Special Section: Papers from Building Global Alliances V:   The Challenges of Migration for Health Professional Women
Policy, Politics, & Nursing Practice
Trafficked Women: Links to
Migration and Other Forms of
Transnational Movement
Laura J. Lederer, JD1
Abstract
This article is based on a presentation delivered to The Fifth Annual Building Global Alliances Symposium: “The Challenges
of Migration for Health Professional Women,” convened by CGFNS International, Philadelphia, PA, December 8, 2008.
Keywords
global migration, human trafficking, Trafficking Victims Protection Act
I want to thank CGFNS International for sponsoring this
important gathering on the challenges of migration for pro-
fessional women. It is a very important but much neglected
topic. I have been asked to speak to you about trafficking in
persons, which is a subset of global migration. It is a criminal
enterprise in which people are recruited, harbored, trans-
ported, and bought and sold, by force, fraud, or coercion, for
purposes of forced labor or commercial sexual exploitation.
Human trafficking is not only a law enforcement issue and a
human rights issue but it also affects public and private health.
Yet we have only begun to examine the health implications
of human trafficking. I want to start today with a story that
I believe puts a human face on trafficking in the United States.
A story that makes the harm visible—which is one of the most
difficult tasks we have with trafficking in persons, because
we don’t see it in our everyday life.
This is the story of Rosa, who was a young girl trafficked
from Mexico to the United States. Rosa was 13 and waiting
tables in a restaurant in a small village near Vera Cruz,
Mexico, when she was approached by an acquaintance of her
family who said to her, “You know, you can make ten times
more money in the U.S. doing what you are doing here in
Mexico. I know someone who can find you a job in Texas—
you can send money home to your family, you can have your
own life. If you don’t like the job, we will get you another one.
If you’re homesick, we will take you back home to visit your
family. You can’t lose.” Rosa was young and hopeful. She
asked her parents if she could go but they forbade her. How-
ever, she wanted a better life than what she had, so, against her
parents and friends’ warnings, she accepted the offer.
She was told to go the main hotel in town on Friday eve-
ning. When she got there on Friday evening, there was a car
waiting, with several other young girls about her age from
neighboring villages. She got into the car and the driver drove
11(2) 147­–150
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them into the dessert as far as they could toward the U.S.
border. There, they met dozens more young women and girls
from other towns in Mexico.
On the ground, Rosa saw backpacks and water bottles.
The women and children were told to pick up a backpack and
a water bottle, and then, following a path laid out for them, they
began to walk. They walked for 4 days and 4 nights—through
the desert, across the Rio Grande, and into Brownsville, Texas,
where they were picked up by a white van. Then they were
driven across Texas, across Louisiana, and into a rural area
in Florida. They stopped in a rural town called Avon Park, in
front of a series of trailers. There, they were ordered out and
the van drove away.
A big burly man came up and told them, “I’ve just pur-
chased you.” Rosa learned then that she was in a brothel and
that she would have to buy her freedom by sexually servic-
ing men.
Rosa was young. She was a virgin. She was Catholic. She
knew that what she was being told to do was a sin and she
started to cry and begged to be taken to a restaurant to work.
But she was told, “There are no restaurant jobs—only this.”
When she refused to do what they said, the burly man brought
out three other men who took her into one of the trailers and
gang-raped her to induct her into the “business.” Then they
locked her in the trailer without food and water until she
succumbed.
For the next 6 months she was a prisoner. She was forced
to service 10 or more men a day. On the weekends, it was as
1
Global Centurion, Washington, DC
Corresponding Author:
Laura J. Lederer, JD, Global Centurion, 1513 Pennsylvania Ave. SE,
Washington, DC 20003
Email: llederer@globalcenturion.org
148 Policy, Politics, & Nursing Practice 11(2)
many as 20 to 30 men. The men bought a ticket, which was
a condom, for US$20, but they often didn’t use it.
Twice, Rosa was impregnated and twice, she was forced
to have an abortion. Each time, she was forced back in to the
brothel the next day. She was beaten if she refused the cus-
tomers’ demands. She was guarded 24 hr a day, even when
she went to the bathroom. She was passed around at private
parties that the traffickers held in the evenings and on week-
ends. Once, she and several others tried to escape. When they
were caught, the traffickers assembled all of the young women
and children and they pistol-whipped those who had tried to
escape around the head and face, in front of everyone, to deter
anyone from trying to escape. Shortly after this beating and
the second abortion, she started to feel sick and crazy. She
said she felt like she was outside her own body. She felt dead
but alive. To keep her functioning in the brothel, the traffickers
gave her drugs and alcohol to numb her pain.
