Health and community services for trafficked women: an exploratory study of policy and practice.
Abstract: The trafficking of women has attracted considerable international and national policy attention, particularly since the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (2000), of which the Australian Government has been a signatory since 2005. The provision of health and community services for trafficked women is a central feature of this Protocol, but in Australia service provision is made difficult by how trafficked women are understood and treated in policy and legal terms. This study aimed to explore the provision of health and community services for trafficked women in the Greater Sydney region through a series of interviews with government and non-government organisations. The findings reveal that services have been inaccessible as a result of sparse, uncoordinated, and poorly funded provision. The major obstacle to adequate and appropriate service provision has been a national policy approach focusing on 'border protection' and criminalisation rather than on trafficked women and their human rights. We conclude that further policy development needs to focus on the practical implications of how such rights can be translated into the delivery of health and community services that trafficked women can access and be supported by more effectively.

Keywords: trafficked women, health and support services, policy, rights, social citizenship
Article Type: Report
Subject: Community service (Analysis)
Community service (Laws, regulations and rules)
Women (Civil rights)
Human smuggling (Analysis)
Human smuggling (Demographic aspects)
Authors: Schofield, Toni
Hepworth, Julie
Jones, Mairwen
Schofield, Eugene
Pub Date: 06/22/2011
Publication: Name: Australian Journal of Social Issues Publisher: Australian Council of Social Service Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2011 Australian Council of Social Service ISSN: 0157-6321
Issue: Date: Summer, 2011 Source Volume: 46 Source Issue: 4
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8340000 Community Services NAICS Code: 6242 Community Food and Housing, and Emergency and Other Relief Services
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Legal: Statute: Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, 2000
Accession Number: 301964266
Full Text: Introduction

This article reports on exploratory research conducted in mid-2007 to examine health and community services for trafficked women in the Greater Sydney region, Australia. The majority of those trafficked into Australia are women working in the sex industry, mainly in Melbourne and Sydney (McSherry & Kneebone 2008; Schloenhardt et al. 2009; Schloenhardt & Loong 2011). According to the United Nations Office on Drugs and Crime (UNODC 2008), sexual exploitation is the main purpose of human trafficking worldwide. The trafficking of women has attracted considerable national and international policy attention, with policy makers committed to 'protecting victims' and eradicating the trade that is considered to operate on a vast scale globally (Segrave 2009). The exact number of people who have been trafficked into Australia is currently unable to be determined (McSherry & Kneebone 2008; Schloenhardt et al. 2009; Commonwealth of Australia 2010). Recent estimates differ greatly depending on the source of information (Schloenhardt et al. 2009). Non-government organisations (NGOs) such as Project Respect (2009) have estimated that approximately 1,000 women in Australia are trafficked for prostitution each year, while Government sources propose a much lower figure (Commonwealth of Australia 2010).

The provision of health and community services for trafficked women is a central feature of the main international policy on trafficked persons--the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (2000)--of which the Australian Government has been a signatory since 2005. Service provision also is a key concern of a US-based initiative established in 2005 to monitor, evaluate and rank international efforts, including those of Australia, to prevent human trafficking and protect those who are victims of it, particularly women and children (Chuang 2006). Since 2009, the Australian Government has focused more explicitly on health and support services for trafficked people, providing guidelines (Commonwealth Attorney General's Department 2008) designed to ensure 'best practice'. Yet as recent commentary in this field has pointed out, there is 'limited scholarly research' on health and health service provision for trafficked people in Australia, including the implementation of the new guidelines (Schloenhardt & Klug 2011: 411). As Schloenhardt and Klug (2011: 397) point out, '[m]uch of the available information (related to the health and health care of trafficked people) stems from official government sources, media reports, and, in particular, the reported case law'.

Accordingly, although the data presented in this article pre-date recent Australian policy reforms related to health and support provision for trafficked women, the analysis we provide is unique. It is based on a systematic empirical investigation of health and community services provision to trafficked women in Australia, particularly the barriers to access that they experience, and is informed by a critical theoretical framework that offers a foundation for understanding the political dynamics--both national and international--involved in the development of Australian policy in this field. To ensure the contemporary relevance of our analysis, we compare our findings with information on health and support provision to trafficked women after 2009. Our central purpose is to contribute to advancing knowledge and understanding of 'the problem' (Bacchi 2012) of health and community services for trafficked women from a policy perspective. As Carol Bacchi (2012) has convincingly argued, the ways in which policy problems are 'represented to be' shapes the types and adequacy of policy actions, including service and program development, to address them.

