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Sold into sexual slavery; victims and conduits of HIV/AIDS

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
Day My God Died
, Gina still speaks for thousands
of girls and women who, trafficked internationally, are unwitting conduits
for a global epidemic.

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 Frie
nds of Maiti Nepal, who in turn helped him contact the nongovernmental
organization in Kathmandu featured in
Day My God Died
, Maiti

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


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.”

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.”


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.

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?’”


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.

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

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


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.

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.”