Our Bodies, Ourselves (169 page)

What distinguishes trafficking is the use of force, coercion, and lies to recruit, transport, and exploit people as forced labor or slaves. False enticements include the promise of a good job or false marriage proposals that turn into bondage situations. Some young women and girls are sold by their own families who can no longer afford to feed and shelter them. The growth of websites promoting sex tourism fuels the rapid growth of the trafficking industry.

A twenty-two-year-old sex worker in Calcutta recalls how she was trafficked from her native Bangladesh at age seventeen:

I didn't come of my own wish; I was sold. They picked me up from the street over there and brought me.…For the first two or three days, I was very stubborn about not joining this line [of work]. They starved me for those two or three days and never even gave me water to drink.

The tactics used to instill fear in victims and to keep them enslaved—whether in a field, a factory, a brothel, or a war zone—include rape, beatings, starvation, forced drug use, confinement, and isolation.
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Traffickers also trap victims into cycles of debt, control victims' money, confiscate passports and other identifying documents, threaten falsely that victims will be imprisoned or deported for immigration violations if they contact authorities, and threaten to injure or kill family members back home if they resist.

In 2000, the United Nations negotiated international standards against human trafficking and began tracking the situation in every country. That same year, the U.S. Trafficking Victims Protection Act (TVPA) made human trafficking a federal crime. It was enacted to prevent human trafficking overseas; to protect victims (including U.S. citizens) and help them rebuild their lives in the United States; and to prosecute traffickers of humans under federal penalties. The TVPA created the T visa, a special temporary immigration visa for human trafficking victims that allows victims to sue their traffickers in federal district court and provides access to a range of social services, legal assistance, and public benefits. Many organizations, including Amnesty International (amnesty.org), are working to end human trafficking and to improve the conditions that lead to trafficking.

Between 100 and 140 million girls and women in the world have experienced female genital cutting (FGC), also known as female genital mutilation (FGM), a traditional cultural practice that is also an extreme violation of human rights, including the right to bodily integrity. More than 3 million girls each year on the African continent alone are subject to the practice, which usually involves excising the clitoris and may include partial or total removal of the labia and suturing the vagina, leaving a small opening for menstrual flow. While FGC/M is viewed in practicing cultures as a rite of passage to prepare girls for womanhood or for other sociocultural reasons, its fundamental purpose is the control of female sexuality. The practice can have serious health consequences, including hemorrhage, shock, pain, infection, difficulties during childbirth, and psychological and sexual problems.
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FGC is practiced in at least twenty-eight countries in sub-Saharan and northeastern Africa, as well as a few countries in Asia and the Middle East. It is generally performed on preadolescent and adolescent girls, but in some countries, such as Mali, it is often performed on girls between the ages of one and five. While FGC is practiced by people from all educational levels and social classes, among urban and rural residents, and among many different religious and ethnic groups, increasing recognition of FGC as a human rights issue has led to it becoming less common among urban and more educated residents in most countries for which survey data are available.
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The prevalence of FGC in a number of practicing countries is nearly universal: 85 percent or more of women ages fifteen to forty-nine in Egypt, Eritrea, Guinea, Mali, Sierra Leone, and Somalia are circumcised. In Burkina Faso, Central African Republic, Côte d'Ivoire, Egypt, Eritrea, Kenya, and Tanzania, a decline in the percentage of younger women who have been circumcised suggests that the practice is declining. For example, in Kenya, where circumcision usually occurs before age fourteen, less than 15 percent of girls ages fifteen to nineteen are circumcised, compared with 35 percent of women ages thirty-five to thirty-nine. On the other hand, in the Gambia, Mali, and Somalia, the prevalence among young women is virtually unchanged from that of older women.

Through a joint program, the UNFPA and UNICEF have brought together governments, NGOs, religious leaders, and small community groups to substantially reduce the practice within seventeen participating countries by 2012. Opportunities for nondirective dialogues among women and men of all ages have demonstrated promise as vehicles for the necessary social change and altered power dynamics, which will help to eliminate this harmful practice.

Egypt and Eritrea are among the numerous countries that have passed legislation prohibiting FGC. While these laws may discourage the practice, they appear to spur the “medicalization” of FGC.

Parents are also increasingly turning to the medical profession rather than to traditional circumcisers to perform the procedure. For example, nearly a third of circumcisions in Egypt are now medically performed. The medicalization of FGC is controversial, considered to be both unethical and in some countries outlawed, while at the same time likely to be safer than a procedure performed in the bush by a traditional circumciser. Greater success has been achieved through recognizing the cultural significance of the practice and the fact that parents view the procedure as an obligation. Alternative rite-of-passage
programs and ceremonies help girls and their families acknowledge the transition to adulthood without the “cut.”
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In several countries, women have been recognized as refugees under the 1951 UN Convention Relating to the Status of Refugees (Geneva Refugee Convention) on the grounds that they would be at risk of FGC if they returned to their country. However, there are still only a tiny number of such cases. In the United States, the Citizenship and Immigration Services and international laws and treaties recognize gender-based violence as a human rights violation. Still, women are often denied asylum in the United States because the definition of a refugee entitled to protection is too narrow.