Australian feminist approaches

Australian policy and legislation pertaining to the trafficking of women and their entitlement to support and assistance in 'receiving' countries has been the subject of vigorous discussion and debate, particularly among feminist scholars (McSherry & Kneebone 2008; Segrave 2009; Holmes 2010; Milivojevic & Segrave 2010). Australian feminist commentary and analysis has mainly focused on policy and legislation as state institutional mechanisms that render trafficking in women a process of violation enacted along two main axes: one related to persons (in this case, the 'victims' and the 'perpetrators' of the crime of trafficking); and the other to national borders. Feminist commentators have pointed out that trafficked women are viewed as either 'victims of crime' and 'victims of human rights violation', or as 'illegal non-citizens'. The construction of trafficked women as illegal non-citizens is linked to the assertion and protection of national 'border regimes' that restrict the mobility of labour, primarily women from poor to rich countries, including those engaged in sex work, through policies related to border protection and illegal migration (Segrave 2009; Milivojevic & Segrave 2010). Women trafficked for sexual purposes are thereby rendered 'illegal non-citizens' whose status as citizens can only be re-established through 'repatriation' to their source countries (Milivojevic & Segrave 2010: 46-50).

The imperative to control border transgressions to maintain state sovereignty and integrity is the main driver of policy related to trafficked women, according to much of the feminist literature. Virtually no women who are publicly identified as victims of trafficking are allowed to stay in Australia. As a consequence, while trafficked women are rendered victims, they are nevertheless also perpetrators of border violations, together with those who have trafficked them. Maintaining national border integrity demands their return to their country of origin and prosecution of those who orchestrated the breach.

Social citizenship and policy on health and social support for trafficked women

So what about policy related to the provision of social support and assistance to trafficked women in Australia? Is it also animated by border control and integrity? Does it reflect a response attuned to the violation of trafficked women's human rights? Or does it operate on the basis of both? To date there has been no in-depth empirical investigation of how this policy has been working and no solid evidence for determining whether it too is shaped by the logic of border protection. The main purpose of this article, then, is to examine how policy related to the provision of social support and assistance to trafficked women in Australia approaches 'the problem' and shapes the strategies or measures adopted to address it through programs and services. In doing so, the article locates of the research findings within a discussion of Australian and international public policy and legislation on trafficked women and their status as citizens when they reach their destination countries.

It is critical to recognise that access to social support and assistance in Australia in general depends on being a citizen or permanent resident. Conferral of democratic citizenship in Australia not only secures political and civil entitlements but social rights as well. These are generally operationalised through the universal provision of access to social resources such as education, health care and social/community services. Such social rights are understood within international social policy literature as constitutive of social citizenship that in turn is acknowledged as fundamental to democratic citizenship (Dwyer 2010). At the heart of democratic citizenship is participation in the life of the polity and civil society but, according to social policy scholars, such participation is contingent on access to social resources (O'Connor et al. 1999).

Trafficked women in Australia have no such status as citizens with social rights to health and community services. At the same time, they do have human rights as outlined in the Declaration of Universal Human Rights (UN 1948) that support the provisions of the UN Protocol to entitle trafficked women to access health and community services in their destination countries such as Australia. There is as a consequence a significant tension in trafficked women's social entitlement in Australia. Yet national citizenship is the most significant because UN human rights are not supported by institutional mechanisms that permit them to be enforced in nation states, even among those who are signatories to human rights instruments. This situation reflects what Milivojevic and Segrave (2010) have described in relation to the civil and political rights of trafficked women in Australia. And, as they also argue, the dynamic that generates it is border protection and national sovereignty. What we want to add here is that such a dynamic also applies to social citizenship. But how does it apply? What is the nature of health and support services for trafficked women in Sydney and how are they working? These questions are a central focus of this article.

International and Australian policy on trafficked women: providing support and assistance

The standard definition that prevails internationally in relation to 'trafficked women' is derived from Article 3(a) of the United Nations' Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (UN 2000). It defines 'trafficking in persons' as:

Those identified by public authorities in receiving countries as having engaged in trafficking as defined above are subject to criminal prosecution, conviction and punishment. Those who are the objects of such activities--such as women deceitfully recruited for sexual purposes--are necessarily victims of crime. The criminalisation of the trafficking of women has prevailed as the dominant public policy and management response in Australia (McSherry & Kneebone 2008; Segrave 2009; Schloenhardt & Loong 2011), as it has in most parts of the world (Milivojevic & Segrave 2010). Yet although trafficked women are, by the Protocol's definition and Australia's Criminal Code, victims of crime, this does not mean that they enjoy the same rights as victims of crime who are Australian citizens. While trafficked women usually enter the country on legitimate or authorised visas, these are often fraudulently obtained and cancelled once the women have been identified as victims. Once in the hands of the Australian Federal Police they are accorded a Bridging F Visa (BFV), and, in some cases, a Permanent Witness Protection Visa (WPV) if they agree to co-operate with the AFP in prosecuting the offender (Simmons & Burn 2010: 716). These procedures regularise their status as migrants. However, this is not conferral of Australian citizenship and the rights that attach to this status.

