploitation of trafficking victims by increasing their vulnerabilities and mental health issues, while simultaneously limiting access to vital support services for victims and survivors.