Child trafficking referrals in Portugal (2010–2017).
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"},{slug:"intechopen-s-chapter-awarded-the-guenther-von-pannewitz-preis-2020-20200715",title:"IntechOpen's Chapter Awarded the Günther-von-Pannewitz-Preis 2020"}]},book:{item:{type:"book",id:"6552",leadTitle:null,fullTitle:"Silver Nanoparticles - Fabrication, Characterization and Applications",title:"Silver Nanoparticles",subtitle:"Fabrication, Characterization and Applications",reviewType:"peer-reviewed",abstract:"Silver nanoparticles are the subject of immense interest because of their distinct chemical and physical properties that are different from their bulk counterpart. This makes these nanoparticles very important in many fields including antimicrobial applications, biosensor materials, composite fibers, cryogenic superconducting materials, cosmetic products, and electronic components. This book aims to provide in-depth study and analysis of various fabrication, characterization, and application techniques of silver nanoparticles that lead these nanoparticles very important in the recent technology. This book presents deep understanding of the new techniques from basic to the advanced level. 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In this era of functional MRIs, neurobiology and the sequencing of the human genome, it is easy to forget that the complex phenomenon of mental illness is to some degree socially constructed. The trend towards globalisation has seen a Western social bias (one could even say an American bias) towards the classification and treatment of mental illness.
In this chapter we argue that the homogenisation of the experience, classification and treatment of mental illness, whilst having some benefits, has also done harm and that this is especially true of the complex phenomenon of depression.
The chapter examines:
the effects of the Diagnostic and Statistical Manual on the homogenisation and simplification of mental illness and in particular depression,
the phenomenology of depression across cultures in light of the Westernisation of mental illness, and,
the role of “Big Pharma” in pathologising the cultural expression of sadness.
In addition, the chapter will suggest some ways forward to a more nuanced approach to the diagnosis and treatment of depression.
Sarah’s depression
Sarah had been diagnosed with depression following the death of her much loved father some eighteen months previously. Her symptoms were severe enough for her to be diagnosed with the DSM-IV category of Major Depression. The prescribed medication had helped somewhat but some two and a half years after her father’s death her depression and its accompanying anxiety saw this once confident woman lose her business and her marriage.
Sarah was eventually referred to a group and individual psychotherapy program. In this program Sarah told the story of her father’s death. Her father had been scheduled for a hip replacement. The surgery was delayed and his eventual admission coincided with Sarah’s scheduled move to a distant city to set up a new business. The surgery went ahead but Sarah’s father developed postoperative pneumonia. Not wishing to alarm Sarah and necessitate her unnecessary return, her sister Jane, expecting their father to recovery quickly, kept the information from Sarah. However their father’s condition deteriorated and by the time Sarah was notified it was too late and her father died whilst she was on a flight home.
All of this was explored in therapy but Sarah’s symptoms remained. Then some months into therapy Sarah was notified that her mother had suddenly become ill and had been admitted to the same hospital. Sarah arrived at the hospital in good time and was able to be with her mother up until her death. Shortly before her death her mother began talking to her dead husband as if he were in the room with them.
On returning back to therapy following her mother’s funeral Sarah seemed to have changed. Sarah related that when her mother was talking to her dead father Sarah remembered her last conversation with him: something she had hitherto forgotten. She had gone to see him prior to his operation and her travel interstate. Her father, who had never been in hospital before, appeared anxious and said to Sarah, “You are leaving me here to die”. She assured him that he would be fine and back on his feet in no time.
Reflecting on this in therapy Sarah was surprised that she had forgotten the comment and reflected on the fact that she had indeed left him to die, albeit unknowingly. In the following weeks Sarah went over this comment time and again; she had not meant to leave him to die, it was not deliberate. Sarah then went through a period of grieving for both her parents and the grief turned to a period of mourning at their passing. Gradually over the following months Sarah’s depression and anxiety lifted. At six and twelve months follow-up her depression and anxiety had not returned.
Carolyn’s agoraphobia
Carolyn’s Agoraphobia had begun without any identifiable cause. Following a panic attack in a supermarket checkout queue she found it increasingly difficult to go out in public. Cognitive Behaviour Therapy (CBT) and anxiolytics had helped a little but her anxiety and accompanying depressive symptoms persisted.
Carolyn was eventually referred to individual and group psychotherapy. Progress was slow and Carolyn’s anxiety made it difficult to travel to therapy. Some weeks after commencing group therapy, a group member brought up the topic of loss. This client spoke of the loss of a child as being the greatest loss one could suffer. Carolyn broke down and began crying uncontrollably. Over the next few sessions she recounted how twenty-five years previously she had been admitted to hospital following complications of her first pregnancy and subsequently suffered a late miscarriage. She recounted how today it would have been considered a still birth, how she had not been allowed to see the baby and how she was told to forget about it and try to get pregnant again. Her husband and her family never mentioned it again.
Over subsequent group therapy sessions Carolyn recounted the days and months following the “miscarriage”. She recounted how she had tried to put on a brave face and not cry and how secretly she went back to the hospital and asked where the child’s grave was, only to be told there wasn’t one. She had not spoken to anyone about it from that day to this. Over the following weeks she cried, “Twenty five years worth of tears”. Gradually, Carolyn’s symptoms of anxiety and depression subsided and she found herself once more able to go out in public without fear of a panic attack.
What do these two stories have to say about depression? In both cases the clients had been diagnosed and treated with medication which had some affect on the symptoms but did not bring about a resolution of the problem. In the case of Carolyn, Cognitive Behaviour Therapy was used and once again had some affect but did not resolve the problem. Both the medication and the CBT were used to treat the surface symptoms. As Darian Leader puts it, the consequence of treating the surface symptoms is that, “The interior life of the suffer is left un-examined, and priority given to medicalizing solutions…The problem has to be got rid of rather than understood (Leader, 2008:2)”. Medication in this case aimed to restore presumed chemical imbalances in the brain. CBT was aimed at restoring presumed faulty cognition. In both cases the underlying loss was left untouched and in fact remained hidden. In Sarah’s case the guilt associated with her father’s death and the loss of her identity as a dutiful daughter remained hidden even from her. In Carolyn’s case the surface symptoms which were predominately of anxiety, meant that grief and loss were not even associated with her case and were masked as much by the diagnosis as anything else. This concentration on the appearance, diagnosis and surface symptoms effectively blocked a deeper and more wide ranging explanation of the symptoms.
The other interesting element of both cases is that the surfacing of the underlying loss and its subsequent resolution took time. Time is one thing we often do not have for clients in today’s world: time for them to explore their reality and, as the experts of their own experience, to teach us. Indeed in some countries psychiatrists spend on average two hours per year in face-to-face dialogue with clients (Leader, 2011). Sarah and Carolyn’s recovery also took place within an alliance with others. Both women underwent a period of public (albeit within the group) mourning in which both appeared to integrate their experiences into their life story.
