Trafficked

Slight and soft-spoken, the dark-eyed girl called Gina looks into the camera and speaks of her ordeal in a flat, disembodied voice, chronicling a story relived a thousand times. “The first night, they forced me to have sex. When I refused, they held me down, beat me, and raped me. I was seven years old.”

From her village in Nepal, Gina was kidnapped and sold by her abductors to a brothel in Mumbai, India, 1,000 miles away. She was proffered repeatedly to men willing to pay a premium for sex with a child. Some brothel customers believe a virgin can thwart or cure an HIV infection; others equate youth with purity and freedom from disease. By the time Gina was rescued, at age 11, she was dying of HIV/AIDS. Immortalized in the PBS television documentary The Day My God Died, Gina still speaks for thousands of girls and women who, trafficked internationally, are unwitting conduits for a global epidemic.

Watching the Emmy-nominated film on PBS one night in 2004, Harvard School of Public Health (HSPH) Associate Professor Jay Silverman was struck by both the horror and the global health implications of sex trafficking. In the age of HIV/AIDS, he realized, forced prostitution is often tantamount to murder. Many victims, compelled to service dozens of men per week, were contracting HIV and radiating the infection. Upon rescue or escape, critically ill women and girls were returning to their homelands, bringing the virus with them.

“This very provocative film crystallized my determination to contribute to our understanding of sex trafficking from the perspective of public health,” says Silverman, who for six years has directed the Violence Against Women Prevention Practice at HSPH. Silverman reached out to the U.S.-based Friends of Maiti Nepal, who in turn helped him contact the nongovernmental organization in Kathmandu featured in The Day My God Died, Maiti Nepal.

The NGO provides shelter, medical care, education, and job training for repatriated sex trafficking survivors. In Nepali, “maiti” means “mother’s home.”

‘VIRGINS’ WITH HIV/AIDS

On August 1, 2007, an HSPH-led team that included researchers from Boston University, University of California, and a child-oriented network of NGOs called ECPAT International (End Child Prostitution, Pornography, and Trafficking), published a study of Maiti Nepal’s survivors in the Journal of the American Medical Association (JAMA). Of women and girls trafficked between 1997 and 2005, the researchers found that 38 percent had HIV. At greatest risk by far, they discovered, were children—those who fetched the highest prices, perhaps because of their presumed virginity. One in seven study subjects had been sold before her 15th birthday. More than 60 percent of these children were HIV-positive.

To conduct the study, Silverman received partial funding from the U.S. State Department’s Office to Monitor and Combat Trafficking in Persons. Among those who studied victims’ case records and medical documentation were two HSPH collaborators, doctoral student Michele Decker and postdoctoral fellow Jhumka Gupta. Says Decker, a former rape crisis counselor, “I had noticed in my work that women in prostitution were often marginalized and incredibly vulnerable before they were prostituted. The trafficking studies are an amazing opportunity to try to understand what’s going on: What factors are putting victims at greatest risk? What can we do to intervene?”

Gupta was at that time a doctoral candidate in HSPH’s Department of Society, Human Development, and Health. Earlier she had completed a six-month fellowship in Mumbai, working on HIV outreach and education with children and adolescents. “You’d hear about parents being scared about their kids getting kidnapped and being forced into child labor,” she says. “And if you’d push a little further, you’d hear about the danger of being sex-trafficked.”

Says Silverman, “We in public health have too often turned a blind eye to sex trafficking and those most vulnerable to its consequences—very young girls. As our study reveals, they may well be a key piece of the global HIV/AIDS puzzle.”

INVISIBLE CRIMES

Following JAMA’s publication, Maiti Nepal’s founder and chair, Anuradha Koirala, wrote to the HSPH team by email. “[As a result of the paper], we have become more aware of the combination of factors placing the youngest girls in the highest risk category of medical consequences from trafficking. We better understand the risk to the general Nepalese population as victims return, becoming a potential source of infection to the country.”

Silverman offers possible explanations for the heightened risk faced by young girls. These children are least able to demand that clients use condoms. They may be ignorant of sexually transmitted diseases and their transmission. Their still-developing genital tracts, traumatized again and again, become torn and highly susceptible to infection.

But to the HSPH team, the most compelling reason for their exceptional vulnerability may be the high value placed on these children. From anecdotal reports, the researchers learned that traffickers sell younger girls at higher prices. For children, brothel owners can demand up to twice the usual fee from clients who prefer virgins, who are presumed to be disease-free. These most valuable of human commodities are forced to serve many more men than are mature women.

These children are virtually invisible, Silverman says. Hidden from police, they are sequestered under floorboards, even caged. Forbidden to visit medical clinics or participate in health promotion programs, they fall under the radar of public health studies. Says Decker: “This really does beg the question, ‘Where are these girls in our public health picture of prostitution and trafficking?’”

DRIVEN BY PROFIT

Silverman likens sex trafficking to organized crime, with one driving motivation: profit. Attempts to study or disrupt international trafficking networks must abide by this reality.

Early in 2007, Silverman, Decker, and Gupta published online a report in the International Journal of Gynecology and Obstetrics that illuminated the inner workings of this dark enterprise. With help from the Rescue Foundation of Mumbai, the team reviewed the case and medical records of 160 women and girls who had escaped or been rescued. More than half the victims had been trafficked as minors; nearly 60 percent were trafficked by people they knew, including husbands. Many had been drugged. Others were taken by force. Some went willingly, desperately poor and alone and lured by promises of a better life.

Many girls and women experience a violent initiation into sex work, the researchers learned. Victims who refuse risk being beaten and raped into submission.

Meanwhile, the researchers say, efforts to stop this abuse and find those enslaved remain few and underfunded. Police and other officials are often bribed to look the other way.

As shown in The Day My God Died, trafficking victims are so terrorized and traumatized that rescue is exceedingly difficult. Rescuers typically go undercover as customers, then try to persuade children and women who are trapped to leave with them when they return as part of a police-run raid. But leaving is “a very scary proposition,” explains Silverman. “It’s hard for victims to trust anybody. If they try to get out and they’re discovered, the consequences can be dire.”

Against a rising tide of disease, Silverman, Decker, and Gupta suggest social and economic solutions. Boost educational and economic opportunities for women and girls, they urge. Devise policies, laws, and interventions to stem the demand for child prostitutes by imposing harsh criminal penalties, shaming men within their communities, and educating the public about sexual slavery.

In addition, Silverman says, “We need to comprehend men’s motivations for seeking out child sex slaves in the first place.” On that subject, he notes, research has “shockingly little” to say.

FUELING POLICY CHANGE

Ambassador Mark Lagon, director of the State Department’s Office to Monitor and Combat Trafficking in Persons, echoed this stance in an interview with the Boston Globe concerning the JAMA study. “It’s important not only to look at the awful economic situation, and the political situation that makes people vulnerable, but also at the demand that creates this situation,” he said.

To fuel policy changes at the highest levels of government, Silverman, Decker, and Gupta will continue to document the harsh realities and public health consequences of sexual slavery. Silverman has received funding from the United Nations Development Programme to expand the work to several countries in Southeast Asia. Research in southwest China, too, is planned.

“The United Nations has recognized sex trafficking as a major facet of the global epidemic of violence against women and girls, as well as a horrendous violation of human rights that nations are legally bound to stop,” Silverman says. “But stopping this crime must also be seen as critical to stemming the international spread of HIV/AIDS.”