Child trafficking referrals in Portugal (2010–2017).
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\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:"6019",leadTitle:null,fullTitle:"Nematology - Concepts, Diagnosis and Control",title:"Nematology",subtitle:"Concepts, Diagnosis and Control",reviewType:"peer-reviewed",abstract:"Nematology being an established discipline covers a wide range of area ranging from basic aspect to the advanced and applied aspects involving recent advances in molecular techniques. 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The scope of this book is not to provide a comprehensive overview of methods and applications but to provide a 'snapshot' of current approaches using well established and newly emerging techniques. Taken together, these chapters provide a broad sense of how the limits of what is achievable with neuroimaging methods are being stretched.",isbn:null,printIsbn:"978-953-51-0097-3",pdfIsbn:"978-953-51-6829-4",doi:"10.5772/908",price:139,priceEur:155,priceUsd:179,slug:"neuroimaging-methods",numberOfPages:374,isOpenForSubmission:!1,hash:"e4321a4d45346699f9ada729290e156a",bookSignature:"Peter Bright",publishedDate:"February 17th 2012",coverURL:"https://cdn.intechopen.com/books/images_new/389.jpg",keywords:null,numberOfDownloads:70660,numberOfWosCitations:50,numberOfCrossrefCitations:41,numberOfDimensionsCitations:97,numberOfTotalCitations:188,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 22nd 2010",dateEndSecondStepPublish:"December 20th 2010",dateEndThirdStepPublish:"April 26th 2011",dateEndFourthStepPublish:"May 26th 2011",dateEndFifthStepPublish:"July 25th 2011",remainingDaysToSecondStep:"10 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"49019",title:"Prof.",name:"Peter",middleName:null,surname:"Bright",slug:"peter-bright",fullName:"Peter Bright",profilePictureURL:"https://mts.intechopen.com/storage/users/49019/images/2330_n.jpg",biography:"Dr. Peter Bright was educated at the Universities of Surrey (BSc, 1991), Reading (MSc, 1993) and Cambridge (PhD, 1999). His research in the fields of memory and conceptual knowledge are well known. He has held research positions at the MRC Cognition and Brain Sciences Unit in Cambridge (1994-1995), King’s College London (1998-2001), and the University of Cambridge (2001-2005). He currently holds the position of Reader at Anglia Ruskin University in Cambridge (since 2005).",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"3",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1008",title:"Radiology Diagnosis",slug:"radiology-diagnosis"}],chapters:[{id:"28784",title:"Functional Neuroimaging: A Historical Perspective",slug:"the-origins-of-functional-neuroimaging-techniques",totalDownloads:2350,totalCrossrefCites:1,authors:[{id:"60542",title:"Prof.",name:"Alberto",surname:"Priori",slug:"alberto-priori",fullName:"Alberto Priori"}]},{id:"28785",title:"fMRI for the Assessment of Functional Connectivity",slug:"fmri-for-the-assessment-of-functional-connectivity",totalDownloads:2897,totalCrossrefCites:2,authors:[{id:"54145",title:"Mr.",name:"Till",surname:"Nierhaus",slug:"till-nierhaus",fullName:"Till Nierhaus"},{id:"61280",title:"Dr.",name:"Daniel",surname:"Margulies",slug:"daniel-margulies",fullName:"Daniel Margulies"},{id:"61281",title:"MSc.",name:"Xiangyu",surname:"Long",slug:"xiangyu-long",fullName:"Xiangyu Long"},{id:"61282",title:"Prof.",name:"Arno",surname:"Villringer",slug:"arno-villringer",fullName:"Arno Villringer"}]},{id:"28786",title:"Functional Near-Infrared Spectroscopy (fNIRS): Principles and Neuroscientific Applications",slug:"functional-near-infrared-spectroscopy-fnirs-brain-studies-and-others-clinical-uses",totalDownloads:3698,totalCrossrefCites:23,authors:[{id:"50810",title:"Prof.",name:"Jose",surname:"Leon-Carrion",slug:"jose-leon-carrion",fullName:"Jose