In this chapter we shall explore the consequences of classifying and treating depression based upon the surface symptoms. We shall also explore how culture and context influence surface symptomatology. We suggest a way forward which acknowledges our shared humanity and the need to look beyond surface symptomatology in the treatment of depression.
Naming something does not explain it.
In the 1960s many school biology classes taught that the Platypus was a “freak of nature”: as it suckled its young and laid eggs it was neither a mammal nor a reptile. Of course because something does not fit neatly into a human classification system does not make it a “freak of nature”. To believe so is to believe that by naming something we have explained it. Yet to some extent this is what we are doing when, using a diagnostic system based on surface symptoms or descriptions, we classify human behaviour as this or that disorder: the diagnosis becomes the explanation for the symptoms. Whilst there are undoubted advantages to standard classification systems (communication between clinicians; ability to examine the natural history of a disorder and develop targeted treatment regimens) the major disadvantage is that the individual, their experience, their inner life, their uniqueness, their humanity culture and context, can be overlooked or ignored and the surface symptoms alone treated.
The debate about psychiatric classification and its consequences is not new. The debate has generally revolved around description versus aetiology. Kraepelin believed that pure description would eventually lead to and be replaced by a system based on aetiology (Zigler & Phillips, 1961). Unfortunately this has not happened.
The danger with an emphasis on description is that it may leave little room for the interpretation of psychopathology (Zigler & Phillips, 1961). In addition if the descriptions are drawn from one dominant cultural perspective then from the beginning their cross-cultural universality should be questioned. In such a system, the manifestations of mental illness may be forced to fit preconceived frameworks and paradoxically the zeal for classification may see more and more human behaviour pathologised.
The dominant classification system in the world is the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM) of Mental Disorders: now about to be released in its fifth version. Whilst the DSM has assisted clear communication between physicians when discussing mental illness and its treatment, it has also been accused of medicalising (and therefore pathologising) an ever-increasing range of behaviours (Flaskerud, 2010). The original DSM I, which was first published in 1952, contained 103 diagnoses; by the publication of DSM-IV-TR in 2000 this had grown to 365. This growth in diagnostic categories has not been without its critics. The APA has been accused of manufacturing madness by pathologising a wider and wider spread of human behaviour. This has been achieved, say the critics through devising new diagnostic categories and broadening the criteria for the old ones. The most recent controversy surrounds the suggestion by the APA that the new edition of the DSM remove the bereavement exclusion in the diagnosis of major depression and add complicated grief as a new diagnosis (Frances et al, 2010).
That the DSM is a descriptive classification system is clear. The DSM-IV-TR (APA, 2000) in addition to listing surface symptoms, also discusses prevalence, course, familial pattern and differential diagnosis but not aetiology. As a consequence of its purely descriptive stance there have been those who argue that the DSM lacks validity as it is a classification system without a theoretical/explanatory basis or an agreed upon scientific model other than a general assumption of a biological causation of mental illness (Thakker & Ward, 1998; Flaskerud, 2010).
According to Gary Greenberg (2010, p. 15) “the DSM is an unparalleled literary achievement. It renders the varieties of our psychospiritual suffering without any comment on where it comes from, what it means, or what ought to be done about it”.
Criticisms of the DSM are abundant and we do not propose to outline them all here. However there are some points of critique which are of relevance to this chapter. The first is the imposition of a North American/Western European perspective on mental illness and the relegation of other cultural perspectives to curiosity status. The second is the mistake of thinking we are describing stable entities when what are really being described are also socio-political constructs.
That the DSM has a North American/Western European bias is evident. The DSM-IV-TR (2000) relegates non-western syndromes to an appendix called “culture-bound syndromes (APA, 2000: 897-903)”. This ignores the fact that the DSM itself is culture bound and a product of North American Western European culture (Flaskerud, 2010). It further assumes the universality of its primary syndromes, some minor culture bound influences aside (Thakker and Ward, 1998). The socio-political construction of the DSM, even within its own cultural paradigm, is well illustrated by the fact that the mental disorder of homosexuality was cured with a stroke of a pen when it was eliminated from the DSM II in 1974 (Flaskerud, 2010). Prior to this societal change, homosexuality was deemed a mental illness and treated by various means including aversion therapy.
A mental disorder is defined as the "existence of a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions" (ICD-10, World Health Organisation (WHO), 1992, p. 5). A person is considered to have a mental illness when the clinical presentation meets the criteria defined either in the DSM-IV (APA, 2000) or the ICD-10 (WHO, 1992). Conversely, a mentally healthy person will not exhibit clinically recognisable symptoms, behaviours or functional distress.
Importantly, the diagnostic process for any person is concerned with the accurate assessment by the clinician. This assessment occurs through the interaction between the clinician and the client and is based on an interrogatory process. Any examination of the rates of mental illness within a given community rests on the assumption that the diagnosis is accurate. Forming an accurate diagnosis is based on a number of factors including cultural variances in the expression of mental illness and cross-cultural communication patterns. Self-disclosure by the client in the assessment procedure is a communication variable that influences the nature and amount of information the clinician is able to secure during the interview. Clinicians therefore, need to be culturally sensitive to the differences in communication practices within cultures that affect self-disclosure as well as the cultural differences in illness expression and help-seeking behaviour.
According to Marsella (1981) any ideas relating to mental health must be viewed in the context of what constitutes “the self”. Given that cultures ascribe and define notions of self, reality and illness, it is fundamental to study mental health and illness in a holistic framework with regard to social, contextual and cultural history (Marsella & White, 1982). “Cultural conventions about the self, reality, social rules, and patterns of emotional expression, for example, simply make universal criteria of psychiatric illness difficult to attain and the idea itself problematical” (Fabrega, 1987, p. 386).
Burr and Chapman (1998) argue that psychiatry has pathologised culture by perpetuating cultural stereotypes as definable categories and failing to acknowledge the institutionalised racism that exists. Moreover, these authors argue that,
“Health carers seem to be characterised as either cultural translators or functionaries, whose practice is largely circumscribed by a social system characterised by social and economic inequality” (Burr & Chapman, 1998, p. 435).
Historically, there have been challenges to the assumptions that cross-cultural similarities in abnormality exist. Earlier, cultural anthropologists suggested that abnormality was relative and should be addressed in conjunction with the cultural norms and deviations tolerated relative to that society (Kleinman, 1996). Since these early warnings questioning the validity of applying non-specific diagnostic criteria to non-Western social groups, a number of studies have empirically demonstrated the need to define concepts of normality and abnormality according to normative standards relevant to reference populations (Kleinman, 1996).