She was only “rescued” when one of the young women
jumped out of the second-story window at one of these pri-
vate parties and ran to a neighboring house. The neighbors
called the local police. The police called what was then the
INS (Immigration and Naturalization Service [now ICE—
Immigration and Customs Enforcement]) and the FBI who
then set up a sting operation and sent agents in to the brothels
pretending to be customers. More than 40 young women and
girls were rescued and a dozen traffickers were arrested.
A medical doctor examined Rosa. She had several sexually
transmitted diseases. She had broken bones from the beatings
that hadn’t healed properly. She had pelvic inflammatory dis-
ease and scar tissue from the forced abortions. She was addicted
to drugs and alcohol. She was suffering from post-traumatic
stress syndrome, including nightmares and flashbacks, depres-
sion, and suicidal tendencies. In short, she was physically,
mentally, emotionally, and spiritually broken.
To make matters worse, when Rosa was discovered, the
United States did not have a trafficking law. Instead of really
rescuing Rosa, the police arrested her and the other young
women and children and locked them up in jail alongside the
traffickers. We had never seen a case like this in the United
States. We didn’t have a victim-centered approach to the
case. We simply didn’t understand what we were seeing until
2 weeks later when we hired Spanish-language interpreters
for the interviews and began to separate out what had hap-
pened and realized that we had victims on one hand and a set
of really serious criminals on the other hand. We didn’t have
anywhere to put the victims.
Later, Rosa and the other victims were taken from jail to a
battered wives shelter and there they were told to pretend they
were victims of spousal abuse because that was the shelter’s
mandate. We did not have any center that could give them
the set of services that they needed for what they had been
through. While at the center, Rosa wanted to see a priest, but
was instead taken to a psychiatrist because that was the medi-
cal model this shelter had for addressing violence against
women. They were there for the next year and a half while
this case came to trial. It was our first sex trafficking case in
the United States. The battered wives shelter did the best they
could but it was not set up to address the kinds of problems
that these young women and children had developed.
In 1998, a very broad-based group of women’s rights organi-
zations, faith-based groups, children’s groups, and labor groups
came together and helped to draft the Trafficking Victims Pro-
tection Act (TVPA), which was enacted in 2000. It is a model
law. It’s a law that is being used in many countries as they draft
their own laws to address the problems in their countries.
The law accomplished four things:
First, it expanded the definition of trafficking. Trafficking is
an organized activity. We needed a law that reached the recruit-
ers, transporters, harborers, the buyers, the sellers, all of those in
the pipeline of activity. So the first thing that the definition did
was to include all of those. So now the law reaches even the
recruiter who came up to Rosa in Mexico and lured her into this
industry.
Second, it increased penalties for trafficking. Previously,
laws for trafficking humans were minimal. In fact, Rosa’s traf-
fickers went to trial before the law was passed and most of them
received sentences of three months to a year. Now, with the
TVPA, the penalty is 20 years to life.
Third, the law takes a victim-centered approach. Human traf-
ficking involves the buying and selling of real human beings.
When the case is completed, there is a victim—a human being
who needs help to get back to life. We talk about the three Ps–
prevention, prostitution and protection. Then, we have expanded
that to the four Rs: rescue, rehabilitation, re-integration and res-
toration. In the United States, we wanted to make sure that we
weren’t doing what is still happening in other destination coun-
tries. We didn’t want to deport victims—people who had been
hurt in our country. We wanted to give them a second chance
and we wanted to assist them with that restorative process. This
victim-centered approach is very important. It gives the traffick-
ing victim a temporary visa, which allows them to stay in the
United States for three years while they get some of the emer-
gency medical, legal and other kinds of care that they need.
Fourth, the law created the President’s Interagency Task
Force on Trafficking, which is a cabinet-level task force chaired
by the Secretary of State. It also includes the Attorney General,
the Secretaries of Health and Human Services, Labor, Homeland
Security, Defense, the Administrator of the US Agency for Inter-
national Development (USAID) and others. Each of these agen-
cies plays a vital role in addressing human trafficking. We found,
as we began doing this work, that the agencies were not talking
to one another. So we needed this interagency task force. Since
then, this has become a model all over the world for setting up
task forces and commissions that can deal with the problem
holistically and at the highest levels of government.
The TVPA also created an office in the State Department to
monitor and combat trafficking in persons. It produces an annual
report that assesses and rates every country in the world on their
Lederer 149
progress in addressing trafficking. If a country is making no
efforts to comply with the standards of the TVPA, the U.S. has a
very carefully tailored set of sanctions that involve withholding
non-humanitarian, non-trade-related assistance. The sanctions
are aimed at the things government cares about–military assis-
tance, educational exchange money, cultural exchange money.
