Running head: SEX TRAFFICKING AND INCREASED RISK OF HIV IN INDIA 1

Sex Trafficking and Increased Risk of HIV in India

Monica Lawson

Western Washington University

Global Health Inequities and Interventions NURS 452

Hilary Schwandt, PhD MHS

July 24th 2017

SEX TRAFFICKING AND INCREASED RISK OF HIV IN INDIA 2

Sex Trafficking and Increased of HIV Introduction

The U.S department of state reports that millions of women and children fall prey to sex

trafficking in India. It is hard to know exactly how many individuals are sex trafficked because

this business is kept underground (U.S. Department of State, 2016). The women and children

which are sold into prostitution or sex trafficked are of low socioeconomic status and enter this

industry either with the promise of a better life or by force. There are a variety of ways women

enter the sex trade industry including being sold by family members. In fact, in a study done in

West Bengal India noted that 86% the sex workers in the study had been trafficked at a young

age by someone known to them which speaks to socioeconomic hardship and desperation

experienced by families (Sakar et al, 2011). As of 2015 it was estimated about 2,118,100 people

are living with HIV or AIDs in India (Central Intelligence Agency, 2017). Depending on the

district >30% of the general population are female sex workers living with HIV. The prevalence

of sexual exploitation as well as HIV in India is not coincidental (Beattie et al, 2014). There is a

wealth of literature that points to a correlation between sex trafficking and increased risk of HIV

this is related to a variety of risk factors including habitation in brothels, young age of sex

trafficked victims, disempowerment, and corrupt police involvement all of which have a direct

link to violence against sex workers.

Sexual violence directly correlated to HIV

Sexual violence has been shown to increase risk of HIV. Due to the coercive nature of

sex trafficking, victims of this trade are at higher risk for HIV then the average sex worker

(Sarkar et al, 2011). Many times sex trafficked individuals are beaten and raped as a way to

control them and make them submissive. This violence has lasting effects as a two year follow
SEX TRAFFICKING AND INCREASED RISK OF HIV IN INDIA 3

up study showed that women who experienced multiple violent encounters were 50% more

likely to contract HIV (Wirth, Tchetgen, Silverman, & Murray, 2012). A research study done

on the impact of community mobilization on risk taking behaviors as well as prevalence of HIV

found that about 63% of the female sex workers reported violence early on in their career. Of this

population 37% reported a history of violence despite joining the profession voluntarily. Most of

the violence seen in this population was sexual as they found 55% reported sexual abuse, 15%

physical abuse, and 30% both types of abuse. Successful condom negotiation was about 38% for

most recent clients and even lower if recent violence had occurred. It was noted that of HIV

positive female sex workers about 23% were victims of violence while only about 8% were HIV

positive and had not been exposed to violence. Female sex workers are forced to have sex with a

customer without a condom for fear of physical violence or death (Sarkar et al, 2011). The

repeated rape and physical abuse these women face puts them at an even higher risk for

contracting HIV due to vaginal mucosal damage from repeated injury (Wirth et al, 2012).

Sexual violence in younger population of sex trafficked victims

The increased of HIV in younger populations is a complex issue and related to multiple

factors. Younger female sex workers under age twenty are forced to see more clients per day

and do not have the confidence to negotiate condom use. This population is more prone to

violence and are many times hidden in brothels which are associated with increased violence and

lack of condom use. It was found that sexual violence makes victims 2.3 times more likely to

contract HIV in comparison to those that have not been violated. Trauma to their cervical

mucosa which is still developing makes them at an even higher risk for HIV(Sakar et al, 2011).

Unfortunately, sex traffic victims under 20 years of age are an underrepresented group. This is
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related to social isolation and lack of outside resources for this population. Youth are at even

greater risk when they are virgins as many men believe being young and a virgin makes them

more clean and free of disease, this means that demands are high for the young and

inexperienced (Silverman et al, 2006). It is also important to mention the ethical concerns as to

whether it is appropriate to study current child victims without intervention while this would be a

more accurate study design it is considered unethical (Wirth et al, 2012).

The brothels role in violence and increased risk of HIV

Sex trafficking victims are commonly sent to brothels where they are more easily

controlled with violence or confinement. The brothel owners use rape and physical violence to

control these victims (Wirth, 2012). The brothel owners ultimately have the power as to whether

a prostitute can negotiate condom use and can force these victims into unprotected intercourse.

One study which surveyed women and girls rescued from sex trafficking in Mumbai India found

the age when trafficked was between eight years old and twenty-nine years with an average of

about sixteen years old, the majority of which were originally trafficked to brothels. Most of the

victims in brothels are women and young girls. Startling still is that 65.9% of the sample

population reported that they were trafficked to brothels as minors. This same study found that

the longer the female sex worker stays in brothel the higher the risk of contracting HIV. For each

month a woman spends at a brothel their risk of contracting HIV increases by 3% to 4%. This is

frightening considering many female sex workers report being held in brothels for a number of

years (Silverman et al, 2006).