The concept of mental health has traditionally been embedded in psychological and behavioural characteristics. According to MedlinePlus (2012) “Mental health is how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others and make choices. Like physical health, mental health is important at every stage of life, from childhood and adolescence through adulthood”. Somatic expressions have until recently largely been ignored mostly due to the scientific models that have defined illness. Models of causality are now including epistemological and ontological paradigms, which interact to identify mental illness across many cultures (Marsella, 1981). Although some (APA, 1994; Gaw, 2001, Weller & Baer, 2008) would argue that there are identifiable and unique “culture-bound syndromes”, these syndromes are also found across quite disparate cultures.
In parallel with the rise of a descriptive nosology has been the rise of the biomedical model of causation of mental illness. This model assumes that mental illness including depression arises from chemical imbalances in the brain, which in turn may have a genetic cause. The consequence of this pairing of a descriptive nosology with a biological causation has been that contextual factors or the life world of the patient as well as their inner life world are seen as much less important to both understanding and treating depression. It has also seen the rise and rise of pharmacological treatments especially since the advent of the SSRIs starting with Prozac in 1988. Of this more later.
Regier (2004, p. 25) describes the problem: Various critics of the current diagnostic system have characterised the expansion of diagnostic categories as a “guild” attempt to justify payment for any condition a psychiatrist might see in practice, or as fabrications of the pharmaceutical industry to justify the sale of their products”.
According to the World Health Organisation (2012), depression is the leading cause of disability as measured by years lived with disability (YLD) and the 4th leading contributor to the global burden of disease in 2000 (WHO 2012). By 2020 depression is projected to be the second highest ranked cause of years of productive life lost due to disability (DALYs). Various reasons for this apparent epidemic have been posited varying from the rise of individualism (Ehrenreich, 2007) and dissolution of a sense of community (Levine, 2008) to, paradoxically, the use of anti-depressants as front-line treatment for depression (Whitaker, 2011).
However, behind the alarming statistics and the posited causes, the influence of a descriptive classification system, depression awareness campaigns and the marketing of antidepressants by drug companies, makes the picture even less clear.
As previously stated, the classification of depression is based upon surface symptoms from a predominately North American/Western European perspective. The term depression has come to replace earlier terms such as “melancholia” and “mourning” which subsumed depressive symptoms within them and at least hinted at contextual factors. The DSM has elevated depression from a symptom to a disorder. Whilst the DSM has a definition and set criteria for depression, the term has a variety of meanings to the general public; both figurative and literal (Summerfield, 2006). Coupled with this is the global campaign to raise awareness of the disease so that treatment can be effected and the “epidemic” fought.
In Australia, the spearhead of this campaign is the not for profit organisation “Beyond Blue” (www.beyondblue.org.au). The Beyond Blue website contains symptom checklists some of which are so broad that many people may be concerned that they are in fact depressed. For example, the website contains the SPHERE symptom checklist which is a “… scale developed as part of a national mental health educational project aimed at increasing GP\'s rate of identification, effective treatment and management of common psychological disorders like depression” (Beyond Blue website). The scale contains 27 items grouped under behaviours, thoughts, feelings and physical symptoms. On entering four symptoms at random into the checklist (“not getting things done”, “it’s my fault”, “indecisive” and “tired all the time”) the site advised that: “If you scored 3 or more of the [27] symptoms, you probably have a depressive illness [emphasis added]”, and should see a doctor. Contextual factors are not taken into consideration.
The doctor that most people undertaking such a symptoms test will see will likely be a General Practitioner (GP). Dumit (2005) states that in the USA 75% of all prescriptions for antidepressants are written by non-psychiatrists. GPs are increasingly facing clients armed with symptom checklists, often supplied by drug companies, which may influence prescribing behaviour (Dumit, 2005). The situation in the UK is similar. Summerfield (2006) states that whilst there is little empirical evidence for an epidemic of depression, with prescriptions for antidepressants rising in the UK in the 1990s from 9 million to 21 million, there is evidence of an epidemic of prescribing. We are now seeing the diagnosis of depression and the prescription of SSRIs rising in non western countries.
Depression is a complex phenomenon. It is experienced by different individuals in different ways. The phenomenology of depression is also influenced by the cultural context. For example, in the West people diagnosed with depression are likely to present with predominately psychological symptoms. That in other parts for the world somatic symptoms tend to dominate has long been known (Ryder, 2008; Tanaka-Matsumi & Marsella, 1976). That different cultures view depression and the expression of sadness in different ways is also well known. Indeed, until recently this was also the case in Japan. Sadness and depression were often positively viewed as “… yielding enhanced awareness of the transient nature of the world (Kirmayer, 2002)”. Up until the 1990s “Utsubyô” (the Japanese term for depression) was considered a severe but rare disorder (Watters, 2010). Other lesser forms of depression were seen as a personal affliction which did not require treatment (Kirmayer, 2002).
However, the Japanese attitude to depression changed dramatically in the late 1990s when Japan saw a 46% increase in cases of depression diagnosed between 1999 and 2003. In 2005 it was estimated that 2 million Japanese suffered from depression as defined by the DSM (Schulz, 2004). Although the rate of suicide in Japan is much higher than other countries (twice that of USA and four times that of UK), the prevalence of depression is still lower than the USA and only 53% of suicides are attributed to depression (Sado et al 2011). Nevertheless the Japanese experience mirrors reports in the professional and popular press of an “Epidemic of Depression” (Levine, 2008). This epidemic of depression has set alarm bells ringing in Japan not least because on the economic front alone it has been estimated that the total cost of depression in Japan in 2005 was ¥2 Trillion (Sado, et al 2011).
Interestingly this rise of depression in Japan coincided with the rise in the use of the DSM and the marketing of SSRI antidepressants.
The DSM 111 was introduced to Japan in 1980 but its uptake was slow. The conventional classification of mental illness had been influenced by German neuropsychiatry of the early 20th century (Someya, 2001, Kirmayer, 2002). However, by 2000 there was a general acceptance and use of the DSM by the younger generation of psychiatrists (Someya, et al 2001).
Whilst there is some evidence that the cardinal symptoms of depression as described in the DSM appear as clusters or syndromes in many cultures, there are many other symptoms that reflect cultural idioms of distress and “ethnophysiologies” (Kirmayer, 2002). As globalisation takes hold and a degree of cultural homogenisation takes place there may well be a shift in these culture bound manifestations which reflect a shifting globalised perspective on distress and the individual’s place in society. Such homogenisation may see the descriptive nosology of the DSM adopted as the standard across cultures. As Kirmayer puts it,
“The notion that a comprehensive or complete nosology can be created without regard to culture and context can be sustained only by adopting a reductionistic perspective that ignores the fact that human beings are fundamentally cultural beings (Kirmayer, 2005:193)”.