Leon-Carrion"},{id:"98537",title:"Mr.",name:"Umberto",surname:"León-Domínguez",slug:"umberto-leon-dominguez",fullName:"Umberto León-Domínguez"}]},{id:"28787",title:"Measurement of Brain Function Using Near-Infrared Spectroscopy 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Pitfalls",slug:"pediatric-cranial-ultrasound-techniques-variants-and-pitfalls",totalDownloads:29788,totalCrossrefCites:2,authors:[{id:"59028",title:"Prof.",name:"Lisa",surname:"Lowe",slug:"lisa-lowe",fullName:"Lisa Lowe"},{id:"61485",title:"Mr.",name:"Zachary",surname:"Bailey",slug:"zachary-bailey",fullName:"Zachary Bailey"},{id:"61486",title:"Dr.",name:"Kristen",surname:"Fickenscher",slug:"kristen-fickenscher",fullName:"Kristen Fickenscher"},{id:"61487",title:"Dr.",name:"Amy",surname:"Dahl",slug:"amy-dahl",fullName:"Amy Dahl"},{id:"61488",title:"Dr.",name:"Megan",surname:"Saettele",slug:"megan-saettele",fullName:"Megan Saettele"}]},{id:"28795",title:"Impact of White Matter Damage After Stroke",slug:"impact-of-white-matter-damage-after-stroke",totalDownloads:3324,totalCrossrefCites:1,authors:[{id:"51073",title:"Prof.",name:"Rüdiger J.",surname:"Seitz",slug:"rudiger-j.-seitz",fullName:"Rüdiger J. Seitz"},{id:"59697",title:"Dr.",name:"Robert",surname:"Lindenberg",slug:"robert-lindenberg",fullName:"Robert Lindenberg"}]},{id:"28796",title:"Tissue Fate Prediction from Regional Imaging Features in Acute Ischemic Stroke",slug:"tissue-fate-prediction-from-regional-imaging-features-in-acute-ischemic-stroke",totalDownloads:1350,totalCrossrefCites:0,authors:[{id:"49676",title:"Dr.",name:"David",surname:"Liebeskind",slug:"david-liebeskind",fullName:"David Liebeskind"},{id:"61090",title:"Dr",name:"Fabien",surname:"Scalzo",slug:"fabien-scalzo",fullName:"Fabien Scalzo"},{id:"61091",title:"Prof.",name:"Xiao",surname:"Hu",slug:"xiao-hu",fullName:"Xiao Hu"}]},{id:"28797",title:"MRI Assessment of Post-Ischemic Neuroinflammation in Stroke: Experimental and Clinical Studies",slug:"mri-assessment-of-post-ischemic-neuroinflammation-in-stroke-experimental-and-clinical-studies",totalDownloads:1797,totalCrossrefCites:1,authors:[{id:"62233",title:"Prof.",name:"Norbert",surname:"Nighoghossian",slug:"norbert-nighoghossian",fullName:"Norbert Nighoghossian"},{id:"96814",title:"MSc.",name:"Marilena",surname:"Marinescu",slug:"marilena-marinescu",fullName:"Marilena Marinescu"},{id:"96817",title:"Dr.",name:"Fabien",surname:"Chauveau",slug:"fabien-chauveau",fullName:"Fabien Chauveau"},{id:"96818",title:"Dr.",name:"Tae-Hee",surname:"Cho",slug:"tae-hee-cho",fullName:"Tae-Hee Cho"},{id:"96819",title:"Prof.",name:"Yves",surname:"Berthezène",slug:"yves-berthezene",fullName:"Yves Berthezène"},{id:"96821",title:"Dr.",name:"Marlène",surname:"Wiart",slug:"marlene-wiart",fullName:"Marlène Wiart"}]},{id:"28798",title:"Intracerebral Hemorrhage: Influence of Topography of Bleeding on Clinical Spectrum and Early Outcome",slug:"intracerebral-hemorrhage-influence-of-topography-of-bleeding-on-clinical-spectrum-and-early-outcome",totalDownloads:2011,totalCrossrefCites:0,authors:[{id:"49979",title:"Prof.",name:"Adrià",surname:"Arboix",slug:"adria-arboix",fullName:"Adrià Arboix"},{id:"59341",title:"Dr.",name:"Elisenda",surname:"Grivé",slug:"elisenda-grive",fullName:"Elisenda Grivé"}]},{id:"28799",title:"Genetic Risk Factors of Imaging Measures Associated with Late-Onset Alzheimer’s Disease",slug:"genetic-risk-factors-of-imaging-measures-associated-with-late-onset-alzheimer-s-disease",totalDownloads:1568,totalCrossrefCites:0,authors:[{id:"49220",title:"Prof.",name:"Christiane",surname:"Reitz",slug:"christiane-reitz",fullName:"Christiane Reitz"}]},{id:"28800",title:"Neuroimaging Findings in Dementia with Lewy Body: A