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Sex Trafficking and the HIV/AIDS Pandemic

Testimony of Holly Burkhalter, Physicians for Human Rights Before the House International Relations Committee

Thank you, Mr. Chairman, for holding this important hearing. I am honored to be here. My name is Holly Burkhalter, and I am the Director of U.S. Policy for Physicians for Human Rights, a Boston-based human rights organization. Since forming our “Health Action AIDS” campaign two years ago, Physicians for Human Rights has engaged in extensive activities to mobilize the medical, nursing, and public health communities in the United States to confront the global HIV/AIDS pandemic. Our Health Action AIDS advisory board includes this country’s leading specialists in HIV/AIDS prevention, care, and treatment, many of whom are engaged in overseas programs.

Women and Girls’ vulnerability to HIV/AIDS: A priority of Physicians for Human Rights and our Health Action AIDS campaign is to support the right of people everywhere to avoid contracting HIV/AIDS, and, if infected, to secure care and treatment. We are particularly concerned about women and girls’ special vulnerability to AIDS. Discrimination and subordination of women and girls in many countries has denied them schooling, access to health care, the opportunity to work, has constrained their legal rights and economic opportunities, and has also disproportionately heightened their risk of contracting HIV/AIDS. Despite their relative equal numbers in the population, for example, young women in sub-Saharan Africa are many times more likely to contract the disease than their male age cohorts. A 2002 UNICEF study in Ethiopia, Malawi, Tanzania, Zambia, and Zimbabwe, for example, found that there were five to six 15-19 year-old girls infected with AIDS for every boy in that age group.

In part, such disparities are a reflection of physiological differences – women are as much as 2-4 times more likely than men to contract the disease through heterosexual acts. Female genital mutilation also increases the risk of HIV transmission.[1] But the high rate of infection among 15-19 year-old girls also reflects women’s powerlessness within and outside of marriage to control the terms of sexual contact. Moreover, while fidelity after marriage is required for many African and Asian women, many men do not uphold such norms. According to Stephanie Urdang of the U.N. agency for women, UNIFEM, among the highest HIV/AIDS risk factors for southern African women is marriage. Among the highest HIV/AIDS risk factors for women in India is marriage.

A report on sexual violence in Sierra Leone by Physicians for Human Rights noted the high rates of rape and gang rape in the context of civil war, but pointed out as well the vulnerability of Sierra Leonean women and girls to sexual violence from boyfriends or husbands. Nearly 67% of urban women interviewed for a survey on AIDS knowledge, practices and behaviors revealed that they had been beaten by an intimate male partner, and over 50% reported being forced to have sexual intercourse. In over 90% of these cases, a boyfriend or husband was the perpetrator. [2]

Vulnerability of Trafficked Women and Girls to HIV/AIDS: If women and girls are more vulnerable to the disease because of political, social, and cultural inequality, those most at risk are surely those who are trafficked – coerced, forced, or tricked into commercial sex. Sex trafficking is an almost inevitable death sentence for the victims for several reasons. First, because they are virtually or literally enslaved, trafficking victims have no ability to insist upon condom use and are vulnerable to dangerous sexual practices most associated with transmission. Second, trafficking victims are forced to endure intercourse with multiple partners. And third, violence is common in commercial sex and particularly prevalent when women or children are forcibly subjected to sex against their will. Injuries and abrasions sustained during sexual contact heighten physical vulnerability to AIDS transmission. [3] And young girls’ physically immature bodies are highly vulnerable to injuries, significantly heightening their risk of infection. Moreover, having other sexually transmitted diseases (STDs) heightens the risk of contracting HIV by up to a factor of 10.[4] STDs are more common among women than men, and women often contract STDs at a younger age than men.[5]