Given Japanese cultural views of depression, it is not surprising that Japan was not seen as a large market for antidepressants. However, that changed in the late 1990s when drug company GlaxoSmithKline began marketing its new SSRI, Paxil (Watters, 2010).
The campaign began with the GlaxoSmithKline convening a group of experts in cross cultural psychiatry in order to promote the concept of depression in Japan and reconceptualise somatic symptoms and social anxieties as indicators of an illness amenable to pharmacological treatment (Kirmayer, 2006). One more cynical aspect of this campaign was the marketing of depression as a “kokoro no kaze”: cold of the soul (Watters, 2010) for which the remedy was a kind of psychic Aspirin; an SSRI.
Whilst the upshot of this campaign may well have been the treatment of Japanese people who had hitherto been undertreated or not treated at all for depression, the subsequent drug company community information media campaign aimed to broaden the market for SSRIs in Japan. This was achieved by presenting depression as “…intentionally ambiguous and ill-defined, applicable to the widest possible population and to the widest possible range of discomforts (Kitanaka, 2006 quoted in Watters, 2010: 226)”. Whilst in no way a cynical or a deliberate attempt to mislead, the symptoms checklists seen on the Beyond Blue website may have a similar effect in that three or more vague discomforts of the common lot for humanity which coincide with a two week period of depressed mood are seen as “probably” indicating depression.
The GlaxoSmithKline community information campaign in Japan may have also been aimed to overcome another barrier to the diagnosis and treatment of depression: stigma. Again, this may have been of benefit for some Japanese suffers of depression as stigma is a barrier to many individuals who would otherwise seek treatment (Cross and Walsh; 2012). Dumit, however, takes a more cynical view: “Marketers see stigma as inhibiting self recognition of patient status and therefore reducing prescription demand (Dumit, 2005)”. Indeed Dumit believes that differences in diagnosis between races or genders are seen by drug marketers as an opportunity to achieve “parity”. In this way the lesser market [Japan for example] is seen as ‘undertreated’. Efforts to open up the market and achieve parity are characterised by “…the funding of epidemiological studies, the introduction and invention of new languages and the creation of websites explaininis seen by drugg the symptomatology of the conditions (Dumit, 2005:11)”. This has seen an interesting shift from previous expressions of illness and suffering in which the patient’s experience of suffering and identification as a sufferer took primacy over one where it is possible for the patient to be a sufferer without knowing it. Indeed the patient may need to be assisted to develop insight into their state by public service campaigns, drug company information, experts in the field, symptoms checklists and diagnostic manuals. Objective opinion takes precedence over subjective experience.
Overall there appears to be a lowering of the threshold for symptomatic treatment of depression. For some commentators this amounts to “disease mongering” which interferes with the individual’s coping mechanisms and culturally appropriate ways of dealing with distress (Das, 2011).
The increasing pathologising and medicalising of human behaviour has been well documented (Greenberg, 2010). Some see this as evidence of the rise of the medical-industrial complex (Das, 2011) and the manufacturing of illness (and attendant cures). However, it also brings into question notions of happiness and expectations of the human condition in contemporary society.
In North American/Western European societies the story of depression is illustrative of a deeper malaise which in turn is being exported to other cultures. This malaise includes: an uncritical adoption of a descriptive nosology of mental illness; the gradual broadening of what constitutes mental distress; simplistic genetic and biological models of causation with attendant simplistic pharmacological treatments.
This has had a number of consequences. The gradual broadening of the definition of mental disorders and the lowering of thresholds for diagnostic categories has seen hitherto unpathologised human experience pathologised (Atrens, 2011). This has brought about a fundamental change in expectations of what life should bring and in fundamental notions of happiness, suffering and what it means to be human. This situation is nicely satirised by a slogan on the T shirt seen recently: “I used to care but I take a pill for that now.’ Not only is there change in the expectations of what constitutes suffering and the human experience, there is another more insidious effect. If the cause of our problems resides in our biology, our neurones and our genetics, then it is, at its core, a problem of the individual. This splitting of the individual from their society and context is analogous to the focus on surface symptoms discussed earlier. The surface symptoms of the deeper malise in our societies is the disorder of the individual. The cure then is to treat the individual rather than explore the part that society, culture and context plays and therefore need for social reform.
There is little doubt that the suffering and disability (and indeed mortality) caused by severe depression needs to be alleviated wherever possible and in all cultures. It is however less clear that lesser forms of unhappiness, dissatisfaction or distress require a medical diagnosis and pharmacological treatments. This is even more the case where cultural and other differences are poorly understood. Collectivist societies (such as those commonly found in Asia and Africa) will differ markedly in their expression of sadness and depression and will often require a different approach to individualist societies. Nevertheless, it could be argued that underlying issues of separation and loss are common across cultures (Leader, 2008) but the culture then shapes the expression of the surface symptoms.
Descriptive nosologies, simplistic biological models of causation and the attendant emphasis on pharmalogical treatments may not be helping to alleviate mental distress but may be making it worse (Atrens, 2011).
As Kirmayer states:
Health and illness reside not just in the individual but also in networks of relationships that are culturally defined. The creation of discrete disorders involves bracketing off social context. A comprehensive psychiatric nosology must reserve a place for human predicaments. Rather than focusing exclusively on problems presumed to be intrinsic to the person, or even to the central nervous system, we need to continue to develop and refine a typology of the range of human predicaments (Kirmayer, 2005:195).
We live in a time in which claims proliferate about a multitude of issues regarding social reality and people’s lives. Because some of these issues are understood as adversely affecting a significant part of the population, they create a collective discourse and demands for action. When important societal groups (e.g. politicians, social change groups, the news media and numerous citizens) recognize these claims as legitimate and valid, they become social problems. As such, from a social constructionist perspective, the emergence and recognition of social problems are based on both the empirical evidence of their existence and impact as well as on the perceptions of their implications and need to be solved [1].
As Best [2] mentioned, social progress paradoxically creates social problems for different reasons. On the one hand, it generates a general expectation of perfectibility, which fosters a growing intolerance towards social difficulties and shortcomings. On the other hand, as the biggest challenges of humanity are within our reach (e.g. increased life expectancy, control of diseases), those that once were considered small now seem bigger and more serious (e.g. quality of life, lifelong learning). Moreover, the growing exigence of societies, together with the multiplication of relationships and communication networks, lowers the tolerance threshold of the population. Finally, because social progress improves life expectancy and standards of living, it fosters fears of loss as well as inflates perceived risks and defensive postures [2].
At given times and in relation to certain phenomena, a discrepancy exists not only between social perceptions and the available data on the issues but also among the perceptions of different social groups. For instance, policymakers might be attentive to a certain subject based on their knowledge, and this view might not be shared or valued in the same way by society as a whole. We believe that child trafficking meets this standard worldwide and, specifically, in Portugal.