The Protocol does contain provisions, in Part II, Article 6, that involve 'assistance to and protection of victims of trafficking in persons'. These provisions confer obligations on Australia to provide adequate health and community services to assist trafficked persons in dealing with the harms they incur as 'victims of crime'. Significantly, however, prior to Australian policy reforms enacted in 2009 (see below), access to such support was conditional on co-operation by 'victims' with the AFP in prosecuting trafficking offenders. Bridging Visas were not routinely granted to trafficking victims. Partly in response to such national interpretations of their obligations under Article 6 of the Protocol, the UN Office of Drugs and Crime (UNDOC), in conjunction with the UN Global Initiative to Fight Trafficking (in Persons) (UN.GIFT), developed 'model laws' establishing a set of obligations and principles (UNDOC & UN.GIFT 2009) for both 'sending' and 'receiving' countries of trafficked persons. These seek to ensure that, while those who are trafficked are victims of crime, they are also 'human rights bearing' (Schloenhardt & Loong 2011: 153-57). The provisions of the recent model laws in relation to the receiving countries such as Australia mean that trafficked persons need to be treated as human beings whose basic human rights have been violated and who need to be supported through health and vocational/community services. As Shigekane (2007) maintains, this provision requires the inclusion of specialised services and treatment.

In the light of the introduction of new UN principles and obligations for assisting 'trafficked persons' in 2009, the Australian Government sought to develop its support and assistance to trafficked women through its Support for Victims of People Trafficking Program and Return and Reintegration Scheme. Access to the support offered by the Program is conditional on possession of a visa (either BFV or WPV). The Program is funded by the Department of Families, Housing, Community Services and Indigenous Affairs that works with the Australian Federal Police targeting issues regarding the personal safety and security of clients. The Department has contracted out the management of the Program since February 2009 to the Australian Red Cross, one of Australia's largest and most reputable NGOs in terms of its humanitarian service provision. However, the Department maintains direct supervision of the Program. This arrangement represents a major departure from the approach of the previous Coalition Government, which contracted an independent commercial organisation to provide support and assistance. The Program is designed to provide 'appropriate support and assistance' to trafficked persons specifically to 'improve the skills of victims of trafficking, so as to assist their ability" to reintegrate upon return to their home country' (Schloenhardt & Loong 2011: 158) and adopts an individual case-management approach. Services include accommodation assistance, links to legal advice and support, access to counselling and mental health supports, and referrals to vocational education and training (Australian Red Cross 2011). Such services provide significant redress for individual human rights violation compared with the Commonwealth Government provision prior to 2009 that attracted international criticism (Munro 2005). The new services, however, are designed to facilitate return and re-integration of those who have been trafficked into their countries of origin (Milivojevic & Segrave 2010; Schloenhardt & Loong 2011).

Recent international research investigating and evaluating the adequacy of health and vocational/community services for trafficked women remains sparse. The United States is a major exception, with national public sector agencies funding evaluations of, and conducting comprehensive research into, a wide range of health and support services to 'victims of human trafficking' in the United States (Caliber 2007; US Department of Health and Human Services 2009). In these studies the data on trafficked persons who originate outside the United States are generally disaggregated by two main categories--'labour' and 'sex'. The former is comprised almost exclusively of men and the latter of women, so it is possible to identify, health and support services for trafficked women. These investigations have identified the major barriers to access and efficacy. Apart from the ongoing barrier posed by medical and dental costs in the United States, the single most pressing problem is the absence of a coordinated program of 'comprehensive services' for 'trafficked persons'. Indeed, it is a challenge that equals the reluctance of 'victims of trafficking' in the United States to use currently provided health and support services because they must be registered with law enforcement agencies first. Accordingly, as the research concludes, it is the integration of relevant NGO service providers and government agencies, supported by increased public resourcing, that is foundational for progressing US policy commitment to 'protecting' those who have been trafficked.