Enormity of the Crime of Sex Trafficking: Though the percentage of HIV transmissions that can be attributed to trafficking has not, to my knowledge, been determined, it seems highly likely that coercing or forcing millions of cases of girls and women into violent, unprotected sex acts with multiple partners is a significant factor in the spread of the AIDS pandemic. The consequences of trafficking can be gleaned from the significance of commercial sex transactions in the national AIDS epidemics in two of the countries where trafficking is most prevalent, Thailand and India. At the height of Thailand’s AIDS epidemic, more than 80% of HIV/AIDS cases could be attributed to women in the sex industry and their clients.[6] Commercial sex work is one of the driving forces behind the AIDS pandemic elsewhere, such as India, where HIV levels among sex workers in Mumbai (Bombay) exceeds 50%.[7] A 1997 study in Sierra Leone showed that 70.6% of those engaged in commercial sex in Freetown were HIV positive, compared to 26.7% just two years earlier.[8]

As reported by Human Rights Watch in its report on Thai women trafficked into debt bondage in Japan, statistics from Japan’s National AIDS Surveillance Committee confirm the particular vulnerability of female trafficking victims and other foreign women to HIV/AIDS in Japan: from 1985 through 1997, non-Japanese females accounted for 34% of all HIV cases and 8% of all AIDS cases. Human Rights Watch goes on to note that a 1997 study presented at the Regional Meeting on Traffic in Women in Asia and Pacific found that more than 90% of all non-hemophiliac cases of HIV/AIDS in Naano and Ibaraki prefectures involved foreign migrants, with most of those infected coming from Thailand and other Asian countries.

The vulnerability of trafficked women to sexually transmitted diseases is compounded by their inability to receive medical testing, treatment, counseling, prevention services, or other health care. Inability to speak or understand the language in a foreign land, poverty and indebtedness, and lack of freedom of movement may grossly impede access to health care. Moreover, as Human Rights Watch noted in its report on Japan, trafficked foreign women and girls are denied access to government-subsidized services for HIV/AIDS that are available to citizens of Japan.

While accurate statistics on the total number of women and girls trafficked into the sex industry are difficult to obtain, given the illegality of trafficking, estimates indicate that the numbers are enormous. The most recent State Department Country Reports on Human Rights affirm that there are 2.3 million women and girls held in prostitution against their will in India alone.

The State Department Country Reports provide other estimates as well. The latest report estimates that at least 10,400 women and girls were trafficked from Vietnam to China in recent years. Local NGO’s in Nepal estimate that from 5,000 to 12,000 Nepali women and girls were lured or abducted annually into India and forced into prostitution, and the Nepali human rights organization, Prayas, estimates that there are from 200,000 to 375,000 Nepali women in Indian brothels.[9] Moreover, the Asia Partnership for Human Development (APHD) Regional Programme Against Trafficking of Women and Children in South Asia notes most of the Nepalese girls currently working in Indian brothels are between the ages of 10 and 20 years. The World Bank’s “Nepal HIV/AIDS Update of 2002” states that “Nepal runs the risk of an increased epidemic due to an active sex trade and high rates of girl trafficking to India for sex work.”

Human rights groups in Bangladesh estimate that more than 20,000 women and children were trafficked annually for the purpose of prostitution, and more than 50,000 women and children were estimated to have been trafficked into India annually, most for the sex trade. Of an estimated 200,000 females engaged in commercial sex in Thailand, approximately 30,000-40,000 are under 18 years of age. There are a similar number of children, about 35,000 according to UNICEF estimates, engaged in commercial sex in West Africa.[10] A leading HIV/AIDS epidemiologist, Dr. Chris Beyrer of Johns Hopkins has linked the phenomenon of sex trafficking to the spread and mutation of the AIDS virus, and stated that new strains of HIV/AIDS are proving resistant to treatment. “What we are seeing is that the trafficking part of the sex industry is aiding the global dispersion of HIV subtypes.”[11]

The HIV/AIDS Pandemic Contributes to Trafficking and Sexual Violence: While it is fairly well understood that prostitution and trafficking are significant contributors to the growth of the AIDS pandemic, it is less well understood that the AIDS pandemic is apparently a factor in the crime of sex trafficking, particularly the traffic in young girls. Men seek ever-younger partners or virgins to avoid becoming infected themselves, or in the mistaken belief that having sex with a virgin will cure a person of AIDS.