Why did we do this? Because we knew if we had a perfect
law for the United States but we didn’t find a way to encourage,
urge, even pressure other countries to address their trafficking
problem then we would not be able to make progress because
this is a transnational problem and so it needs transnational solu-
tions. That is the foreign-policy piece in the law and it is very
important.
Victims of trafficking often endure brutal conditions that
result in physical, sexual, and psychological trauma. The health
risks of human trafficking include not only HIV/AIDS but also
many other sexually transmitted diseases as well as serious
communicable diseases, such as hepatitis and tuberculosis.
In sex trafficking in particular, they can also include unwanted
pregnancy, forced abortion, and/or abortion-related compli-
cations. For example, in the first sex trafficking case in the
United States, a number of the young women and children
who were trafficked from Mexico to rural Florida testified
that they were forced to have multiple abortions and then
forced back into the brothel the next day. In Turkey, young
women and girls told of horrifying abortifacients that were
injected into their stomachs with needles.
Rape and other violence such as battery and assault are
also common. Testifying before the Massachusetts Senate
last year, a young Haitian woman, who was trafficked from
Haiti to Florida when she was 14 years old, stated that she
was then moved up to Massachusetts where she was sold into
domestic servitude. She testified that her traffickers beat her,
cut her with knives and bottles, and raped her with objects
before selling her. She had a two-inch scar on her cheek to
prove it. She also knew of other children who were in similar
slavery-like situations. In a labor trafficking case we had in a
U.S. territory, a young woman lost her eye as a result of the
vicious assaults of her traffickers.
Substance abuse, such as to alcohol or drugs, is a common
result of human trafficking. In testimony in the U.S. Senate,
a young woman who was trafficked from Russia to Israel
testified that her Israeli traffickers gave her Ecstacy and
other drugs to numb her against the brutal physical and psy-
chological abuse she endured. She spent 2 years in Russia in
a psychiatric ward following her rescue and felt crazy and
suicidal much of that time. In Cambodia, trafficking victims
on a fishing boat were given uppers in their food during
hours they were forced to work and downers when they were
put to bed. In South Asia, trafficking victims have testified
about addictions to heroin and those addictions last a
lifetime.
Finally, the mental health issues that affect trafficking victims
are serious and long lasting. Post-traumatic stress syndrome and
other trauma-related symptoms are common. These include
flashbacks, nightmares, insomnia, dissociation, depression, anx-
iety, schizophrenia, suicidal tendencies, and suicide.
The health implications of sex trafficking extend not only
to its victims but also to customers and sex tourists—and
beyond them to the general public as well, because those who
frequent brothels can become carriers and/or transmitters of
serious diseases. For example, only 2 weeks ago, in a recent
raid in San Francisco that closed down 19 brothels, private
residences, and businesses related to trafficking, 101 women
were taken into custody as potential witnesses. Of these, more
than 80% tested positive for TB. Some 20% to 25% of
these had active cases. It is unclear how many customers these
women came in contact with. The CDC was a part of the
operation, and we hope we’ll have more public health infor-
mation on this case as time goes on.
Last, but not least, HIV/AIDS and other sexually trans-
mitted diseases are common health problems in those who
have been trafficked into prostitution. Countries as disparate
as India, Thailand, Russia, Tanzania, South Africa, and oth-
ers all recognize that thriving sex industries are becoming
epicenters for epidemics. In this modern day slavery, where
people are being moved vast distances around the globe to
do someone else’s bidding for someone else’s gain, these
epidemics are moving with them.
I’d like to take a few minutes to discuss what the United
States government has been doing to address the public health
issues and the private health and human rights issues related
to sex trafficking. The Department of State has funded sev-
eral important studies on the link between trafficking in per-
sons and HIV/AIDS in Nepal and India.
We have developed strong policies to combat HIV/AIDS
and human trafficking. We are the largest funder in the world
of vital HIV/AIDS prevention and treatment. In addition, we
have programs in other departments that are making progress
on the health implications of trafficking. For example, recently
the Department of Health and Human Services held a confer-
ence for health providers and public health officials to call
attention to the health needs of human trafficking victims.
These programs are just a beginning. We need to envision
the health problems of human trafficking holistically and to
create a strategic plan of action that addresses all components
of the problem. Let me share a few thoughts in that vein. It is
going to be important to undertake new research. Without
good information, we cannot design good intervention
programs. Most of the NGOs simply improvise. There should
be a uniform routine screening protocol that is developed
and used in every trafficking case around the world. Even in
the United States, depending on which NGO takes responsi-
bility, you may or may not get the kind of health care and
comprehensive screenings needed to address the health prob-
lems of trafficking victims.