In Australia, a recent examination of non-government organisations involved in the provision of health and support services for trafficked women has also yielded significant information about how such women are using health and support services--provided by both government and NGOs since the 2009 legislative and visa changes (Hunt 2011). As the report explains, and as noted above, although current Australian Government provision of health and support services for trafficked women is managed by the Australian Red Cross, services more commonly used by trafficked women are provided by a range of other NGOs. The Australian Government and/or State governments responsible for health and community services fund much of this provision. Yet there is a distinct cleavage between how the Australian Government and NGOs understand and respond to the status of trafficked women. According to Hunt (2011), the Australian Government still views the victim primarily as a potential witness and this role takes priority over the Government's responsibilities in addressing human rights concerns such as victim assistance. By contrast, NGOs focus more on trafficked women as victims of human rights violations (rather than of crimes), and often provide victim assistance to those not able to access the Support for Victims of People Trafficking Program. This division renders co-ordination and integration of a comprehensive approach to health and support services for trafficked women a formidable challenge.

As explained earlier, the data collected for our study pre-date the introduction in 2009 of the Australian Government's Support for Victims of People Trafficking Program and Return and Reintegration Scheme, and the administration of the program by the Australian Red Cross. We have nevertheless sought to make the data relevant to current policy debates and discussion on the issue by subjecting them, in our discussion section, to an analysis informed by recent information and commentary on the Australian policy reforms in this field. At the heart of our analysis is the pattern of health and support services provision for trafficked women emerging from our data. The following outlines the approach and methods we adopted in collecting the data.

Methodology

A qualitative research design using semi-structured interviews was used to collect data from key informants working in policy, research and service delivery in the Greater Sydney region. The study was given ethical clearance by a university human research ethics committee and subsequently also obtained ethical clearance from one community-based organisation which required the study to be assessed by its research ethics committee prior to their agreement for one of its employees to be a key informant.

At the commencement of the study, information about what services existed for trafficked people in the Greater Sydney region was sought by the researchers. A number of sources were searched to find service lists, such as State and federal health and community services websites, registers and websites of community'-based organisations, and telephone directories. Because lists of services provided for analogous populations (such as refugees) existed, it was considered possible that services for trafficked populations would also be listed. However, no list(s) of designated services was found. Thus, an exploratory approach was taken that aimed to seek the views of a small number of key informants. A rapid appraisal approach (cf. Murray 1999; Lumley & Daly 2006) identified a number of disparate organisations that were likely to come into contact with trafficked women and children. Yet as the study progressed, it became extremely difficult and time consuming to identify organisations and recruit key informants. The relevant health and community services were scarce and embedded within organisations that were primarily known to address populations other than those who had been trafficked, and service provision often operated in a covert way contributing to an overall reluctance to participate. It was considered necessary for service provision to be covert for two main reasons: to facilitate the anonymity and safety of victims of trafficking and because community organisations feared losing their charitable status if it was discovered that they delivered services to populations other than those nominated in their agreements. Disclosure of such a practice would have financial and operating consequences for the organisations.

Purposive sampling, using both 'critical case' and 'snowball' (Patton 2002) techniques, was employed. Approximately 120 phone calls and 55 emails resulted in contact with 15 key organisations. The eligibility criteria stated that potential representatives had to: (1) have direct experience of working within the field of human trafficking, and (2) be employed within one of the following sectors: (a) health and/or social service policy development, (b) clinical health service provider, and/or (c) information provision. Nine organisations met the eligibility criteria and were invited to participate by phone and/or a face-to-face meeting. Of these, seven organisations agreed to participate. The main service provider for the Australian Government declined to be interviewed. The participating services were each asked to nominate a representative who had the most expertise related to human trafficking to be a key informant. All of the key informants were both senior representatives of their organisations and had direct experience with addressing the issue of human trafficking. The names of the organisations were de-identified, but included: a professional medical organisation, a non-government sexual health service, a law enforcement department, a women's health policy unit, a community sexual health service, a religious organisation, and a community legal service. The informants responded to the interview questions based on their own experience and professional views of human trafficking. The seven key informants included six women and one man, and they had been contacted prior to being interviewed to discuss the participant information sheet and sign a consent form.

The interview questions (see Appendix 1) were developed following a review of research on community-based service delivery, human trafficking and health needs. The 12 questions were designed to be exploratory and to facilitate discussion about the nature of existing services, service needs and multi-sectoral collaboration. Three researchers (JH, TS, & M J) conducted the interviews between June and October, 2007. The semi-structured interviews were conducted as face-to-face individual interviews with six key informants and via a telephone interview with one key informant. All informants were interviewed at their places of employment. The interviews were recorded using field-notes that were typed into expanded transcripts on the same day.