In South Africa, these factors very likely have contributed to a dramatic rise in child rape. According to statistics from the South African government, child rape incidents increased from 7,559 in 1994 to 15,732 in 1998, and are believed to have surpassed the 20,000 mark in 2000.[12] Some 50,000 rapes in South Africa are reported annually; the South African Medical Research Council estimates that this figure represents 10 percent of the actual total. In the first nine months of 2001, 15,650 child rape cases were reported; 5,859 of the reported cases of child rape - more than one-third - were against children under the age of 11.[13]

The AIDS epidemic drives the sexual exploitation of women and girls in other ways, as well. With so many family breadwinners dead or ill, orphaned children and widows engage in “survival sex,” which places them at risk of the disease. More than 12 million African children have lost one or both parents to HIV/AIDS, and the number of children living on the street has grown exponentially. Save the Children/Sweden interviewed service providers for street children orphaned by HIV/AIDS in Kenya, Uganda, Tanzania, and Ethiopia, and noted that “an unprotected girl working on the streets will sooner or later end up working as a prostitute.”[14] Some estimates place the number of HIV/AIDS-orphaned children living on the streets at 350,000.[15]

Trafficking Can Be Stopped: It is very hard to imagine a crueler crime than sex trafficking or a more violent mode of AIDS transmission. There is one unique aspect to this crime, however, that offers hope that it can be eradicated, saving the lives of hundreds of thousands of women and girl trafficking victims and eliminating a significant source of AIDS transmission. That unique feature is that holding women and children in sexual slavery is illegal in every country in the world. It can only flourish when government officials are actively complicit. Thus ending sexual trafficking only requires the will of a country to end official complicity in violent sexual crimes. Physicians for Human Rights urges this Committee to incorporate measures to pressure governments to end sex trafficking as an integral part of “best practices” in HIV prevention.

Ending Trafficking as a Means of AIDS Prevention: Currently, “best practices” in HIV/AIDS prevention are known to include a number of medical and political interventions. Medical professionals know that successful strategies to prevent HIV/AIDS transmission include national leadership to promote safe sexual practices (such as Uganda’s “ABC” approach), making condoms widely available to those most likely to engage in high-risk behavior (such as truck drivers, men who have sex with men, and people involved in commercial sex), needle exchange for injecting drug users, voluntary counseling and testing and treatment of sexually transmitted disease, including HIV/AIDS, and assuring safety in medical settings by eliminating reuse of needles and syringes, securing a safe blood supply, and enabling health workers to adhere to universal safety precautions.

There is another AIDS prevention practice that should be endorsed and promoted that has not yet been incorporated into campaigns to confront the pandemic: eliminating sex trafficking.

As Gary Haugen of the International Justice Mission has stated, trafficking and child prostitution requires the active protection of a country’s police and judicial establishments. In order for those who force or coerce women and girls into prostitution or who engage children under the age of 18 in any commercial sexual transaction to pursue their illegal operations, brothel owners must offer the victims of multiple felonies (assault, rape, theft, abduction, illegal detention, etc.) to the public on a regular basis. How can they do this? By operating with the complicity of local law enforcement officials. How else can one explain how brothels in Cambodia offering five-year-old trafficked Vietnamese girls to Western pedophiles were able to pursue this trade in broad daylight at locations known to anyone who cared to surf an Internet porn site, or walk through the Sway Pak neighborhood in Phnom Penh?

Using the Leverage of the Trafficking Victims Protection Act: If government authorities can be persuaded that it is in their or their country’s interest to end sex trafficking, then traffickers and brothel owners will become uniquely vulnerable because of their complete dependence on corrupt police, immigration authorities, or judicial personnel. Consider the case of Cambodia. The forced prostitution of extremely young children (almost all of them very young Vietnamese girls) and of women coerced into sexual bondage has flourished in Cambodia for many years. Indeed, it is considered to be one of the top three countries in the world for such crimes, along with India and Thailand. When the Congress enacted the Trafficking Victims Protection Act of 2000, it handed the U.S. Government a powerful tool to encourage Cambodia and other countries to take action against traffickers and those corrupt government officials who facilitate their illegal activities.