Review",slug:"neuroimaging-findings-in-dementia-with-lewy-body-a-review-",totalDownloads:4762,totalCrossrefCites:0,authors:[{id:"56196",title:"Dr.",name:"Elisabetta",surname:"Farina",slug:"elisabetta-farina",fullName:"Elisabetta Farina"},{id:"61427",title:"Dr.",name:"Francesca",surname:"Baglio",slug:"francesca-baglio",fullName:"Francesca Baglio"},{id:"61428",title:"Dr.",name:"Maria Giulia",surname:"Preti",slug:"maria-giulia-preti",fullName:"Maria Giulia Preti"}]},{id:"28801",title:"Endoscopic Intracranial Imaging",slug:"endoscopic-intracranial-imaging",totalDownloads:1416,totalCrossrefCites:0,authors:[{id:"54034",title:"Dr.",name:"Oscar Humberto",surname:"Jimenez-Vazquez",slug:"oscar-humberto-jimenez-vazquez",fullName:"Oscar Humberto Jimenez-Vazquez"}]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"24375",firstName:"Sandra",lastName:"Bakic",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"sandra.b@intechopen.com",biography:"As a Commissioning Editor at InTech, I work closely with our collaborators in the selection of book topics for the yearly publishing plan and in preparing new book catalogues for each season. This requires extensive analysis of developing trends in scientific research in order to offer our readers relevant content. Creating the book catalogue is also based on keeping track of the most read, downloaded and highly cited chapters and books and relaunching similar topics. I am also responsible for consulting with our Editorial Advisory Board members on which book topics to add to our catalogue and sending possible book proposal topics to them for evaluation. Once the catalogue is complete, I contact leading researchers in their respective fields and ask them to become possible book editors for each book project. Once a book editor is appointed, I prepare all necessary information required for them to begin their work, as well as guide them through the editorship process. I also assist editors in inviting suitable authors to contribute to a specific book project and each year, I identify and invite exceptional editors to join InTech\\'s Editorial Advisory Board. I am responsible for developing and maintaining strong relationships with all collaborators to ensure an effective and efficient publishing process and support other departments in developing and maintaining such relationships."}},relatedBooks:[{type:"book",id:"1349",title:"Neuroimaging",subtitle:"Cognitive and Clinical Neuroscience",isOpenForSubmission:!1,hash:"c31b8cddd9fb1eff4ad0fc68854b9f54",slug:"neuroimaging-cognitive-and-clinical-neuroscience",bookSignature:"Peter Bright",coverURL:"https://cdn.intechopen.com/books/images_new/1349.jpg",editedByType:"Edited by",editors:[{id:"49019",title:"Prof.",name:"Peter",surname:"Bright",slug:"peter-bright",fullName:"Peter Bright"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1348",title:"Neuroimaging",subtitle:"Clinical Applications",isOpenForSubmission:!1,hash:"d079672454f0551916e81fc3685b846a",slug:"neuroimaging-clinical-applications",bookSignature:"Peter Bright",coverURL:"https://cdn.intechopen.com/books/images_new/1348.jpg",editedByType:"Edited by",editors:[{id:"49019",title:"Prof.",name:"Peter",surname:"Bright",slug:"peter-bright",fullName:"Peter Bright"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2266",title:"Infrared Spectroscopy",subtitle:"Life and Biomedical Sciences",isOpenForSubmission:!1,hash:"21ed0818c4fcaf44b2f1e201e68014e3",slug:"infrared-spectroscopy-life-and-biomedical-sciences",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/2266.