Regarding Portugal, the following reasons (some general, others country-specific) are put forward to contend that child trafficking is not perceived as a social problem as previously defined: (i) it is relatively unknown among most of the population, (ii) it involves children as victims, (iii) it involves children who are often from disadvantaged backgrounds and/or foreign origins, (iv) it is a police matter and (v) it involves a small group of the population.
Let us discuss each aspect briefly.
Research on the public awareness of trafficking in human beings (THB) is scarce. However, as Sharapov [3] asserts, it is a distant subject for most of the population. Various European countries (e.g. Scotland, Belgium, Czech Republic, Finland and Romania) generally view it as having little relevance to their daily lives. This sense of detachment is not so much due to the lack of information on the subject, as to how this information is framed (i.e. primarily as a legal and criminal issue on the margins of normal everyday life) [4]. Portuguese reports on people’s awareness of human trafficking are in line with this general tendency. In a study conducted by Sani, Nunes and Caridade [5], the authors used a convenience sample to find that most respondents showed a poor understanding of THB and recognized the lack of information concerning this phenomenon in Portugal. Most participants viewed THB as the exploitation of immigrants and socially disadvantaged people in search of work. More than half (58.5%) had not heard any information about it over the last 2 years. Among those who had heard information, social media stood out as the privileged method of communication regarding this phenomenon.
Although the relationships among public opinion, the media and public policies are complex and controversial, the available evidence shows that political and media discourses on human trafficking significantly influence public opinion, and (conversely) public opinion affects media and policymaking [3, 4].
With regard to Portugal, the role the media plays in framing the public discourse on human trafficking has received specific attention. Research examining the written press between 2001 and 2004 [6] substantiated the media representation of human trafficking as infrequent, superficial and stereotyped. News on this topic was poor, barely visible and associated with criminal activity and deviant people from other countries and minorities. In a second study focusing on the news published in a tabloid newspaper in 2008, despite the increased visibility of the phenomenon, Couto, Machado, Martins, and Gonçalves [7] identified similar trends in the coverage: it was framed as a criminal problem, essentially involving deviant groups, and is generally related to illegal immigration. This representation facilitates the adoption of a passive and moralizing attitude of devaluation regarding the phenomena and depreciates the people involved. As has been indicated with regard to child trafficking in other European countries [8], a cross-border problem that affects almost only asylum seekers and immigrants or particular cases is unlikely to affect the general community. This assumption leads to the underestimation of the risks of child trafficking and to the weakening of the social relevance of prevention and protection strategies.
Research on human trafficking and, in particular, child trafficking, is critical. Producing and disseminating knowledge helps sensitize people in general. Moreover, it substantiates more effective processes of identification, prevention, and protection, as well as helps support victims and prosecute criminals [9].
As Clemente [10] stated, the Portuguese investigation concerning human trafficking has developed more slowly and inconsistently than that in other countries (the first publications date back to 2000) [11]. Driven by the increasing attention of the national authorities to the phenomenon, within the framework of international agreements, the academic research made its greatest development beginning in 2007 onwards. As in other European countries, where the empirical literature on child trafficking is scarce [12], the scientific approach to this problem in Portugal since the beginning consisted primarily of secondary research articles on the sexual exploitation of women based on official statistics. For various reasons, this research appears to report only one-third of the referrals per year [11]. Reports on the prevalence of the phenomenon to monitor and evaluate prevention, protection and rehabilitation programmes have been more systematic and frequent than that regarding trafficked victims, the circumstances of their victimization or the trafficking process, its rationale, dynamics and other people involved. Nevertheless, the study of the social representations of human trafficking, in particular those of specific groups including practitioners, has been a significant part of the investigation undertaken in Portugal in this field, yet with sampling limitations. In these types of scholarly papers, child trafficking is often referred to in connection with the characterization of the age of the victims. However, research specifically focusing on child trafficking is scarcer. In this regard, the RCAAP1 portal is a privileged source of access to Portuguese academic production. From 2006 to 2016, 12 papers on human trafficking were registered from Portuguese repositories [13]. However, only eight titles include the keywords “child trafficking” as of 2019: a working paper and seven master’s theses.
In short, the still incipient scientific production and media coverage focusing on criminal cases reinforce the lack of information associated with public opinion and, to that extent, create a distance with regard to this phenomenon.
As has been elaborated elsewhere [14], a widespread social consensus exists regarding child welfare matters. Although these matters are frequently used by politicians and the media as rhetorical devices and emotional assets [15], this discursive intensity is not always consistently translated into policies or practices. On the other hand, this unanimity, even if it arouses ethical shock and emotional indignation, does not induce social pressure or collectively persistent action in relation to children’s issues.
If children whose parents fail to protect their best interest are socially vulnerable, relatively invisible and voiceless, child victims are viewed even as more helpless. This issue is especially relevant because, as Gearon [16] argued, child trafficking narratives are pervaded by the notion of victimhood, conveying representations of helplessness, vulnerability and lack of agency. This convergent negativity (those of children and victims) [14] easily evokes empathic social responses but does not necessarily make the victim a priority.
Furthermore, the formal requirements for eligibility to the protection system, which are understood in light of the social representations of victimhood, create a paradox. On the one hand, the confirmation of the status of a victim is a mandatory requirement for accessing assistance. On the other hand, when victims do not comply with the social expectations of powerlessness and passivity, the question of their responsibility often arises regarding the situation in which they find themselves. Although they are children, if their participation in trafficking is understood as active and voluntary, then their status as child victims gives way to that of the criminal children: those who should be blamed, convicted and punished, rather than protected [16]. Although the victim is viewed as an object of behaviors and situations beyond their control or ability to self-determine, the circumstances of children allegedly involved in criminal activities are dimmed, and their behaviors and condition tend to be abstracted and decontextualized [14]. In short, whether they match the stereotype of a victim or not, children who are victims of trafficking have no voice or do not deserve to be heard. Either case applies to what Clemente [10] called “the deafening silence of trafficked people” (p. 663).
Public opinion is an indication of societal attitudes towards certain phenomena. With regard to human trafficking, if public opinion expresses the culture of society, then it might reflect the social discrimination of women and children as well as a social tolerance towards violence and exploitation [8], which would enable an understanding of the symbolic construction of this phenomenon. On the other hand, because public opinion influences policymaking, if well-formed and informed, it can also help reduce the structural factors that underlie trafficking [3].
Victims of child trafficking and exploitation often come from abroad and the margins of society. According to the final report of the study of groups at high risk for human trafficking in the European Union [8], the risk of child trafficking is significantly higher for children with disabilities or who engage in risky behaviors, from dysfunctional, disadvantaged and/or social excluded families, communities or neighborhoods in areas of conflict or crisis. Generally, they might be viewed as problem children. This label reinforces their inherent negativity [14], social invisibility and exclusion [17]; they are the children of others. As such, instead of a positive approach to the phenomenon based on a human rights perspective, they might evoke attitudes of socially organized denial [18], rejection, disinterest or criticism.