Cervical cancer kills 275,000 women each year, with the majority of those deaths occurring in developing countries.
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It is the leading cause of cancer death among adult women in the developing world and the second most common cancer among women worldwide. The largest number of cervical cancer cases and subsequent deaths occur in South and Southeast Asia, but women in Africa are most likely to die of the disease compared with other regions of the globe.
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Cervical cancer is caused by several types of the human papillomavirus (HPV), with two specific types causing about 70 percent of all cervical cancers.
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HPV is associated with other cancers as well. Cervical cancer is both preventable and treatable, making the disparities in the likelihood of dying of the disease a matter of social justice. Several effective screening methods exist to identify precancerous lesions and early stages of the disease, including Pap tests, visual inspection methods, and, more recently, HPV DNA testing.
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However, Pap tests require trained cytologists plus laboratory facilities to read tests accurately, and many countries with weak health care systems lack the resources to ensure access. In other countries, where Pap tests are more widely available, they are provided on an opportunistic basis, with poor women least likely to receive the test and wealthier women potentially being tested more than medically necessary.
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HPV DNA testing as a newer technology remains prohibitively expensive for many health care systems, although more affordable technologies are being researched. Visual inspection of the cervix by a trained health care provider remains a feasible option for low-resource settings when provided in tandem with on-site treatment methods such as cryotherapy.
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Two HPV vaccines have been available since 2006 to prevent infection from the types of HPV responsible for the majority of cervical cancer cases—Gardasil, made by Merck, and Cervarix, by GlaxoSmithKline. Both vaccines have been found to be at least 95 percent effective in preventing the types of HPV responsible for most cancers when given to girls before they become sexually active, or to women without prior infection with these HPV types. These vaccines are licensed in more than one hundred countries.
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However, they remain widely unavailable in many low- and middle-income countries owing to a combination of financial and organizational challenges that signal a lack of commitment to addressing this disease.

As recently developed vaccines, Gardasil and Cervarix remain under patent and are prohibitively expensive for many health care systems. Donation programs have enabled vaccine demonstration programs in some settings, but these
will not be sustainable. Moreover, viable financing programs will require that the manufacturers offer reasonable pricing. The Global Alliance for Vaccines and Immunisation (GAVI), a global mechanism to finance immunization programs, is currently working on plans to support subsidized purchases for low-resource settings.
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The World Health Organization recommends that the vaccine be targeted to young adolescent girls, who must receive three doses of the vaccine for it to be fully effective, but adolescent girls tend to have extremely limited contact with health services. Demonstration programs have found that school-based programs may be an effective mechanism to reach young girls, but they will miss girls who leave school prior to adolescence.
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Messaging around the vaccine is also critical to address low awareness about cervical cancer and HPV, as well as to prevent misconceptions about the rationale for targeting young girls.
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Without a concerted and coordinated global effort to ensure access to the vaccine to prevent future cases in tandem with screen-and-treat programs to address the current burden of cervical cancer, the gross disparities between women in rich and poor countries will persist.

Perhaps no other worldwide catastrophe has so poignantly revealed the vulnerability of women in society as the AIDS epidemic. The ability of the international community to secure broad-based access to the HPV vaccine is being watched closely by HIV activists, since a future vaccine for HIV/AIDS, one of the great hopes of the medical world, is likely to face similar struggles.
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As of 2010, an estimated 33.3 million people are living with HIV/AIDS worldwide,
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nearly half of them (15.9 million) women. Two out of three people infected with HIV (22.5 million) live in sub-Saharan Africa. In this region, thirteen women are infected for every ten men, and three-quarters of HIV-positive young people are female. Most women contract HIV during unprotected heterosexual sex. Gender power imbalances, transactional sex driven by poverty, and greater biological vulnerability put women at higher risk of HIV than men.

The pandemic of HIV/AIDS has led to the deaths of more than 25 million people worldwide in the last thirty years. Families, communities, societies, and whole countries have been ravaged by this ultimately preventable disease. The impact of the HIV epidemic also falls more heavily on women, who assume the bulk of caregiving when their male partners, children, and parents fall ill.

Women with HIV and women whose partners die of AIDS often suffer discrimination and abandonment. In a study in India, almost 90 percent of the HIV-positive women interviewed were infected by their husbands. Despite being monogamous, they were often blamed for their husbands' illnesses. In some contexts, women's lower status in the family and community make it less likely that they have access to health care, including antiretroviral treatment.
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In many places, a woman will be expelled from her home and her family when it is learned that she is infected, even though she has remained faithful.

As the epidemic has progressed, it has become increasingly feminized, especially among youth. Young women age fifteen to twenty-four are 2.5 times more likely to be infected than young men, too often as a result of gender-based violence and coerced sex. Studies have consistently found that women subject to violence by a sexual partner are more likely to be infected with HIV.
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These findings contribute to a growing global recognition of the need for women-centered prevention efforts that focus on addressing harmful gender norms, gender-based violence, and the economic vulnerability of women.
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Stepping Stones is a widely acclaimed community-based HIV prevention program that engages young and older men and women in critical reflection and cross-generational dialogue about harmful gender norms, including gender-based violence, and how they increase the risk of HIV. Thousands of participants have been introduced to the Stepping Stones curricula in a number of African countries. In a recent evaluation conducted in South Africa, home to the greatest number of people living with HIV in the world (5.5 million), Stepping Stones training was associated with a significant reduction in intimate partner violence perpetrated by young men. After two years of follow-up, those who had participated in the Stepping Stones program reported a 38 percent reduction in intimate partner violence as well as a one-third reduction in the incidence of genital herpes (HSV-2) infections in comparison with a control group.
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