All seven interviews were included in the analysis. Qualitative content analysis of the interviews (Grbich 1999) was conducted in two stages to identify major themes and sub-themes within individual interviews and common themes across all of the interviews. The themes were defined as groups of verbal data that were organised in relation to and reflected the question areas rather than being representations of thematic conceptualisations. First, each interviewer analysed the data and independently identified major themes and sub-themes. Second, the research team held several meetings to analyse the data across all of the interviews and build a consensus about which themes and sub-themes were in the data set. This process contributed to the validity of the analytic interpretations (Patton 2002). Additionally, data analysis involved the application of qualitative techniques, including 'data saturation' (Guest et al. 2006), whereby a point is reached when further analysis elicits no new information. While the sample size had already been limited by the recruitment difficulties outlined earlier, it was still possible to identify data saturation within seven interviews. This reflects the observation made by Guest and colleagues (2006) that data saturation can occur as early as six interviews and the data at that stage of the analysis can provide the basic elements for meta-themes.

Results

In this section the results are presented in the form of illustrative quotations from the key informants in response to specific question areas and analytic comments. Theme 1 was based on qualitative data included throughout the interviews that revealed different understandings of the problem of trafficked women. Themes 2, 3 and 4 were based on responses to specific interview questions and the questions from Appendix 1 are identified at the beginning of the presentation of each theme.

Theme 1: Representing the problem of trafficked women

Australian governments identify trafficked women in terms of the definition provided by the UN Protocol. The informants in this study, however, displayed no such definitional consensus. There was, in fact, a marked division in prevailing representations of trafficked women and these emerged through various interview questions as key informants spontaneously elaborated on their understandings. One approach articulated the prevailing or dominant policy understanding of trafficking as a crime, as reflected by Informant 1 from an NGO:

I don't have any other language to represent the needs of women to government than to say they are victims. Nothing else is as effective or pragmatic as victims of crime. (Informant 1, NGO, community legal service)

Informant 2, who works for a government women's health policy unit, also used the term 'victim' in relation to her representation of trafficking:

Victims do not say they are trafficked because of their illegal status and possible repatriation.... They [women] often don't know they're trafficked. They don't identify as being trafficked. (Informant 2, government women's health policy unit)

Significantly, this representation articulates a basic feature of the UN Protocol's definition of trafficking--that it does not require knowledge or awareness by the trafficked person for it to be a criminal act.

The other approach, less commonly expressed but nevertheless robustly espoused, rejected the use of the term 'victim of trafficking', as Informant 3, a service provider in an NGO sexual health service, demonstrated. She challenged the notion that women should be considered victims, instead arguing for not using this term because it implied 'saving trafficked women'. She believed that the dominant policy approach was 'disempowering' for women as she works with:

women [who] direct what they need ... [and] are very resourceful ... given choices of how to handle ]their situation]. (Informant 3, NGO, sexual health service)

Informant 4, from a government sexual health service, went further than Informant 3, and proposed that migrant sex workers on a 'debt contract' are not trafficked women. Both Informants 3 and 4 identified sex workers with whom they had had direct contact as 'indebted women', which contrasts with the official definition of the problem used by other government agencies and some NGOs.

A further significant difference in informants' understandings of trafficked women was related to the size of population(s) affected by trafficking. Based on their direct contact, some informants talked about the numbers and ages involved:

I see three cases per week. The majority are cases of sexual servitude. I have seen two cases under 18 years old. If the government is right that there are one hundred in Australia, then I have seen them all. (Informant 1, NGO, community legal service)

The federal Government's estimated prevalence of human trafficking in Australia is challenged in this extract. In contrast, Informant 3 suggested that in the agency where she worked the number of adult women involved was very small:

Last three years we have seen five individuals on a debt bondage contract. [Name of agency] works with adults on a debt contract but (they) are not asking for your help. (Informant 3, NGO, sexual health service)

Both informants proposed that there are very few cases of trafficking involving minors in Sydney. However, informants' estimates based on their own experience as practitioners cannot be seen as a reflection of the overall prevalence of trafficked persons in Sydney.

Informants' direct contact usually involved health and community support for trafficked women in detention centres, on the street (homeless), at outreach mobile health provider services, in brothels and in private houses (serving the function of brothels). This information gives a sense of where and how trafficked women are likely to live and work, and shows their living conditions are those of socially marginalised people.