Thus, the genesis of trafficking is essentially sociopolitical, culminating in a legal phenomenon. Experts [16] have criticized the criminal perspective that has dominated child trafficking “as immigration-led and prosecution-focused” (p. 497) and as a threat to human and state security [19]. This simplistic view overshadows the broader dimension of the phenomenon, which as Gearon [16] asserted is not limited to international movements (legal or illegal) or migrant children. In fact, as Palmer [20] claimed, child trafficking is a complex, multidimensional and dynamic process; it is a shape-shifting phenomenon characterized by different patterns across countries. It involves national citizens, migrants (i.e. other EU citizens), immigrants from third world countries, children with their families and unaccompanied asylum-seeking children. It might begin long before it is detected, with or without family involvement, for a variety of purposes, and as part of more or less sophisticated networks. However, according to Crawley’s research in the UK [21], even the intervention of health and welfare professionals is permeated by the logic of immigration control [22], where the concern with the protection of the territory overrides that of children. In the same vein, Clemente [10] characterized the Portuguese support system for victims of trafficking as victim-oriented in theory but as focused on internal security objectives in practice. This feature corresponds to the current trend of protection systems, which are increasingly focused on control rather than care [23].
This partial viewpoint hinders interventions focused on the rights and needs of children and their protection [16]. As experts have argued, the majority of children who eventually become victims of exploitation and/or trafficking have previously been deprived of their rights [24]. In this sense, they contend that the criminal matrix of the definition of child trafficking frequently overshadows its true nature and origin: child trafficking is primarily a matter of rights and protection, and, as such, it reveals the shortcomings of protection and welfare systems [24, 25]. Therefore, the priority or almost exclusive emphasis on legal and procedural aspects and the subsequent production of penal legislation, national action plans and support measures for victims at the expense of action towards the structural conditions that underlie trafficking are criticized. Enforcing the United Nations Convention on the Rights of the Child is the most effective way to prevent the exploitation and trafficking of children and youth as well as safeguard their rights and respond to their needs.
Data available on human trafficking and, specifically, child trafficking provide only an approximation of the reality. In addition to being a hidden phenomenon [19], illegal and clandestine [26], concepts of trafficking differ across countries as various reports have highlighted. Because trafficking is usually closely connected to crimes such as illegal immigration, aid to illegal immigration, forgery and criminal association, the distinction among these phenomena is not clear [24]. Consequently, defining these terms involves a wide range of legislation [27] and a variety of mechanisms to identify phenomena. Furthermore, even at the national level, experts have identified many discrepancies in the data reported across different sources, as in the case of Portugal [11]. These findings support the idea of numerous unreported cases (the dark figures of trafficking). Therefore the low numbers of child trafficking represent the tip of the iceberg [19, 28].
Additionally, the eligibility criteria for acquiring the status of trafficking victim and receiving assistance significantly modify the available data on this phenomenon.
Especially with regard to child trafficking, the criterion used to set the age of the victim, whether at the time of referral or at the beginning of trafficking, remains a sensitive issue. Neves and Pedra [11] drew attention to the fact that many victims have been subjected to exploitation for several years, even though their identification in the system occurred during adulthood. This consideration provides a different basis for calculating the number of child trafficking victims as well as targets and adjusts the interventions made available to people in these conditions within the legal and protection systems. In fact, according to Catch and Sustain [29], trafficked children (especially those with a long history of being exploited) tend to be treated by the legal and the protection systems according to their immigration status or the crimes in which they might have been involved, rather than the crimes that they have suffered along the way. This procedure is contrary to Directive 2011/36/EU, which recommends the development of comprehensive child-sensitive protection systems and the mobilization of recovery processes as soon as children are identified as victims of trafficking.
Another eligibility criterion concerns the distinction between the child trafficking statistics and the risk of child trafficking (i.e. trafficked children and those vulnerable to exploitation and trafficking). In line with this view, researchers have claimed that the groups of children targeted to prevent and combat trafficking (currently unaccompanied asylum-seeking children, child victims of trafficking and child victims of sexual exploitation) should be revised to include accompanied child migrants, undocumented children and homeless children [24]. According to scholars and practitioners, within the logic of prevention and effective interventions, authorities should expand their focus to include children at risk of being trafficked, favoring more comprehensive interventions in addition to focused responses. This option would imply overcoming a segmented view of the intervention, based on children’s status, to adopt an ecological, systemic, multidimensional and dynamic perspective of children’s vulnerability [24].
For the reasons outlined above and given the absence of reliable and disaggregated data [29], comparisons of national data are far from linear [24].
Nevertheless, despite the scarcity of consistent data, according to the United Nations Office on Drugs and Crime [30], human trafficking could likely reach up to 4 million victims. Most are female (72%) and trafficked for sexual exploitation, although significant regional variations are observed [30]. The Organization for Security and Cooperation in Europe (OSCE) estimates that children account for over 30% of the world’s human trafficking [31]. According to the 2018 Global Report on Trafficking in Persons, in 2016, 23% of these children were girls, which is more than double than that identified in 2004 [32]. As the International Labour Organization (ILO) specified, 26% of the 20.9 million people who were victims of forced labour between 2002 and 2011 were children [33].
As noted in the report of Catch and Sustain [29], child trafficking occurs in all European countries, without a clear division among countries of origin, destination or transit. In the European Union (EU) in 2015–2016, approximately 56% of the victims identified were from non-EU countries. The majority were female (68%), and the dominant forms of exploitation were for sexual and labour purposes (56 and 26%, respectively); relevant geographical variations were also observed. Children accounted for 23% of the victims detected and for 23% of all victims of trafficking for sexual exploitation [34]. However, considering the cases reported to/by NGOs and official agencies, experts in this field estimate that the dark figures might be five times higher than official statistics report [35].
The “official data on human trafficking (TSH) in Portugal indicate a residual phenomenon, with approximately 80 cases reported each year on average, with a total of 250 victims in 2009, 2010 and 2011. Of these cases, less than 25% were confirmed (58)” ([11], p. 23). Regarding child trafficking, prior to 2010, national data were subsumed under the general data of human trafficking. Nonetheless, since national data on human trafficking began being collected, reports indicate that few children were victims of this type of crime (e.g. in 2008, the minimum age of the reported cases was 1 year old; in 2009, the minimum age was 12 years old). In accordance with the Report of the Group of Experts on Action against Trafficking in Human Beings [35], between 2008 and 2011, 17 children met this condition, the majority of whom were female (median age = 14 years old). Sexual exploitation, labour exploitation (n = 3) and attempted adoption (n = 3) were the identified purposes of trafficking.
