I go around and I cannot see any dirt Her house is in the next door so anytime

I go around and i cannot see any dirt her house is in

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very well. I go around and I cannot see any dirt. Her house is in the next door, so anytime she can go there [and say], “Oh you’re not cleaning, you’re doing like this, like that, like that.” So, sometimes it’s so straining in your physical, you’re so tired and then you’re tired in your mind and then emotionally. Discussion For health professionals to effectively serve survivors of human trafficking, it is essential that we understand psy- chological coercion and appreciate its potential effects on our patients’ health. All of the survivors we interviewed reported experiencing many nonphysical coercive tactics at the hands of their traffickers. By examining the role of psychological coercion in human trafficking through the lens of Biderman’s framework, we gain insight into the chronic stress experienced by victims, allowing for a bet- ter understanding of how trafficking limits victims’ social and personal coping resources and contributes to acute and chronic health problems (Pearlin, Menaghan, Lieberman, & Mullan, 1981). Traffickers, as described by our participants, typically employed multiple coercive tactics to deprive the women of their dignity and autonomy and render them depen- dent. These experiences of psychological abuse, some- times in combination with physical and sexual violence, subjected victims to extreme stress. Stress refers to the arousal of physiologic responses to environmental demands or pressures that exceed an individual’s ability to adapt and absence of the means to obtain sought-after ends (Aneshensel & Mitchell, 2014; Gale Encyclopedia of Medicine, 2008). Mediated through key regulatory systems of the body including the nervous system, immune system, and the endocrine hypothalamic-pitu- itary-adrenocortical (HPA) axis, stress induces physio- logic changes that can manifest as mental and physical health problems (Hori, Ozeki, & Teraishi, 2010; McEwen, Eiland, Hunter, & Miller, 2012; Segerstrom & Miller, 2004). Stress proliferation, in which primary stressors lead to a cascade of secondary stressors (Pearlin, Aneshensel, & Leblanc, 1997), further overwhelms the ability to meet physical and cognitive demands and reduces coping ability. As studies from around the world have increasingly documented during the last decade, the traumas of forced labor are associated with mental and physical, acute and chronic, health effects (Cwikel, Chudakov, Paikin, Agmom, & Belmaker, 2004; Hossain, Zimmerman, Abas, Light, & Watts, 2010; Oram, Stöckl, Busza, Howard, & Zimmerman, 2012; Silverman et al., 2008; Tsutsumi, Izutsu, Poudyal, Kato, & Marui, 2008; Zimmerman et al., 2008; Zimmerman et al., 2006). Although most studies have focused on survivors of sex trafficking, emerging data, including our own, demonstrate a preponderance of health effects among survivors of trafficking in many other industries (Baldwin & Fehrenbacher, 2014; Turner- Moss, Zimmerman, Howard, & Oram, 2014).
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1178 Qualitative Health Research 25(9) In some cases, the nonphysical tactics of coercion described by survivors in our sample could lead directly to health problems observed in survivors. For example, the poor access to nutritional foods described by the
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