Finally, a number of the informants believed that the issue of women trafficked to Australia was not adequately addressed by Australian policy makers and legislators. Once again, key informants spontaneously talked about this area without a specific question or prompt. Informant 6 from a medical organisation, which submitted expert evidence to government inquiries into trafficking 2000-2004, reported:

The whole issue never got the seriousness it deserved. You will always get prostitution but that's not the point, this is a whole different situation. (Informant 6, medical organisation)

Theme 2: Existing health and community services for trafficked populations

In response to questions 1-4, which asked about the nature, development and efficacy of services (see Appendix 1), informants described services that fell into one of two categories, either (a) federal and State government services, or (b) NGOs and religious/charitable services. These were reportedly sparse, uncoordinated, and mostly regarded as being culturally insensitive and inaccessible. The overall picture painted by the informants was one of a serious lack of adequate and appropriate provision. Most reported that there were no government-funded, specifically-dedicated health and community services for trafficked women that take into account the breadth and specificity of needs of this population. The main government service provision, at the time this study was conducted, we defined as being prosecution-led, meaning that services were only available to those individuals who were willing to co-operate with the Australian Federal Police in their investigations of allegations of trafficking and where their primary goal was to pursue and convict the trafficker. Individuals who did co-operate, however, were at risk themselves of being charged with immigration violations, and of being held in detention centres and/or deported. In contrast to the prosecution-led approach, some government, non-government health and community, agencies, and charities developed services in accordance with the human right to having basic health and social needs met without conditions. We refer to such an approach here as humanitarian, illustrated by an NGO service:

We take a collaborative community approach; a community response network approach based on the NYC [New York City] network.... We work with ongoing public awareness, case management and support, [and] use a comprehensive intake procedure dealing with legal, social and health needs. Some of the cases are already on support and some have nothing. [Name of government assistance program] provides very little support for women. They provide minimal services and are definitely not comprehensive. There is no acknowledgement by the police or government of the period of reflection needed by women. (Informant 1, NGO, community legal service)

Not surprisingly, Informant 1 was, therefore, critical of the then Commonwealth Government's claim that it offered 'comprehensive services'.

Support for the then Commonwealth Government's approach to service provision was only expressed by one informant--Informant 7--who was employed in a policing role related to trafficking. He described how visas are linked to a 'comprehensive support system' that included, for example, medical services and accommodation that are available during the period of co-operation with the [name of law enforcement department] to any individual suspected of being trafficked. He stated:

We have a multi-agency approach led by the [name of law enforcement department]. The States identify a victim and then the [name of law enforcement depamnent] take on further investigations from there. The support provision does include a welfare component. Services are made available to all who need them and according to their needs.... Support is offered as a means to break the cycle of exploitation mediated by not wanting to produce a cycle of welfare. (Informant 7, law enforcement department)

It was evident from informants, however, that most of the health and community services for trafficked women were provided by religious and charitable organisations. According to Informant 1, they had provided: 'the first dedicated accommodation for trafficked women in Sydney'. As an example of services provided by a religious organisation, this informant stated:

I provide emotional support, mentoring, companionship, sense of worth, and referrals to other services such as AA.... My visits to [name of centre] detention centre have been very effective. The staff there didn't know about trafficking. Neither does immigration. They asked me to do training of staff to help the women by being more culturally sensitive and understanding about the mental health problems of these women. (Informant 5, NGO, religious organisation)

The major conflict between the views of all the other organisations and the law enforcement organisation related mainly to the link with prosecution. Informant 7 from the law enforcement department described the government approach as being one where 'women's welfare is paramount', but all the other informants reported that trafficked women who needed assistance did not access government services because of the context and conditions that applied.

Theme 3: Barriers to service use

In response to question 5 (see Appendix 1), informants identified cultural, financial and legal barriers to service use. The majority of trafficked women with whom they had come into contact were from South East Asia and understood limited English. This posed one of the most significant barriers, as Informant 1 commented:

We lack translation services ... Our need is mostly for Thai, and we don't have enough psychologists and can't get dental care ... Psychologists are difficult to obtain and I need them for assessments of trauma. (Informant 1, NGO, community legal service)

Women's limited financial resources also constrained their access to health care but so, too, did a lack of information about the availability of services. Most commonly, informants emphasised women's fears about the possible legal and socio-cultural consequences of accessing services because of immigration violations, and disclosure of their identity in Australia and in their home countries as illustrated in the three extracts below:

There are status barriers if they are illegal and detected as unlawful ... They will not seek help from the government and more likely go to [name of hospital] to provide health services. ... Victims will not seek help from government sources. (Informant 1, NGO, community legal service). They would be worried about the criminal repercussions. They are not aware of their entitlements. At the detention centre they have been evasive, they did not want to see me, did not want to talk about who brought them here. There were lots of unsaid things, and they were indirect, very fearful of authority. (Informant 5, NG O, religious organisation)

Women are concerned about police corruption and are worried they may be disclosed as sex workers to people in their own country. (Informant 3, NGO, Sexual health service)

Having little awareness of their entitlements promoted a culture of fear and silence and, as Informant 3 stated, women feared the possible disclosure of their sex work in their home countries. According to participants, the disclosure typically results in a woman becoming ostracised by her family and community, which leaves the women without assistance to prevent further exploitation either in Australia or their home countries.