Police role in violence and increased risk of HIV

According to the World Health Organization police play a pivotal role in violence against

sex workers which impacts risk for HIV. In a survey of sex workers in India 70% reported
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violence by police. It was also found that many prostitutes believe that violence is part of the job

and reluctant to report crimes due to these claims being dismissed by authorities. Research out of

both India and Indonesia indicates that many times sex trafficked women as well as sex workers

are grouped together during police raids to be beaten and raped in exchange for going free as

well as placed in places where they are reportedly sexually exploited. The result of this terrible

violence is that women work on the streets which makes them even more prone to violence

which in turn makes them more susceptible to contracting HIV. It seems that law enforcement

and the laws regarding prostitution may increase violence against sex workers and in turn could

increase risk of HIV (World Health Organization, 2005).

Disempowerment of the female sex worker

These victims of sex trafficking are disempowered by the lack of control over their own

bodies and lives. Their energy is focused on immediate survival and avoidance of violence if

possible which does not involve prevention of HIV or sustainable health behaviors. These

women live with daily anxiety and fear which causes them to be depressed and turn to alcohol

and drugs to self-medicate. Many sex workers turn to injecting drugs which puts them at a high

risk for contracting HIV. Injecting drugs and unprotected sex has been shown to be the fastest

growing prevalence rate of HIV (World Health Organization, 2005).

Limitations to the Available Research

There are limitations to the available research. Most of the available data and current

research about sex trafficking and HIV was taken from convenience samples of women who

have been rescued from the industry (Wirth et al, 2012). There are no comparative studies

regarding female sex trafficked individuals and non-trafficked female sex workers but rather sex

trafficked individuals included in studies of female sex workers. This makes inferences regarding
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sex trafficking difficult. Other limitations include lack of research in adolescent and child sex

workers as sex trafficked victims. This is largely related to ethical concerns however it is

important to note that this population of youth are at a higher risk for HIV related to gender,

young age, and biological vulnerability related to cervical ectopy (George & Sabarwal, 2013). It

may be beneficial in future research to focus on male behavior regarding sexual exploitation and

increased risk of HIV considering many Indian men prefer to have sexual intercourse with virgin

sex workers. Male behavior is an important factor to consider as an Indian man that has

intercourse with a female sex worker is 70% more likely to contract HIV (Silverman et al, 2006).

Interventions

Current research suggests that interventions to prevent sex trafficking be

combined with HIV prevention (Wirth et al, 2012). However, a study done in 2014 out of

Karnataka India suggested that community mobilization was the answer to best prevent HIV

infection among sex workers. This study found that empowerment of female sex workers lead to

improved condom negotiation and reduced HIV risk behaviors. The program that was developed

focused on community involvement and empowerment of these women. The goal was to not

only motivate and give confidence to the female sex works but also to reduce violence,

harassment, and stigma. The program was funded by the Bill and Melinda Gates foundation and

had several phases of involvement which took approximately 10 years. The first phase involved

training female sex workers to be peer educators. A safe place was established where sex

workers could gather to rest or socialize. These centers provided the women with services such

antibiotics for gonorrhea and chlamydia in addition to hosting events and meetings.

Word of mouth spread and these centers became a hub where the female sex workers

could meet and share their stories which empowered them and unified them. The program
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created support groups which were then focused on critical thinking skills and reflection. The

second phase built on the first by empowering the female sex workers to work with local policy

makers, police, human rights lawyers, government officials, and the media. The goal of this

intervention was to reduce the stigma, violence, and discrimination these women face. The

result of this was more groups were formed in the community and community-based institutions.

Once this was done the final phase was in 2013 which involved the transferal of the program to

the female sex workers and the state government. The results of the study revealed a strong

correlation with the program and increased condom negotiation. It was also found that the

overtime there was a reduction in violence associated with the program (Beattie et al, 2014).

Conclusion and implications

Sex trafficked individuals are at increased risk of HIV related to a variety of factors but

the most prevalent theme is violence. The violence these women face is linked to every HIV risk

factor seen in the literature. The more violence a female sex worker faces the more at risk she is

to contract HIV (Sakar et al, 2011). This was demonstrated by brothel owners beating sex

trafficked victims into submission and forcing them to have intercourse without a condom

(Silverman et al, 2006), corrupt police raping and beating prostitutes in exchange for freedom

(World Health Organization, 2005), and Young sex trafficked victims being unable to negotiate

condom use due to fear of violence (Sakar et al, 2011). The results of such violence cause

disempowerment which in turn harms the victims chances of successful health behaviors (World

Health Organization, 2005). Community involvement such as the program out of Karnataka State

has been shown to decrease violence against female sex workers over time as well as empower

them to negotiate condom use which is an important component of HIV prevention efforts
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(Beattie et al, 2014). Further studies should be conducted specifically on sex trafficked victims as

comparative studies if possible. As well as research efforts into sex work activism and HIV

prevention. Research into sexual violence reduction methods would be useful as well as

successful education programs conducted in combination with police efforts. Interventions to

empower these women and hopefully educate them enough to protect themselves from further

violence and risk of HIV should continue. This is a multifactorial problem and should be

addressed as so. Police cooperation and community involvement is needed to destigmatize

female sex workers and hopefully protect them rather than harm them.
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References

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R., Ramesh, B.M., Blanchard, J.F., Heise, L., Vickerman, P., Moses, S., & Watts, C. (2014).

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George, A., & Sabarwal S. (2013). Sex trafficking, physical and sexual violence, and HIV risk among

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Epidemiology 177( 3), 23241. doi:10.1093/aje/kws338.

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