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3390",title:"Electrodiagnosis in New Frontiers of Clinical Research",subtitle:null,isOpenForSubmission:!1,hash:"ccd9da6b93d7419d735f17e246f78fe2",slug:"electrodiagnosis-in-new-frontiers-of-clinical-research",bookSignature:"Hande Turker",coverURL:"https://cdn.intechopen.com/books/images_new/3390.jpg",editedByType:"Edited by",editors:[{id:"63331",title:"Prof.",name:"Hande",surname:"Turker",slug:"hande-turker",fullName:"Hande Turker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"772",title:"Positron Emission Tomography",subtitle:"Current Clinical and Research Aspects",isOpenForSubmission:!1,hash:"3812ec1b51ddc478d2a17167a0a576d3",slug:"positron-emission-tomography-current-clinical-and-research-aspects",bookSignature:"Chia-Hung Hsieh",coverURL:"https://cdn.intechopen.com/books/images_new/772.jpg",editedByType:"Edited by",editors:[{id:"126167",title:"Dr.",name:"Chia-Hung",surname:"Hsieh",slug:"chia-hung-hsieh",fullName:"Chia-Hung Hsieh"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"601",title:"Applied Aspects of Ultrasonography in Humans",subtitle:null,isOpenForSubmission:!1,hash:"1ae2d6052ed8fe2ea909f848105a45f7",slug:"applied-aspects-of-ultrasonography-in-humans",bookSignature:"Phil Ainslie",coverURL:"https://cdn.intechopen.com/books/images_new/601.jpg",editedByType:"Edited by",editors:[{id:"87381",title:"Prof.",name:"Philip",surname:"Ainslie",slug:"philip-ainslie",fullName:"Philip Ainslie"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"719",title:"Magnetic Resonance Spectroscopy",subtitle:null,isOpenForSubmission:!1,hash:"22a011ac72d696199044d841c9ac653b",slug:"magnetic-resonance-spectroscopy",bookSignature:"Donghyun Kim",coverURL:"https://cdn.intechopen.com/books/images_new/719.jpg",editedByType:"Edited by",editors:[{id:"85279",title:"Prof.",name:"Dong-Hyun",surname:"Kim",slug:"dong-hyun-kim",fullName:"Dong-Hyun Kim"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1481",title:"Radioisotopes",subtitle:"Applications in Bio-Medical Science",isOpenForSubmission:!1,hash:"408245da32dcf9a061e72275dd348b04",slug:"radioisotopes-applications-in-bio-medical-science",bookSignature:"Nirmal Singh",coverURL:"https://cdn.intechopen.com/books/images_new/1481.jpg",editedByType:"Edited by",editors:[{id:"48584",title:"Prof.",name:"Nirmal",surname:"Singh",slug:"nirmal-singh",fullName:"Nirmal Singh"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"163",title:"Ultrasound Imaging",subtitle:"Medical Applications",isOpenForSubmission:!1,hash:"aa3c22596ff5852287143fe66a643289",slug:"ultrasound-imaging-medical-applications",bookSignature:"Igor V. Minin and Oleg V. Minin",coverURL:"https://cdn.intechopen.com/books/images_new/163.jpg",editedByType:"Edited by",editors:[{id:"3712",title:"Prof.",name:"Oleg",surname:"Minin",slug:"oleg-minin",fullName:"Oleg Minin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"722",title:"Medical Imaging",subtitle:null,isOpenForSubmission:!1,hash:"3f49fd64e920334f3d51343640f6ee82",slug:"medical-imaging",bookSignature:"Okechukwu Felix Erondu",coverURL:"https://cdn.intechopen.com/books/images_new/722.jpg",editedByType:"Edited by",editors:[{id:"68312",title:"Prof.",name:"Okechukwu Felix",surname:"Erondu",slug:"okechukwu-felix-erondu",fullName:"Okechukwu Felix Erondu"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"62741",title:"Laparoscopic Endoscopic Cooperative Surgery: Current Status and Perspective",doi:"10.5772/intechopen.76983",slug:"laparoscopic-endoscopic-cooperative-surgery-current-status-and-perspective",body:'In the last decade, LECS has been performed all over the world in association with the invention of new operative techniques. Approaches are grouped into three major categories: laparoscopy-assisted endoscopic resection (LAER) in which resection is performed primarily by the endoscopic team under laparoscopic control; endoscope-assisted laparoscopic resection (EALR), where the laparoscopic teams perform the resection under endoscopic monitoring; and combined laparoscopic endoscopic resection (CLER), which is performed by the laparoscopic and the endoscopic teams. Description of