We need a literature review to gather all of the studies on the
health issues related to trafficking in persons and to analyze
150 Policy, Politics, & Nursing Practice 11(2)
them. We need new studies to investigate the particularized
health problems, including studies on HIV/AIDS, in trafficking
and prostitution. We need the establishment of a global database
that links data on the nature and scope of problems, health stud-
ies, treatment protocols, and more. To date, there have been a
few, but we need more articles in medical journals. We need to
be writing about this and communicating about this to the medi-
cal community to address specific areas of interest, such as unin-
tended pregnancies and forced abortions, and the need for
age-appropriate education in families about human trafficking
and its health and other consequences. We must design educa-
tional modules and include those modules in the sex education
programs, in the abstinence programs, in family health pro-
grams, and in other curricula that already exist today.
There is no reason why we cannot do it. It just hasn’t
been done. A coordinated effort with the United States
government—perhaps through the CDC, perhaps state by
state—to administer a retroactive health study on the U.S.
trafficking victims that we have would be beneficial. So far,
we’ve given T visas to almost 2,000 foreign national victims
trafficked into the United States. We need a survey that looks
back over not only what their health problems were when they
were first rescued but also what they are struggling with now.
There is still other work that needs to continue. Politics
and values drive health programs in the field. We must
work harder to design programs that go further than just harm
reduction, especially programs to include identification of
victims, report, and rescue. We must work toward harmo-
nizing the President’s Emergency Plan for AIDS Relief
(PEPFAR), Global Fund, IOM (International Organization for
Migration) and other HIV/AIDS and/or TIP (Trafficking in
Persons) grant-making and other programs. We should fold
antitrafficking messages into ABC (Abstinence, Be Faithful,
Use Condoms) programs; and fold HIV/AIDS messages into
antitrafficking programs. We need to address the basic
human rights principles of freedom from sex slavery—not
just the narrower concern of condom distribution to protect
from disease. We need to take a comprehensive and holistic
approach to health concerns related to human trafficking—
not just HIV/AIDS and treat the mental as well as the physi-
cal TIP-related health problems. Finally, we need to link our
domestic efforts on health and human rights to those happen-
ing internationally.
As the United States has continued its work, other coun-
tries also have begun to work on this issue as well. They have
been drafting and passing laws; training law enforcement
agencies to combat human trafficking; devoting resources to
helping poor countries provide shelter and services to traf-
ficking victims. Yet, there is still much to do.
The U.S. government must partner with international
organizations like CGFNS to achieve good results because
governments do some things well: we can set policy; we can
employ diplomatic tools to encourage other governments to
take action; we can prepare national education campaigns to
raise awareness at home and in schools; and we can utilize
tax payer resources to assist groups in providing services.
This, however, is not enough. Often times, the first line of
contact—and sometimes the only contact—between a traf-
ficking victim and the mainstream world, is the health care
professional.
Alert doctors, nurses, emergency service providers, and
other health care professionals who took the time to look
beneath the surface to ask questions, and to ferret out the real
nature of the health problem confronting the young person in
front of them have uncovered a number of recent trafficking
cases in the United States. This work is the bravest, and
perhaps most important, work that must be done. Our urgent
tasks are threefold: first, we must develop policies and pro-
grams to address the medical and health implications of traf-
ficking in persons. Second, we must train health professionals
so that they are able to identify trafficking victims. And third,
we must integrate rescue into palliative care.
If we partner and work together, I know we will make
progress on this important issue. Thank you.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
Reference
Trafficking Victims Protection Act of 2000, Div. A of Pub. L. No.
106-386, § 108, as amended.
Bio
Laura J. Lederer, JD, is vice president of Global Centurion, a non-
governmental organization devoted to ending child trafficking.
At the time of this presentation, she was executive director of the
Senior Policy Operating Group on Trafficking in Persons, a high
level interagency policy group that staffed the president’s cabinet-
level Inter-Agency Task Force on Trafficking in Persons as well as
senior director of global projects in the Office to Monitor and Com-
bat Trafficking in Persons at the U.S. Department of State. She also
served as senior advisor on Trafficking in Persons to Under Secretary
of State for Democracy and Global Affairs, Paula J. Dobriansky. She
founded and directed The Protection Project at Harvard University’s
John F. Kennedy School of Government and continued as director
when the project relocated to the Johns Hopkins University School
of Advanced International Studies in 2000.
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