While mindful of the various and specific contexts of each of the case study cities, we identified several cross-case thematic findings. These findings relate to the scale and scope of trafficking, key determinants of sex trafficking, barriers to health workers’ participation in antitrafficking efforts, and future opportunities for local health systems to address sex trafficking.
Uncertain Prevalence of Sex Trafficking
The difficulty in determining the scope of sex trafficking was identified as a major theme in all eight cities. Many respondents commented that sound methodologies for accurately estimating the prevalence of sex trafficking have yet to be developed. Respondents attributed some of the difficulty in developing these methodologies to the hidden nature of sex trafficking. Respondents further noted the lack of centralized databases for tracking victims as contributing to the difficulty in reliably estimating the extent of sex trafficking. Several respondents voiced concern over the wide range of published prevalence figures, cautioning that these estimates are mired by competing definitions of sex trafficking, discordance in the perceived agency of women, challenges in identifying victims, and hidden political agendas.
The majority of respondents believed that current estimates undercount the true number of victims; many referring to these estimates as representing “the tip of the iceberg.” The reasons suggested for this undercounting included victims’ reluctance to identify themselves to authorities as well as their inability to recognize their own victimization. Several respondents noted that the long-term exposure to physical threats and psychological manipulation instills fear in trafficking victims and facilitates the trafficker’s ability to exert control over victims. Fear of retaliation against them or their families may prevent victims from attempting escape as well as deter them from reporting or seeking assistance both during and after exiting the trafficking situation. Respondents also identified victims’ shame, denial, fear of authorities (e.g., possible deportation, skepticism about victims’ claims, or judgmental attitudes), and dependence on or traumatic bonding with their traffickers as barriers to self-reporting.
Key Determinants of Sex Trafficking
Respondents identified several key determinants of sex trafficking. Child sexual abuse was viewed as a major determinant of sex trafficking in all eight cities. Family dysfunction and early exposure to violence in the home were also frequently reported as trafficking determinants. Respondents explained that these unhealthy relationships and experiences in childhood result in multiple factors at the individual level, such as low self-esteem, need for affection, and inappropriate sexual boundaries, that increase an individual’s vulnerability to sex trafficking. Financial insecurity, lack of formal education, and lack of viable alternative economic opportunities were also described as important determinants. Respondents believed that these combined economic factors fuel the migration of women and girls out of their rural villages in search of work and/or education, a process during which they are vulnerable to being lured or coerced into sex trafficking. Particularly in the Indian case studies, the role of family poverty in fostering the sex trafficking of girls was critical. In most case sites, respondents believed that family members, some unwittingly and some knowingly, play a role in the trafficking process.
In some cities, societal and cultural norms that reinforce inequalities were also viewed as facilitators of sex trafficking. Societal-level factors appear to play particularly important roles in the cases of India and Brazil. Many respondents, notably in Rio and Salvador, made specific reference to the sexual objectification of women and girls as a form of gender inequality that normalizes sexual exploitation and facilitates sex trafficking. Respondents further explained that this objectification leads to the early socialization of women and girls who, by adopting the view of themselves as sexual objects, become prime targets for exploitation in the commercial sex industry. Respondents also cited the high demand among men for commercial sex and the profitability of the commercial sex trade as important and often overlooked key trafficking determinants. Furthermore, the complex interplay of determinants facilitating the trafficking of women and girls is compounded in the legal sex work industries of India and Brazil, where respondents suggested that some law enforcement officials are complicit in the sex trafficking trade of minors. In Kolkata, social discrimination against darker-skinned individuals and lower-caste individuals also serve as risk factors for sex trafficking. A similar discrimination was described in Rio and Salvador against darker-skinned individuals and those who live in poor urban shanty towns (favelas) or in poor rural communities.
Weak Response of Local Health Systems
Respondents described a myriad of health problems either associated with sex trafficking or consequential to the poor working and living conditions of sex-trafficked victims (Table 2). However, respondents in all eight cities characterized their local health system responses as weak and limited. Although public health facilities were believed to provide the majority of health care for victims, especially in emergency situations, many respondents remarked that local governments had not developed well-coordinated systems of health care for sex trafficking victims.