these approaches and the details about CLER, especially LECS, nonexposed endoscopic wall-inversion surgery (NEWS), and a combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) are described in the following chapters. Various LECS techniques for GIST are recently established, and the application of this approach to early stage gastric cancer, which is difficult to resect with the ESD technique because of severe scars or ulcers, is described. LECS for other organs such as the duodenum or colorectum is also being attempted, but only with expert technique and specialist knowledge. LECS plus biopsy of sentinel lymph node for early gastric cancer is planned as a clinical trial.
Endoscopic resection is performed under laparoscopic control [1, 2, 3]. The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with laparoscopic assistance (Figure 1). Laparoscopic support has many advantages. First, when accidental complications such as perforation or massive bleeding occur during the endoscopic resection, laparoscopic surgeons can treat them immediately. Second, if the endoscopist has difficulty in resecting the tumor as a result of tumor location, the laparoscopic team can reposition the stomach with manipulation of the serosal side. Although laparoscopy-assisted endoscopic resection (LAER) requires a laparoscopic team and general anesthesia in addition to endoscopy, the advantage is greater safety; therefore, perforation risk is high in ESD because of massive tumor or duodenal location, LAER is preferred. Irino et al. reported LECS for duodenal tumors in three patients using LAER, demonstrating feasibility of this approach [4]. A unique point of their method is that the laparoscopist places seromuscular sutures to reinforce the thinned duodenal wall in order to prevent postoperative perforation or bleeding. Seromuscular reinforcement is performed for all cases. As such, these techniques can be grouped into the CLER. The perforation rate for duodenal-ESD is still much higher than for gastric-ESD, esophageal-ESD and colorectal-ESD [5, 6, 7, 8, 9, 10], so LAER or CLER are good alternatives.
The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with laparoscopic assistance.
In this category, laparoscopic surgeons mainly resect the tumor with endoscopic support as follows:
Endoscope-assisted wedge resection:
Under endoscopic monitoring, tumor location is confirmed, and blood vessels in the excision area around the tumor are prepared and if necessary the omentum is dissected, and the greater curvature of the stomach is mobilized by the laparoscopist. Several seromuscular sutures are placed around the lesion (Figure 2) and by pulling the stitches upward with laparoscopic forceps (Figure 3), the tumor is removed with laparoscopic linear stapling devices (Figures 4 and 5). According to laparoscopic surgeons, the staple line can be reinforced with a hand sewing suturing. The abovementioned technique is the most commonly combined surgery in the world, with more than 500 cases published [11, 12, 13, 14, 15, 16, 17]. Although the complication rate is 0–3% [11], the main problem can be excessive gastric resection by the laparoscopic linear stapling devices resulting in transformation or stenosis.
Endoscope-assisted laparoscopic transluminal (transgastric) surgery:
When the tumor is located along the posterior gastric wall, it is difficult for the laparoscopist to obtain a visual field, so a transgastric technique is often used. Under endoscopic monitoring, the laparoscopic surgeons make an incision in the anterior abdominal wall (Figures 6 and 7). The laparoscopic team directly confirms the lesion and removes it with an inverted wedge resection using laparoscopic stapling devices. The opened gastric wall is closed with laparoscopic staplers or hand sewing sutures.