Last year the State Department appropriately placed Cambodia on “Tier III” – a category mandated in the Act reflecting countries with severe trafficking problems that are not taking steps to address them. After a one-year grace period, Cambodia stood to lose virtually all its American foreign aid (except for humanitarian programs), under the authority of the sanctions authorized by the Act. A U.S. human rights group, the International Justice Mission, assembled damning evidence of high-level police corruption and horrifying undercover video footage of brothel owners offering kindergarten-aged trafficked Vietnamese girls to undercover investigators presumed to be sex tourists. Strong diplomatic pressure from the U.S. Ambassador to Cambodia, Charles Ray, ultimately persuaded the country’s highest authorities to at last cooperate in a raid that took place in April and effectively shuttered the Sway Pak neighborhood where the youngest girls had been forced to engage in commercial sex. Dozens of little girls are now in after-care programs, and a Cambodian police major implicated in a protection racket is on trial in the Cambodian courts. His case is believed to be the first of its kind in Cambodia.

It is important to note that human rights groups such as the International Justice Mission do not have to investigate and prepare for prosecution every brothel owner or trafficker in Cambodia to eliminate the market for children and trafficked women in the sex trade. A mere handful of prosecutions that yield significant jail sentences for the perpetrators may be enough to deter those who had never before faced any risk for the crimes they committed against children and women.

The IJM’s experience in Cambodia and elsewhere show that even corrupt and repressive governments will move against police or other officials when they are convinced that the cost of not doing so is significant.

Increase Pressure on Thailand and India: Having done an excellent job on the Cambodia case, the Bush Administration now needs to be similarly tough on other governments that tolerate, protect, and facilitate trafficking and child prostitution. India and Thailand are two of them. Both have had ample warning of a potential loss of foreign assistance and neither has taken appropriate action against police and other officials implicated in trafficking and the protection of brothels that retain women and girls by force. Both of these countries retained their wholly undeserved “Tier II” status – suggesting without evidence that they have begun to take effective action to address severe trafficking problems.

The State Department Trafficking office makes important contributions to the prevention of trafficking and provides a wealth of information about the problem in many countries. But this year’s report, as was the case in the two previous reports, is flawed by a paucity of data on prosecutions, convictions, and punishments for persons engaged in the crime of trafficking, reflecting the negligible response to severe trafficking problems by the governments in question. The case of India is illustrative: this year’s newly released Trafficking in Persons (TIP) report notes that “14 people have been convicted and sentenced in New Delhi so far.”[16] Yet the report indicates that only one case – that of a Swiss couple sentenced to seven years for kidnapping and molesting a child – resulted in a jail sentence, and there is no information in the report about disciplinary or judicial action taken against Indian police officials.

The TIP report notes that “[t]he [Indian] government has significantly increased the number of arrests, prosecutions, and convictions of traffickers and brothel owners over the past year, but backlogged courts slow criminal justice proceedings.” This suggests a surge of activity, yet without seeing data on the total number of convictions (and sentences) from this year and previous years with names of those receiving punishment, it is impossible to know whether indeed there has been an increase or whether those convictions are resulting in the release of even dozens, much less millions of women and girls in sexual slavery in India.

The TIP report entry on Thailand is similarly unprepossessing. The report notes that there were a total of 42 prosecutions and 21 jail sentences, but provides no details whatsoever on the cases. In Thailand, as in almost all other countries with severe trafficking problems, what few arrests occur in brothels are almost invariably the victims themselves. A May 4, 2003 report in the main Bangkok daily, “The Nation,” is illustrative. The paper noted that police arrested 29 Burmese and Shan women in Chiang Mai and charged them with selling sex services, just 1.5 kilometers away from the city’s police station.[17] Although the article noted that the women had been duped into working for a restaurant but later forced to provide sex services, there is no report that the perpetrators of the crime were arrested. If such arrests of perpetrators have been made, we would like to know the details, and encourage the Committee to request them.