Table 1 details the number of child trafficking referrals considering the total number of human trafficking referrals in Portugal from 2010 to 2017. Data, compiled from different sources, represent cases reported before investigation and substantiation. Absolute figures are relatively low, both in relation to human trafficking in general and to child trafficking specifically; however, notable variations have been found over time. The percentage of child trafficking referrals varied from 8.1% in 2010 to 31.2% in 2012.
According to Neves and Pedra [11], 82.4% of the trafficked children in Portugal are 15 years or older. In addition, those who began to be trafficked in childhood tend to be exploited for longer periods than those who start the process in adulthood. In fact, 44% of trafficked children have been exploited longer than 4 years. According to these authors, if the criterion used to set the age of the victim is the beginning of trafficking, then this number would be approximately 30% of all cases of trafficking.
As Clemente [10] asserted, the introduction of the issue of human trafficking in Portugal was prompted by the need to transpose the international directives issued by the United Nations and the European Commission into national law. When Portugal adopted the United Nations Convention against Transnational Organized Crime and the additional Protocol to Prevent, Suppress and Punish Human Trafficking (especially with regard to women and children) in 2004, all legislative changes that followed have given rise to the definition and development of specific policies and procedures. National Plans against Human Trafficking have played a decisive role in the adoption of an integrated intervention strategy, combining interventions at different levels and multiple actors.
In 2007, the Portuguese authorities developed the first National Plan against Human Trafficking (2007–2010) (I PNCTSH) [31], which had four strategic domains: (1) to understand the phenomenon and disseminate information; (2) to prevent, elucidate and train; (3) to protect, support and integrate; and (4) to conduct criminal investigation and prosecute traffickers [31]. With regard to children, (i) they are recognized as being among the most vulnerable populations to human trafficking (along with women), particularly those living in poverty; (ii) trafficking is considered as a violation of their right to be free and protected; and (iii) victims trafficked for reasons of sexual and/or labour exploitation require special assistance and protection. Considering children’s and youths’ vulnerability, the I PNCTSH considers the following specific areas of intervention: (i) to educate children by promoting creative debates and activities in schools about human rights, children’s rights and human trafficking and (ii) to support trafficked children by providing special measures to promote their rights and protection aiming at their global development.
This Plan led to the creation of the Observatory on Human Trafficking (OTSH) in 2008, which was established by Decree-law no. 229 on November 27, 2008. It is responsible for collecting, producing, processing and analyzing data on human trafficking, including child trafficking.
In 2009, two initiatives stood out in this domain [27]: (a) the certification of documents for foreign children attending Portuguese schools (Immigration and Borders Service [SEF] goes to school) and (b) the creation of the first temporary shelter for 6- to 18-year-old refugee children and (CACR). This centre is expected to provide specialized assistance to children and youth in the asylum process (i.e. legal, social and psychological support).
The second National Plan against Human Trafficking (2011–2013) (II PNCTSH) [42] defined the same areas of intervention as the I PNCTSH. Nonetheless, the special situation of children was not differentiated in this Plan, neither conceptually nor in terms of specific measures.
In 2013, Portugal joined (a) the “European Cross-Actors Exchange Platform for Trafficked Children on Methodology Building for Prevention and Sustainable Inclusion”, which aimed to develop an evidence-based intervention model targeting children who are vulnerable to trafficking and promote knowledge about criminal procedures concerning THB in the EU, and (b) the “Improving and Monitoring Protection Systems against Child Trafficking and Exploitation” (IMPACT) Project, which aimed to improve child protection and welfare policies to prevent and protect children, particularly those vulnerable to trafficking and exploitation [24].
The third National Plan (2014–2017) (III PNCTSH) [43] had five strategic areas: (1) prevent, inform, understand and investigate; (2) educate, train and capacitate; (3) protect, intervene and empower; (4) investigate criminality; and (5) cooperate. Regarding children, it included actions such as the development of education for children, adolescents and adults, as well as the development of protocols for the prevention, detection and protection of child victims of trafficking. The implementation of standardized care protocols for the identification, referral and intervention of victims of trafficking, among others, and for child victims of trafficking, in particular, by the National Health Service (NHS), was particularly important.
The fourth National Plan (2018–2021) (IV PNCTSH) [40] defined three strategic objectives: (i) to develop knowledge and raise awareness on THB, (ii) to improve the quality of interventions for trafficking victims, and (iii) to strengthen the fight against organized crime networks. With regard to children, an emphasis was put on the development of guidelines and protocols for intervening with children across different services as well as on reinforcing networking within different services, including the NHS and the National Network for the Support and Protection of Trafficking Victims.
As the four national plans against human trafficking show, children are included as victims of trafficking and are occasionally specifically targeted. However, none of the plans address the specificity of child trafficking.
The Portuguese Penal Code (Law no. 59/2007) defines child trafficking as enticing, transporting, harboring or housing a child or transferring, offering or accepting the child for the purpose of sexual exploitation, labour exploitation, begging, slavery, the removal of organs or adoption, among other criminal activities (Article 160) [24]. In fact, research shows that, most of the time, children are trafficked for labour exploitation (e.g. domestic servitude, agricultural labour, car washing, factory labour), sexual exploitation (e.g. prostitution, pornography and forced marriage), illegal adoption and criminal exploitation (e.g. cannabis cultivation, robbery, begging) [44].
As detailed, this definition entails the intentional action of the offender to exploit a vulnerable person. In the case of children, the critical elements of the definition of human trafficking do not apply [34]: the means (coercion, fraud or deception, abuse of power or of a position of vulnerability) and the victim’s consent. However, the issue of consent is not exempted from controversy because of the debate concerning the age of consent [19], an issue related to the criterion used to set the age of the victim, as previously discussed.
Associated with age and the corresponding development level are, among others, the issues of: a) capacity to consent to their involvement in certain activities or relationships, especially those that are deviant or criminal; b) the responsibility inherent to this (in)capacity; c) the different developmental needs that children might exhibit depending on their age; d) their plasticity and vulnerability to the external world and the consequent and serious implications of their involvement in harmful relationships and activities; e) longer periods of exploitation than those of trafficked adults; and f) more support needed, given the higher likelihood to develop trauma.
As Greenbaum, Yun and Todres ([45], p. 161) argued, “Given the often multiple vulnerabilities leading to trafficking, the complex trauma experienced during (and sometimes before) the trafficking period, and the myriad adverse effects of exploitation, the needs of the child victim may be extensive and multi-faceted”. In fact, the exploitation and trafficking of children are often associated with adverse experiences of abuse, neglect and other forms of violence that harm their physical and mental health. Empirical evidence indicates that between approximately one-fourth and one-half of all trafficked children are victims of physical or sexual abuse [26, 46]. These forms of maltreatment are associated with psychological disorders such as posttraumatic stress disorder, substance abuse, self-harming behaviour, suicide ideation/attempts, depression and various affective disorders and behavioral difficulties [26].