Endoscope-assisted laparoscopic intraluminal (intragastric) surgery:
Indication for this technique is the same as for transgastric surgery approaching the posterior gastric wall. This technique was first reported by Ohashi et al. in [18], and a modified procedure was described by Dong et al. in [19]. All laparoscopic trocars are placed in the gastric cavity, penetrating both the abdominal and stomach walls. All trocars are fixed with balloon inflation of the stomach and the abdominal wall (Figures 8 and 9). The laparoscopist secures a visual field in the gastric lumen, and the tumor is removed by full-thickness resection or laparoscopic stapling devices. The trocar holes are closed with sutures or clips. Figures 1–9 are excerpted from Dimitrios’s report.
Several seromuscular sutures are placed around the lesion.
Surgeons pull the stitches upward with laparoscopic forceps.
The appropriate incision line is determined under endoscopic monitoring.
The tumor is removed with laparoscopic linear stapling devices.
The tumor is located along the posterior gastric wall.
The laparoscopic surgeons make an incision in the anterior abdominal wall.
It is difficult for laparoscopist to approach the tumor.
All laparoscopic trocars are placed in the gastric cavity, penetrating both the abdominal and stomach walls. All trocars are fixed with balloon inflation of the stomach and the abdominal wall. The Figures 1–9 are excerpted from Dimitrios’s report.
Although surgical local resection with laparotomy or laparoscopic surgery is performed for gastric submucosal tumor (SMT), it is difficult when tumors are small or have an intramural growth pattern. It is difficult to determine the appropriate incision line from the abdominal cavity side, so excessive gastric resection might result in transformation or stenosis. LECS is a newly developed technique, first reported by Hiki et al. in [20] for local resection of GIST. This procedure is further categorized into CLER, which is an approach that combines ESD and laparoscopic gastric resection to determine the incision line, to resect the tumor and to close the stomach wall. As LECS can minimize the resected region and preserve the function of the stomach after surgery, the procedure was added to the national insurance list in Japan in 2014, and subsequently rapidly diffused throughout the surgical community [21, 22, 23, 24]. Further applications of LECS then developed, so the first version is named classical LECS to distinguish it from subsequent modified LECS techniques. Classical LECS involves whole layer resection using laparoscopy and endoscopy. However, this technique may lead to contamination of and seeding of tumor cells into the peritoneal cavity, especially when the tumor is associated with an ulcer or epithelial lesion. To prevent peritoneal spread, modified LECS procedures now include inverted LECS with crown method [25], nonexposed endoscopic wall-inversion surgery (NEWS) [26] and a combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) [27].
Hiki et al. first reported classical LECS in 2006 [20] for local resection of GISTS in order to prevent excessive gastric resection followed by transformation, stenosis or stasis of food after surgery. In classical LECS, the incision line is determined by the endoscopist, and an endoscopic mucosal incision is made. Artificial perforation is performed by endoscopic forceps, and the seromuscular layer is dissected using laparoscopic and endoscopic forceps. The gastric wall defect is closed with laparoscopic stapling devices. Hiki described his LECS procedure in detail, and the following are excerpted from his writing.
“Tumor location was confirmed by intraluminal endoscopy.” (Figure 10)
“Blood vessels in the excision area around the tumor were prepared by laparoscopy.” (Figure 11)
“Endoscopic submucosal resection around the tumor and artificial perforation was performed.” (Figure 12)
“Operation device was inserted into the perforation hole, and seromuscular dissection began by laparoscopy.” (Figure 13)
“After resecting the tumor, the incision line was closed using laparoscopic stapling devices.” (Figures 14 and 15). Figures 10–15 are excerpted from Hiki’s report.
Tumor location was confirmed by intraluminal endoscopy.
Blood vessels in the excision area around the tumor were prepared by laparoscopy.
Endoscopic submucosal resection around the tumor and artificial perforation was performed.
Operation device was inserted into the perforation hole, and seromuscular dissection began by laparoscopy.