It is safe to presume that India and Thailand are not holding back on information relating to successful convictions of the policemen who protect and thrive from the traffic in coerced young girls and women. Rather, the paltry numbers provided in the TIP report without edification on what the cases were or who was actually prosecuted reflect reality. It is not up to the State Department TIP office to chase down the data. If it is not freely forthcoming, we may presume that it does not exist. If it does not exist, then we may presume that the governments in question are not taking the steps required to seriously address trafficking. Accordingly, they do not merit Tier II status, and should be downgraded.

Amendment of the Trafficking Victims Protection Act Needed: This being the third year that the relevant governments have failed to take appropriate action resulting in jail sentences for traffickers, brothel owners, and government officials involved in sexual violence and exploitation of women and girls, I believe it is time to amend the Trafficking Victims Protection Act of 2000 to require that the State Department provide the following data on accountability for trafficking: How many cases have been investigated, prosecuted, and jail sentences mandated? What are those cases, and who was convicted? Who among complicit police or other law enforcement officials has been investigated, fired, prosecuted, and sentenced to jail? What crime were they convicted of? How long were the sentences?

The reason that such detail must be required is that in almost all of the very few known cases of prosecution for trafficking, jail time was minimal (under 30 days) or the perpetrators got off with a fine. Imposing fines on brothel owners or traffickers is not an appropriate response to violent crimes against women and girls. It almost invariably results in those fines being passed off to the victims, who end up paying it themselves.

The Congress clearly intended that the Trafficking Victims Protection Act should be used by the executive branch to use the leverage of foreign aid to actually end the crime of trafficking – something that every government has within its grasp. For countries that victimize millions of women and girls and convict virtually no one, three years is too long to get a passing grade. Thailand and India should both be informed that absent detailed judicial records of convictions resulting in significant penalties – jail sentences, not fines – of police officials, brothel owners, and others involved in the sexual slave trade, they will be relegated to Tier III status in 2004, with a diminution in non-humanitarian foreign aid to be expected a year later. This gives such governments a full two years to do what they are demonstrably able to do: end the involvement of their own police, immigration, and judicial authorities that allows entrepreneurs to offer the victims of sexual violence to the public.

Recommendations:

The Trafficking Victims Protection Act provides a unique opportunity for our government to help curtail an epidemic of violent crimes against women and girls, and to sharply curb an important transmission factor in the worst health crisis in human history. Physicians for Human Rights encourages the U.S. Government to incorporate anti-trafficking activities into its HIV/AIDS programs and activities.

   1. The executive branch should request from the governments of countries on Tier II and Tier III (those with a trafficking problem) evidence of the actions taken on specific cases of officials involved in trafficking. Failure to provide such specific cases should be assumed to reflect reality – that governments have indeed failed to take appropriate action. They should be automatically given Tier III status, and preparations to constrict their foreign aid should begin.
   2. Congress should amend the Trafficking Victims Protection Act to require the data described above.
   3. Diplomatic demarches should be prepared to inform India and Thailand that their Tier II status is fragile.
   4. Congress and the executive branch should provide assistance to non-governmental organizations that engage in investigation, documentation, rescue, police training, advocacy to promote prosecutions and convictions, and after-care for victims.
   5. Governments that receive U.S. assistance for HIV/AIDS activities should be encouraged to include an anti-trafficking component in their plans. The U.S. should provide technical advice and support for actions aimed at liberating, sheltering, and rehabilitating trafficked women and children and prosecuting those who profited from the crimes committed against them.
   6. U.S. prevention programs should include efforts to provide health care and HIV/AIDS protection for those most at risk of contracting and transmitting the disease, including women in the sex industry.
   7. The U.S. Government should use the upcoming international HIV/AIDS Conference in Bangkok, scheduled for July of 2004, to highlight the obligation of governments to end trafficking. U.S. officials, including those most engaged in developing HIV/AIDS programs, should use the coming year to strongly pressure the Thai government to take actions against its own officials that it has heretofore resisted or risk embarrassment at next year’s AIDS summit.
   8. The U.S. should promote “best practices” in ending trafficking and rescuing and caring for trafficking survivors by publicizing successes and rewarding good governance with increased assistance, particularly to police and judicial officials willing to take action against official corruption and crime.
   9. When good governance criteria are established to administer new spigots of foreign aid (including the Millennium Challenge Account), actions or the lack thereof to end official complicity in sex trafficking should be a key consideration.
  10. The U.S. government should take steps to collect epidemiological data on the relationship between sex trafficking and AIDS transmission, and should develop enforcement and assistance strategies in the context of its bilateral HIV/AIDS programs, as well as the international programs to which it contributes, to assist the victims of trafficking and to promote prosecution of perpetrators of trafficking and other violent sexual crimes.