In all eight cities, nongovernmental organization (NGO) service providers were perceived as attempting to fill this gap by either providing or facilitating access to healthcare services. For example, several respondents in the cases of New York and India noted that NGO service providers rely heavily on personal contacts in healthcare facilities to secure illness-related episodic care for former victims. In many of the cities, respondents were able to identify various nonprofit free health clinics, community health clinics, mobile health clinics, and emergency departments as local resources for accessing care, but believed that no single facility was designed to meet all the health and mental health needs of this population.
Despite the efforts of NGO service providers and a small number of dedicated healthcare workers in each city, the victims’ lack of access to health care was viewed as being a significant gap and was a major concern among respondents. In particular, the absence of culturally sensitive mental health services for trafficking victims was described as a major gap in services in all eight cities. Furthermore, in Kolkata and Mumbai, many respondents expressed the need for health care for the children of trafficking victims and commercial sex workers.
Barriers to Greater Health System Participation
Respondents reported that the hidden nature of trafficking dramatically restricts victims’ access to healthcare services while they are in trafficking situations. Many respondents also noted that the inhibited health-seeking behavior of victims (and former victims) acts as a barrier to a greater health system response. Victims were believed to refrain from seeking care due to fear of discriminatory treatment, fear of being reported to immigration officials, and fear that they were either not entitled to or could not afford health care. Other victims were reportedly deterred by the long wait times or restricted hours of operation at health facilities. Moreover, many respondents acknowledged that when victims (and former victims) do present to health facilities for illness-related episodic care, their reluctance or inability to disclose their situation further limits the response of local healthcare systems. Respondents explained that the health system’s inability to identify them as victims of trafficking, while multifactorial, also leads to the failure in recognizing the full extent of their health and mental health needs at the time of presentation.
Respondents described a general “reluctance” or “disinterest” within the health system and among health providers to address the broader issue of interpersonal sexual violence and commercial sexual exploitation. They attributed this reluctance to a variety of factors such as health providers’ low level of awareness of trafficking, high patient case load, fear of breaching patient confidentiality, fear of compromising patient safety, and fear of retribution by the traffickers. In the cases of Brazil, Philippines, and India, some respondents noted that health providers’ tendency to either avoid or ignore the overarching problem of violence against women and girls is a product of gender inequalities that exist in the cultural and social norms—norms from which health providers are not immune. Many respondents in these cities commented that health providers can harbor discriminatory attitudes towards women and girls, especially those suspected of engaging in commercial sex. These attitudes reportedly result in punitive and insensitive treatment of victims. In Mumbai and Kolkata, respondents perceived that hospital workers prejudge women in prostitution and treat them less favorably than other patients. In Manila and Rio, multiple key informants reported widespread humiliating treatment of unmarried women who present for reproductive health problems and outright hostility toward women who present for care following complications from unsafe abortions. In addition, several respondents in the Brazil cases noted that some healthcare workers’ negative attitudes toward certain patients (e.g., poor, Black women) can have deleterious effects on women’s access to, and experiences with, health care. Respondents expressed concern that these attitudes among health providers further discourage victims from disclosing their experiences, thereby interfering with their ability to obtain care and referrals tailored to their specific needs.
At the systems level, respondents cited several barriers to greater health system participation in antitrafficking efforts: the dismissal of trafficking as a public health issue, the absence of curricular offerings on trafficking in health professional schools, the dearth of trafficking-related training programs for practicing health workers, the lack of streamlined referral mechanisms to social services for victims, the constraints placed on resources by overburdened healthcare systems, the institutional biases that engender lower quality health care for poor women and girls, and the emphasis placed on a biomedical, rather than holistic, approach to health in medical training.
At the national and policy levels, the lack of participation of health officials in antitrafficking policymaking was noted in several cities. In London, Manila, Kolkata and Mumbai, some respondents argued that the practice of police raids in red-light districts undermine the ability of NGOs and healthcare workers to negotiate access to brothels and provide health care for victims.