After resecting the tumor, the incision line was closed using laparoscopic stapling devices.
LECS technique can minimize the resected region. The Figures 10–15 are excerpted from Hiki’s report.
Although modified LECS techniques are used, the Hiki procedure is a basic concept that is employed throughout low invasive surgery for GISTs. By minimizing the resected region, LECS makes it possible to preserve the postoperative function of the stomach. Hiki maintains that removal of the tumor must be performed carefully with a specimen retrieval bag in order to prevent peritoneal and port-site dissemination of tumor.
In order to reduce the transmural communication during the operation, Nunobe et al. reported the crown method and inverted LECS [25]. By pulling up the incision line of the stomach with several stitches, abdominal cavity contamination is prevented. This technique was named crown method because pulled-up stomach wall looks like a crown (Figure 16). Using the traction of the stitch, the resected specimen is inverted to the intragastric cavity. This technique was named inverted LECS. Inverted LECS with crown method is not only useful for preventing tumor seeding into peritoneal cavity, but also for securing the visual field during the operation. The stitches are also used as a supporting tool when the incision line is closed with a laparoscopic stapling device (Figure 17). Although nonexposed endoscopic wall-inversion surgery (NEWS) [26] and a combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) [27] are described later as nonexposure procedures, inverted LECS with crown method has few limitations such as tumor size or tumor location in comparison with NEWS or CLEAN-NET. As such, it can make it possible to remove the tumor without the contamination of abdominal cavity. Figures 16 and 17 are excerpted from Nunobe’s report.
Surgeons pull up the incision line of the stomach with several stitches and pulled up stomach wall looks like a crown.
The stitches are also used as a supporting tool when the incision line is closed with a laparoscopic stapling device. The Figures 16 and 17 are excerpted from Nunobe’s report.
Classical LECS with crown method is an improved technique that reduces the risk of cancer cell dissemination. However, it can be difficult to completely prevent the contamination because of transmural communication during the procedure. Nonexposed endoscopic wall-inversion surgery (NEWS) was first reported by Goto et al. in 2011 with the goal of minimizing transmural communication during the operation [26]. They performed NEWS in an ex vivo porcine model and described the usefulness of this procedure. By inverting the tumor into the inside of the stomach without opening the gastric lumen, complete resection with nonexposure was achieved. The procedure is as follows:
“Markings around a model lesion are made with electrocautery knife.”
“A circumferential seromuscular incision is made from the outside.”
“The muscle layer is linearly sutured at approximately 5 mm intervals with the lesion inverted into the inside.”
“A circumferential mucosubmucosal incision is performed from inside with electrocautery knife guided by the endoscope.” These figures are excerpted from Goto’s report.
He reported NEWS for three lesions (one anterior wall, one lesser curve and one posterior wall of the gastric body) using porcine stomach, and complete resection was achieved for all lesions safely and without perforation or air leakage. Nonexposure techniques such as NEWS and CLEAN-NET are adequate for SMT without ulceration as well as SMT with ulceration or even early gastric cancer. In his report, the maximal specimen size was 50 mm; however, there is a limit of removable tumor size. Because the resected tumor is removed through the pharynx by the endoscope, solid tumor such as GIST over 30 mm is thought to be difficult to retrieve.
A combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) was first reported by Inoue et al. in [27]. This procedure also involves a nonexposure technique like NEWS, but with a difference. By preserving the continuity of the mucosa, the mucosa works as a barrier (a clean net), to prevent abdominal cavity contamination and seeding of tumor cells into the peritoneal cavity. The specimen is lifted from the peritoneal cavity, so it is retrieved laparoscopically. Inoue actively performs endoscopic and laparoscopic full-thickness resection for not only GISTs but also for early gastric cancer. The procedures are described below.
“Endoscopic markings are placed on the surrounding mucosa of the lesion with electrocautery knife.”
“The mucosal layer is fixed onto the seromuscular layer using four stay sutures.”
“By pulling four stitches upward with laparoscopic forceps, selective seromuscular dissection outside the four stiches is performed using a laparoscopic electrocautery knife.”