Theme 4: Service development needs

The last group of questions (8-11) were about service and training development needs, and barriers to these (see Appendix 1). In response, informants commonly stated that existing services needed significant development and identified several key areas for improvement: greater sensitivity" to the cultural needs of trafficked populations; better accommodation and psychological services; and a policy and service approach that was humanitarian and welfare oriented, instead of being based on criminal prosecution.

In relation to the first of these, Informant 5 commented:

We need to know more about existing services that are culturally sensitive to the needs of these women. We could improve our accommodation for trafficked women and group work; also programs for the reintegration back home and strengthening the connections internationally to assist them to return home and establish a life that does not rely on sex work. (Informant 5, NG O, religious organisation)

Like Informant 5, Informant 4 from a community sexual health service talked about the need for suitable physical space for women who have been trafficked:

There is a need for more refuges for all exploited groups; greater sensitivity to the problem and need for 'safe houses'. (Informant 4, community sexual health service)

The recurring call for a greater sensitivity to the cultural needs of trafficked populations was evident in several interviews. Informants 1 and 5 talked about the importance of training a range of health and community" service providers, while Informant 6 talked about educating brothel users to assist in identifying trafficked women and making links between the women and services.

The urgent need for the development of psychological services was identified by several informants and illustrated by Informant 7: There is a need for psychologists to explain giving evidence and statements about what they've [trafficked women] experienced. They need help to overcome fears. We particularly need to understand their obligation to their families. (Informant 7, law enforcement department)

Informant 3 explained the complexities in developing effective services for trafficked populations. The Commonwealth Government approach was seen as unfeasible because it prevented women from meeting ever-present economic and family demands. As the informant stated:

[women] might want to bring the people to justice but they can't afford to go from a debt bondage to a witness bondage. (Informant 3, NGO, sexual health service)

Informant 6, from a medical organisation, called for greater government attention to the problem of trafficking and its relationship with other criminal sectors. As a pragmatic step towards more effective prevention, she suggested, like Informant 3, that direct work with the sex industry needs to be made a priority to encourage the sector to start 'taking responsibility for what they do'.

Discussion

The in-depth interviews undertaken in this study provide an original source of information and understanding about health and community services for trafficked women in the Greater Sydney region. Such research, by its very character, does not shed light on the distributional features of the problem. It is fundamentally exploratory and based mainly on responses to service provision governed by policy arrangements in 2007, prior to reforms initiated in 2009 that no longer require trafficked women to co-operate with criminal justice authorities in pursuing and prosecuting perpetrators in order to access health support services (Simmons & Burn 2010). The over-riding pattern of health and support provision yielded by the data collected in 2007 is one of significant inaccessibility arising from sparse and uncoordinated services, widely regarded as culturally insensitive--a finding remarkably consistent with those disclosed by publicly funded US research into health and support programs for trafficked women there (Caliber 2007; US Department of Health and Human Services 2009).

Has this pattern changed since 2009? Certainly conditions promoting accessibility of government health and support services have improved with the elimination of the requirement for trafficked women to co-operate with the Australian Federal Police and the Commonwealth Office of Public Prosecutions in apprehending and prosecuting perpetrators of trafficking if they wish to avail themselves of such services. As a number of commentators have already noted, particularly Burn and Simmons (2006), this requirement posed a number of risks to trafficked women including retribution by traffickers and exposure to their family and other networks as participants in the sex industry. As a result, they were significantly more likely to draw on services provided by NGOs.

Yet there is no strong evidence, at present, that the new conditions for access to the Government's Support Program have actually translated into significantly increased uptake of its provisions. Trafficked women are still more likely to continue to turn to the services provided by NGOs (Hunt 2011). These organisations have generally provided services with 'no strings attached' and no judgmental responses. As Hunt's report explains, these NGOs are diverse but share a robust commitment to the health and welfare of trafficked women and to their rights to humanitarian assistance in the face of experiences of severe exploitation. Overwhelmingly, the participants in our study--half of whom worked for NGOs--understood trafficked women as victims not just of criminal violations but of personal abuse that represented violation of their human rights. Virtually all of the NGO interview participants concurred that such violation required adequate and appropriate medical, dental and psychological services that were culturally sensitive and specific to their clients' needs so they might "move on' from what had happened to them. Further, although trafficked women do not need to engage in the processes of criminal apprehension and prosecution to access the Government's Support Program, they do have to co-operate with Australian Federal Police to obtain a referral to it. As Hunt's (2011) report suggests, many trafficked women maintain a deep mistrust of criminal justice authorities, primarily because they associate them with 'repatriation' to their countries of origin and disclosure to their families of their participation in the sex industry.

