Dr. K. Wendy Freed, M.D. Consulting psychiatrist for Miller Children's Hospital Abuse and Violence Intervention Center in Long Beach, CA March 13, 2007

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. • 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
GYN Health Impacts

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

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

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 Q
US 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