HIDDEN IN THE SHADOWS: Sex Trafficking and Women’s Health

1. HIDDEN IN THE SHADOWS:Sex Trafficking and Women’s Health Wendy Freed MD March 13, 2007

2. Objectives • Definition and scope of sex trafficking • Methods of control • Review medical complications • Review GYN complications • Review mental health complications • Interventions with trafficking victims • Address ethical issues

3. UN Definition • Trafficking in persons shall mean the recruitment, transportation, transfer, harboring 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 of 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.

4. UN Definition • Exploitation shall include at a minimum, the prostitution of others,or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or removal of organs. • Consent to the exploitation is irrelevant where any of the means set forth have been used • Recruitment, transportation, transfer, harboring or receipt of a child (under 18) for the purposes of exploitation are considered “trafficking” even if it does not involve any of the means set forth

5. US Law Severe forms of trafficking in persons means – The recruitment, harboring, transportation, provision, or obtaining of a person for labors or services, through the use of FORCE, FRAUD or COERCION for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. …Sex Trafficking in which a commercial sex act is induced by FORCE, FRAUD or COERCION, or if the person in under 18 years of age Source: Victims of Violence and Trafficking Protection Act 2000 22 USC 7102 §103(8)(B)

6. Forms of Trafficking • Sex Trafficking • Prostitution, pornography, stripping, massage parlors, escort services • Labor Trafficking • Farming, construction, restaurants, factories or ‘sweatshops’, begging • Domestic Servitude • Servile Marriage • All forms of trafficking can involve significant sexual violence for women

7. UN Data 2002 • 1 million individuals per year are victims of trafficking 700,000 victims of trafficking are women and children 175,000 individuals are estimated to come from the former Soviet bloc countries 45,000-50,000 individuals are estimated as being trafficked into the United States

8. Trafficking Data • US Dept of State TIP 2005: • 600,000 to 800,000 persons per year trafficked across borders • Female 80%, • Commercial sex industry 70% • About 15,000 per year into USA • ILO 12.3 million people worldwide • One million children worldwide in CSI

9. Vulnerability to Trafficking • Poverty/Desperate situation • Gender inequality • Lack of Education • Prior Sexual Abuse/Assault • Coercion, Manipulation, Deception • Initial Consent / Family Pressure

10. Dynamics of Control • Threats • Violence • Psychological manipulation • Isolation in an unfamiliar location • Restricted access to outsiders • Confiscation of travel documents

11. Adaptations to Captivity • Shock and disbelief • Resistance • Submission/Resignation • Develop survival strategies • Stockholm Syndrome

12. Stockholm Syndrome • Gratefulness for survival • Denial of violence/harm • Identification with trafficker’s perspective on the world • Misperceive roles of rescuers/captors • Difficulty separating from captor

13. Methods of Control • Women trafficked into Ireland describe being bought and sold on multiple occasions, passing through many different countries. They talk about being locked in houses and constantly guarded by traffickers where they are subjected to beating, starvation and rape. If they are uncooperative their family at home may be threatened or they are told they will be passed to even more dangerous owners. • O’Connor 2004

14. Methods of Control • It is a special phenomena noted by Italian police that Nigerian girls undergo much less physical control from their exploiters compared with girls of other nationalities who are trafficked into prostitution. They have no need for physical control because the rites the girls are made to undergo impose the psychological control on them.

15. Methods of Control • The girls are sold to “madams” and made to undergo specific “juju” rites before they leave Nigeria for Italy. They swear never to reveal the identity of their traffickers or madams. Even when they escape prostitution, they continue to repay their debts. • Aghatise, 2004

16. Methods of Control • Playing on the relationship of trust and affection, promises of easy earnings and promises of marriage, Albanian traffickers obtain the consent of the families to take the young women away to as better opportunities in life. With many Albanian girls/women, it is family honor that binds them not to dishonor the family name on pain of death.

17. Methods of Control • When they end up in prostitution, they are caught between a failed dream of love to a man who had sworn eternal devotion to them, destruction of their reputation and the risk of being killed by male family members family for having dishonored the family name. • Aghatise, 2004

18. Violence in Prostitution • 854 prostituted women in nine countries • Physical assault 71% • Rape 60% • Use of drugs or alcohol 70% • Desire to leave prostitution 89% • PTSD 68% • Farley 2003

19. Violence in Cambodia • 1000 (non-trafficked) brothel based and non-brothel based female and transgender persons in prostitution: • No participants were in debt bondage and unable to leave the brothel for the interviews so this data reflects those with relatively more freedom in the ‘’sex industry’ • 90% raped at least once in past year by clients, police or gangs • 75% gang raped in past year • 50% beaten by police, gangsters in past year • Carol Jenkins, The Policy Project, USAID 2006

20. Medical Effects • Violence: beatings, stabbings, broken bones • Head injury and TBI • Facial trauma including broken teeth • TB, Malaria • Hepatitis B, Hepatitis C • HIV / AIDS • Untreated illness, no access to health care • Over treatment with antibiotics leads to drug resistant infections • Death from homicide