Thus, interventions must be multidimensional and address different groups and levels of victims’ needs, not only those that result from trafficking but also those that are at its origin. Child trafficking shares with the other forms of human trafficking multiple, complex and systemic causes, especially specific structural features of the life contexts. Family dynamics are especially relevant for children: dysfunctional families, family abuse/neglect and violence are key variables [24]. Social and political factors such as poverty, social and economic exclusion, limited opportunities to pursue education, scarce and precarious employment, gender-based violence and social inequalities between countries and regions are also important enabling factors. Likewise, more distal elements, such as exploitative relationships, organized crime, illegal migration, corruption and armed conflict play key roles in this phenomenon [43].
Child protection systems are the fundamental framework for providing assistance to child victims or those vulnerable to trafficking [20]. In Portugal, a victim of child trafficking is considered as at risk, falling under Protection Law no. 23/2017 and subject to the same assistance as any national child, regardless of nationality or type of risk. Any person identified as a victim of child trafficking should be reported to a public prosecutor who activates a protection measure.
Based on a review of 20 multinational projects funded by the European Commission on child victims of trafficking, including Portugal, Palmer [20] concluded that “trafficked children across Europe are not receiving the state care and protection that they, as children, are entitled to” (p. 7). This study showed the structural flaws in child protection services at three levels: victim detection, support and service coordination. In short, services fail to adjust their level and type of support to the specific needs of these children and youth, either initially, when detecting and referring cases, or in the provision of appropriate assistance. If in some cases a dominant concern exists with the child’s immigration status that overrides the response to their needs, in others the response to these children’s needs is subsumed within the generic provision available to all children at risk. Solutions range from those that compromise children’s freedom to those that do not guarantee their protection or meet their needs, providing overly bureaucratic services. In these circumstances, child protection systems are more harmful than protective and can even facilitate the exploitation and trafficking of these children [47], actively compromising their rights.
Additionally, combating and preventing child trafficking requires a systemic approach in which communication among the health, education, welfare and justice systems is critical [20]. Regarding Portugal, international reports have mentioned the lack of standardized procedures and referral mechanisms [24].
Despite the recognition of the inclusive nature of health, education, welfare and justice sectoral policies, the status of children continues to determine the type of services and rights to which they have access. In accordance with experts, legislation is inclusive, but procedures are not, and the strategic planning and coordination of actions have flaws. However, others argue for the need for comprehensive laws to integrate the different policy domains, procedures and services [24].
Despite the centrality of the child protection system regarding child victims or those at risk of being trafficked, referrals in Portugal are made through two types of entities: criminal agencies (OPC) and NGOs and the Authority for Working Conditions (ACT). Regarding the OPC, the Immigration and Borders Service (SEF) is responsible for detecting unaccompanied asylum-seeking children and for referring them to the Portuguese Refugee Council (CPR) [24] because it is assumed that they are vulnerable to trafficking [19]. The identification of a case triggers its referral for criminal investigation and court proceedings [24]. After referral, the cases proceed through an assessment process during which they can be classified as confirmed, not confirmed or under investigation. This assessment is complex. Usually a panoply of related offenses exist whose legal distinction is challenging, such as aid to illegal immigration, recruitment of illegal labour, kidnapping, slavery, sham marriages/marriages of convenience, counterfeit and false documents, criminal association, domestic violence or violation [36] and smuggling [12]. This procedure confirms, once again, the police and security framing of an essentially sociopolitical phenomenon.
A common reference in the literature on this topic is the need for the specific training of practitioners who, at different levels, work with and for children, especially those with child victims or children at risk of being trafficked to identify and provide the necessary and appropriate assistance. Immigration officers and other police forces are the frontline staff in most of the national referral mechanisms in Europe. Experts contend that the adequate training of these professionals is critical to ensure that victims are correctly identified and receive appropriate support [19], including cooperation with relevant agencies. In addition to these officials [24], from a comprehensive perspective, teachers [32] and healthcare professionals [48] would benefit from training to identify the signs of exploitation and effectively intervene.
Following Pinto et al. [13], child trafficking is not merely a “distant history” taught in school, but it is also geographically and sociologically distant, as portrayed by the media, and a distant interest for research. Law, politics/public administration, research and education are key instruments for fostering the social appreciation of this problem.
The law is a fundamental constituent of society; it is based on justice and is a driver of awareness. Retrospectively, it reflects social and cultural historicity. Looking forward, however, the law sets the standards for behaviour within a culture and promotes psychosocial adjustment. In this sense, legal changes, under international agreements, build an ethical mindset based on human rights that is progressively shared by populations. Education, training and social pedagogy for the community, their organizations and the media must be an ongoing and relentless social task to create a relational culture that is inclusive, rights-based and culturally sensitive.
Child trafficking results from the failure to protect children and safeguard their rights. It is thus a failure towards all children. Protection should be a systemic and ecological feature of the contexts of children’s lives. Additionally, the response to the various needs of each and every child should be the primary concern of children’s services and programmes. For this purpose, instead of a policymaking approach based on a patchwork of scattered and partial measures, we need effective and integrated public policies, particularly child and family policies, informed by rigorous and systematic research. Moreover, the proliferation of plans with goals insufficiently developed and evaluated should give way to a cohesive national anti-child trafficking approach.
The identification of the child victims of trafficking is a critical condition for the provision of the appropriate support. The gaps observed in most EU countries, including Portugal [20], led the experts to recommend the revision of the criteria and thresholds to be eligible for the child protection system. With respect to Portugal, the Protection Law, based on the distinction between risk and danger, excludes from the threshold for referral children in low-risk situations. In these conditions, the probability of not detecting potential victims of trafficking is not negligible [20]. Therefore, within a broader perspective of the concept of child protection, we endorse the revision of these thresholds and the consideration of different levels of intervention according to the level of risk identified.
Another crucial aspect of the intervention is the first service with which the child victims come into contact for the first time because it determines the subsequent provision made available to them. Regarding children at risk, the interaction among the services involved (e.g. health, education, Immigration and Borders Service, criminal justice, labour), should occur, in any situation, under the coordination of the Child Protection System, regardless of the specific status of the child (e.g. immigration status).
These changes will lead to the cultural shift [16] necessary to assign importance to the big and small issues of our time, regardless of the condition of the people affected, their age or number, so that a problem that affects other people is, by definition, a social problem.
This study had the financial support of Research Centre on Child Studies (CIEC), by the Strategic Project UID/CED/00317/2013, through the National Funds through the Foundation for Science and Technology (FCT) and co-financed by European Regional Development Funds (FEDER) through the Competitiveness and Internationalization Operational Program (POCI) with the reference POCI-01-0145-FEDER-007562.
The authors declare no conflict of interest.
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