Footnotes

1. See UNAIDS, Women and AIDS, Best Practices Collection (Oct. 1997), at 3. Available at http://www.unaids.org/publications/documents/human/gender/womenpve.pdf; UNAIDS, Gender and HIV/AIDS: Taking Stock of Research Programs (March 1999), at 5. Available at http://www.unaids.org/publications/documents/human/gender/una99e16.pdf.

2. “Violence Against Women in Sierra Leone: Frequency and Correlates of Intimate Partner Violence and Forced Sexual Intercourse,” African Journal of Reproductive Health, 1998; 2(1). Cited in “War Related Violence in Sierra Leone,” Physicians for Human Rights, 2002.

3. See UNAIDS, Women and AIDS, Best Practices Collection (Oct. 1997), at 3. Available at http://www.unaids.org/publications/documents/human/gender/womenpve.pdf (“Tearing and bleeding during intercourse, whether from ‘rough sex,’ rape or prior genital mutilation (female “circumcision”) multiplies the risk of HIV infection.”). See also UNAIDS, HIV/AIDS and Gender-Based Violence factsheet, c. 1999. Available at http://www.unaids.org/gender/docs/Gender%20Package/GenderBasedViolence.pdf.

4. See UNAIDS, Women and AIDS, Best Practices Collection (Oct. 1997), at 3. Available at http://www.unaids.org/publications/documents/human/gender/womenpve.pdf.

5. See Royal Tropical Institute (Netherlands), Southern Africa AIDS Information Dissemination Service (Zimbabwe) & World Health Organization/Global Programme on AIDS, 1995-6, "Facing the Challenges of HIV/AIDS/STDs: How Extensive are HIV/AIDS and STDs? (1995) Available at http://www.hsph.harvard.edu/Organizations/healthnet/HIV/docs/sea-aids/gend/gend80.html.

6. See Avert, AIDS in Thailand, http://www.avert.org/aidsthai.htm. Accessed June 18, 2003.

7. See World Bank, Spotlight on India’s AIDS Control Efforts (c. 2001). Available at http://wbln1018.worldbank.org/sar/sa.nsf/0/271dafec85f5958a8525686b005c2d20?OpenDocument.

8. Ministry of Health and Sanitation, National AIDS/STD Control Programme Annual Report for 1998 (Freetown, Ministry of Health and Sanitation, 1998, p. 3

9. “AIDS fuels traffic of Nepali girls to India,” June 9, 03, Reuters.

10. See UNICEF, Profiting from Abuse (Nov. 2001). Available at http://www.unicef.org/pubsgen/profiting/profiting.pdf.

11. April 19, 2002, UPI.

12. See Jean Redpath, “Children at Risk.” Focus (Helen Suzman Foundation), June 18, 2000. Available at http://www.hsf.org.za/focus18/childfocus18.html?FACTNet; Gavin du Venage, “Rape of children surges in South Africa: Minors account for about 40% of attack victim.” San Francisco Chronicle, Feb. 12, 2002. Available at http://www.aegis.com/news/sc/2002/SC020203.html.

13. “Unthinkable Crime,” by Samantha Power. Marie Claire, February 2003.

14. Stefan Savenstedt, Gerd Savensted, and Terttu Haggstrom, “East African Children of the Streets – a Question of Health,” (Stockholm: Save the Children-Sweden, 2000), as cited by “HIV/AIDS and Children’s Rights in Kenya,” Human Rights Watch, June 2001.

15. “Crimes Against Humanity,” Time Magazine, January 12, 2001, p. 8.

16. Trafficking in Persons Report, June 2003, Department of State.

17. “29 Alien Sex Workers Arrested in Police Raid,” The Nation, May 4, 2003.