Similarly, there is no evidence that, despite improvement in the range and co-ordination of services offered by the Australian Red Cross since 2009 to support trafficked women (Hunt 2011), there has been a significant increase in the overall availability of such services. Nor is there any evidence that existing Australian Government services are regarded as more culturally sensitive. As our interview participants stressed, specifically dedicated accommodation and the provision of linguistically accessible and culturally sensitive psychological/mental health services for trafficked women are critically important, but there have been no reports to date of such developments by the Australian Goverrnment (Hunt 20ll). NGO support services for trafficked women, by comparison, have been reported to be more culturally sensitive and able to establish rapport with victims (Hunt 2011).

There is evidence, however, that the overall lack of co-ordination of government and NGO services reported by our interview participants in 2007 remains a critical problem even after the policy reforms of 2009. As reported previously, there is a major lack of integration between the Australian Government's Support Program and the principal NGOs involved in providing health and support services. As significantly there is some division and a lack of co-ordination among NGOs in terms of establishing clear demarcation of responsibilities for service provision (Hunt 2011).

Trafficked women and social citizenship

How can this pattern of health and community service provision for trafficked women be explained in the face of the Australian Government's commitment to the UN Protocol and the policy reforms it introduced to improve support for trafficked women? As mentioned previously, access to social support and assistance in Australia generally depends on being a citizen or permanent resident because conferral of citizenship not only secures political and civil entitlements but social rights as well. As Milivojevic and Segrave (2010) have argued, Australian policy towards trafficked women renders them non-citizens because it is basically informed by the international dynamics of 'border regimes'. The result in terms of service provision for trafficked women is a focus on 'repatriation and reintegration'.

Conclusion

The Australian Government is committed to provide protection and support for trafficked women by ratifying the UN's Trafficking Protocol (2000) and agreeing to adhere to the obligations and principles established by the UNDOC and UN.GIFT (2009). The evidence produced in this study, however, suggests that the health and community services required to operationalise such a commitment do not exist on the scale required. Nor are they provided in conformity with the specific needs of trafficked women. Policy governing health and community support for trafficked women is informed primarily by a commitment to border protection and the preservation of national sovereignty in the face of increased global mobility of labour and migration. The central weapon in such a battle has been the criminalisation of trafficking of people into Australia. Migrant women brought to Australia illegally to work in suburban brothels, and those responsible for trafficking them, have been the main targets of punishment. When identified and interviewed, pursuant to the terms of the Commonwealth's Migration Act 1958, they were usually deported. Amendments to this Act, accompanied by the granting of special visas in 2009, have seen the introduction of conditions designed to accord trafficked women greater access to Australian Government support services but this is still designed to facilitate the 'repatriation and reintegration' of trafficked women to their countries of origin. Such a situation is basically inevitable in the face of a policy that, while officially recognising the human rights of trafficked women, is unable to countenance the translation of such rights into those of social citizenship.

Acknowledgements

The research team thanks the participants for their involvement in the research study, and is grateful to both the university and the community-based ethics committees for granting clearance. Julie Hepworth gratefully acknowledges the University of Sydney for awarding her an International Visiting Research Fellowship during which this research was commenced. The authors also gratefully acknowledge the comments made by the three reviewers and editors, and Jennifer Burn for expert advice.

Appendix 1 Interview questions

1. Would you describe the nature of (insert health if agency delivers specific mental/physical health services) services available through this agency that may be accessed by victims of trafficking?

2. Are these (health) services different from health services accessed by non-victims of trafficking, and, if so, in what ways are they different?

3. How were these services developed?

4. What aspects of these (health) services are effective in addressing the health needs of victims of trafficking and why?

5. Why would victims of trafficking not use these (health) services?

6. How does this agency recognise that a service user may be an unidentified victim of trafficking? (Prompt: and what do they do about this?)

7. What are your observation on the relationship between health service delivery and the retention of victims of trafficking?

8. How could these services be improved?

9. What are the training needs, if any, of health care service providers?

10. What barriers, if any, exist to making changes to improve services?

11. What multi-sectoral collaboration, if any, exists in service development?

12. Do you have any other comments?

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the recruitment, transportation, transfer, harbouring or receipt
   of persons, by means of the threat or use of force or other
   forms of coercion, of abduction, of fraud, of deception, of the
   abuse of power or a position of vulnerability or of the giving
   or receiving of payments or benefits to achieve the consent of
   a person having control over another person, for the purpose
   of exploitation. Exploitation shall include, at a minimum,
   the exploitation of the prostitution of others or other forms
   of sexual exploitation, forced labour or services, slavery or
   practices similar to slavery, servitude or removal of organs.
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