“A full-layer specimen is lifted by four stay sutures. This process allows a wider cancer-free margin around a full-thickness lesion.”
“A full-layer resection using a mechanical stapler is performed and the resected tumor is removed from abdominal cavity side.” These figures are excerpted from Inoue’s report.
The abovementioned procedure with nonexposure technique is advantageous for epithelial tumor and GIST with ulceration. CLEAN-NET also makes it possible to secure a sufficient margin around the tumor and to resect lymph nodes together with the tumor if it is located at either the lesser or greater curvature of the stomach. Because the CLEAN-NET procedure needs the process that the mucosal layer stretches without breaking apart, a large tumor is thought to be difficult to resect.
This technique was reported by Abe et al. in [28]. The same procedure as LECS technique is applied; however, the endoscopist plays an important role in resecting the tumor. The endoscopic team starts full-thickness resection around the tumor, and after two-thirds of the resection is performed, the laparoscopic team finishes the full-thickness resection with laparoscopic devices.
There are some limitations with LECS for removal of duodenal tumors. First, anatomical elements such as the pyloric ring, Vater’s papilla and the third to fourth portion make it difficult to perform. Second, there are a few reports of lymph node metastasis from submucosal invading duodenal cancers or carcinoids, so partial resection is controversial. Small submucosal tumors, duodenal adenomas, or intramucosal carcinomas at duodenal bulb or the opposite side of the papilla are indications for LECS. The basic concept of gastric LECS also applies to duodenum LECS [4, 29]. The difficulty in mobilizing organs and closing the defected walls needs to be advanced.
LECS for colorectal tumors is not often used. We rarely experience GISTs in the colorectum, and in many cases the laparoscopist must achieve adequate mobilization which may be difficult in colorectal-LECS. Some researchers have reported the laparoscopy-assisted endoscopic resection (LAER) for colorectal tumors [30, 31, 32], and as the combined laparoscopic endoscopic resection (CLER). Fukunaga et al. reported LECS for laterally spreading colorectal tumors, which are difficult to resect by the ESD technique because of submucosal fibrosis or multiple surrounding diverticula [33] (Figures 18 and 19). He suggested several concerns about his technique: limitation for tumors located on the mesenteric side, strictures after surgery, and contamination of the abdominal cavity by bowel contents. He proposed several adjustments in his report. Indications for colorectal LECS are the same as for colorectal ESD. Tumors that would be difficult to resect endoscopically are good indications for both. Figures 18 and 19 are excerpted from Fukunaga’s report.
A laparoscopic coagulating system is used to dissect the full thickness of the colon wall along the submucosal line created by endoscopic dissection.
The incision line was closed using laparoscopic stapline devices. The Figures 18 and 19 are excerpted from Fukunaga’s report.
The application LECS has progressed from resection of gastric submucosal tumors to early stage gastric cancer. The current therapeutic adaptation is for removal of low-risk lymph node metastases. Further, there still remains the possibility of lymph node metastasis in treating gastric cancer. On the other hand, some researchers reported the utility of sentinel node biopsy in patients with gastric cancer [34, 35, 36]. Although gastric lymphatic drainage is often complicated, by using the dual tracer method with radiolabeled tin colloid and blue dye, Kitagawa reported that the sentinel node detection rate was 97.5% (387 of 397) and the accuracy of nodal evaluation for metastasis was 99% (383 of 387) in cT1 and tumors <4 cm [36]. These facts implicate that by combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become possible in the future (Figure 20). More research and clinical trials about LECS and biopsy to sentinel lymph node for early gastric cancer are expected.
By combining LECS technique and sentinel node biopsy, LECS with lymph node dissection might become possible in the future.
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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\n\nThe Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
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\n\n*These prices do not include Value-Added Tax (VAT). Residents of European Union countries need to add VAT based on the specific rate in their country of residence. Institutions and companies registered as VAT taxable entities in their own EU member state will not pay VAT as long as provision of the VAT registration number is made during the application process. This is made possible by the EU reverse charge method.
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