21. GYN Health Impacts • Sexual violence/Rape • HIV/AIDS • STI’s • During one act of unprotected sex with an infected partner, an adolescent girl has a 30% risk of genital herpes simplex virus and a 50% risk of gonorrhea • HPV / Cervical Cancer • High number of sexual partners • Young age at first intercourse • Pelvic Inflammatory Disease (PID) and infertility • Unwanted pregnancy: Sexually active adolescents not using contraception have 90% chance to become pregnant within 1 yr • Forced / unsafe abortion

22. Illegal Abortions • Deaths per 100,000 Dev Countries USA • Legal Ab 4-6 1 • Illegal Ab 100-1,000 50 • One in ten pregnancies ends in unsafe abortion WHO 2004 • Complications • Incomplete abortion, puncture or tearing of uterus • Hemorrhage, infection or sepsis, • Chronic pelvic pain, PID, tubal blockage and secondary infertility • 10-50% of women who undergo unsafe abortions need medical care for complications (WHO 1998)

23. HIV/AIDS • Risk of HIV is related to how many sex partners one has • Adolescent girls have a 1% risk to acquire HIV during one act of unprotected sex with an infected partner • Who has power to negotiate condom use? • Violence, tissue damage, young age of girls • Adolescent girls with genital ulcers from herpes, syphilis, or chancroid have 4x risk of acquiring HIV infection

24. Psychological Effects • Post Traumatic Stress Disorder • Depression / Suicidality • Dissociation • Cutting • Substance abuse • Alcohol • Amphetamines

25. Psychological Effects • Sexual Trauma / Shame • Internalized Contempt / Degradation • Betrayal / Loss of trust • Fear / Loss of safety • Damaged sense of self • Cultural Meaning • Value of being good daughter • Virginity/Loss of value

26. Anxiety Nightmares Flashbacks Sensitivity to trauma triggers Numbing Irritability Hypervigilance Startle reaction Poor concentration Loss of sense of future PTSD

27. Access to Health Care • Very restricted access to health care • May bring provider to secure location • Reluctant to bring to public clinics • Poorly trained illicit providers may provide majority of health care

28. Safety in Initial Contact • Victims may be accompanied by their trafficker, pimp or associates • Private interview with trusted interpreter • Will interviewing them cause harm or put them in greater danger? • Assess level of immediate danger • Know local resources and referrals

29. Trafficking Screening QUS DHHS question card, 2003“Look Beneath the Surface” • What type of work do you do? • Are you being paid? • Can you leave your job? • Can you come and go as you please? • Have you or your family been threatened? • What are your living conditions like? • What are your working conditions like?

30. Trafficking Screening Q 2 • Where do you sleep and eat? • Do you have to ask permission to eat / sleep / go to the bathroom? • Are there locks on your doors or windows so you can’t get out? • Has your identification or documentation been taken from you?

31. Ethical Issues • Do we ask? • If we know, what do we do? • Is treating an STI sufficient? • What are the ethical obligations?

32. Ethical Issues • Mexican adolescent girls trafficked to sexually service farm workers in SD • Brothel are small enclosures of reeds in the fields and girls service up to 30 men a day • Public health physician brought to the field to provide health care witnesses sexual abuse • She reported to her supervisors who told her that prostitution was not a “Migrant Health Issue” and only treatment of STI allowed

33. Ethical Issues • A US physician brought to brothel in Cambodia as part of a public health training. She was supposed to examine everyone there, give pelvic exams and treat according to a WHO Syndromal Protocol. She saw a 13 year old girl chained to a bed and was told to give her a pelvic exam and treat her too. • Public health outreach to brothels treat STI’s and give condoms but do not intervene or support alternatives

34. Ethical Issues • Psychiatrist interviews a 14 yr old girl in Cambodian brothel. On return visit the brothel owner asks her to treat the girl’s symptoms of fever and tachycardia. • Brothel owner refuses to let her be brought to public clinic that SHARES a WALL with his brothel. Insists they only treat syphilis. • Old metal tin filled with medications offered for the girl’s treatment.

35. Ethical Issues • In a large Cambodian city, a brothel owner beats a 15 yr old girl to death. • Everyone knows who he is; impunity • Two years later he brings some of ‘his’ women to participate in a govt HIV surveillance project; several women, obviously terrorized, try to slip notes to the interviewer and the phlebotomist

36. Conclusions • Prostitution can never be made safe • Need to address the demand for commercial sex and the socialization of men and boys • Need to address normalization of violence against women and children • Need to address gender inequality • Education for girls: the longer a child is in school, the lower their risk to enter the sex industry • Meaningful economic survival for families

37. References • Prostitution, Trafficking and Traumatic Stress, ed. by Melissa Farley, Haworth Press, 2003 • Child Prostitution: global health burden, research needs, and interventions. The Lancet, V359(9315) 1417-1422 2002 • www.prostitutionresearch.com • www.CATW.org • wendyfreed@mac.com