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Medical Humanities

From Delhi Slums to Los Angeles Wards: Lessons from a Year Working Against Sex Trafficking

Abraar Karan


May 29, 2015


I’ve been asked more than once what working in India against sex trafficking had to do with medicine. “That’s more related to law and human rights,” I remember one classmate saying. “That won’t help us in clinic,” he assured. Several older professors maintained that medicine was the science of treating diseases, not solving complex societal issues. But can medicine be so narrowly defined? Is there not a fundamental component of our profession that is concerned with the problems of people beyond just the malfunctioning of their cells? Now three years into medical school, I can say with confidence that these experiences continue to influence my work with patients and have changed the way that I approach medicine.

A large part of this personal growth came from the people I met on my journey. I remember the afternoons I spent listening to stories—stories from women rescued from brothels, many of whom were lured by promises of lucrative jobs in big cities only to find themselves drugged, beaten and tortured until they had to succumb to survive. I heard from women who chose to work in this sector—they said they were sex workers, not sex trafficked—who were driven here by financial disaster. I spoke with men and women who practiced cultural sex work, where husbands actually served as the pimps of their own wives. I listened to all silently. I learned that listening is far more important than speaking—a lesson I practice every day when I see patients.

It wasn’t easy to hear these stories. They open one’s eyes and soul to the reality of human nature, and the potential that any person has if placed in the wrong environment. They provoke feelings of sympathy and rage all at once.

I was told I could have a better life. I was promised a job in the city. I never knew what I would be doing.

I heard this from Nandini, a girl who had been tricked into the trade, in a small humid apartment in the Old City region of Hyderabad, India. We were at the headquarters of Prajwala, an anti-trafficking NGO that rescued girls from brothels around the country. She did not make eye contact with me. She couldn’t.

Other stories, however, were very different.

I was making good money. I started working of my own will. The brothel madam always treated me well and I could leave whenever I wanted. I had to pay back loans and feed my children.”

These were the words of Salima, a woman who was part of a major raid on a brothel in Bombay. She was awaiting her court date, hoping to return to work once she was legally able to do so. I learned that there are a number of women who choose, out of financial hardship and abusive domestic relationships, to engage in a more regulated form of sex work. Hearing stories of women who were not physically forced (although one could argue that they were systematically) made me realize the assumptions I had made based on a very biased media portrayal that was heavily focused on kidnapped women like Nandini. I learned to identify and accept the flaws in my own assumptions, a lesson which I have carried over into my practice of medicine. I appreciate the importance of never assuming that things must be a certain way, remaining open to any possibility for the cause of a disease or the choice of a patient.

Although I now can understand the benefits of the challenges I had faced, at the time I could not always appreciate the lessons hidden within the difficulties. I became frustrated at several points during the year, but I realized that to make a difference, I first had to understand the system. Even brothel owners and pimps were once children, innocent to their future crimes; girls like Salima, who chose to return to the trade—even they were once the objects of someone’s affection, love and care rather than lust and misogyny. The johns, a term for customers of prostitution, were often poor men who earned $1 a day suffering from intensely poor labor conditions, while the brothel madams who managed the working girls were often sex trafficked themselves when they were younger. Traffickers, or the men who were responsible for luring young girls, were often trained from a young age, influenced when they were still impressionable youth, and the girls who were no longer willing to leave—many of them had psychologically adapted in what many experts call a Stockholm Syndrome type of development. For every actor involved in the system of sex trafficking, I studied why and how they came to be and this shaped the success of our intervention strategies. I learned that the ultimate outcome that one sees is the product of many complex, interconnected parts which need to be truly comprehended to solve, treat and heal.

For much of my year in India, I worked with a non-profit organization in a small slum with a tribe engaging in cultural sex work. The tribe had been practicing their tradition in the sex trade for several decades, but otherwise lived as nuclear families. Women would clean their homes and take care of their children. Men were protective of their wives when it came to other men in their own community, and children spoke of their parents with admiration. But come nightfall, women stood in front of their mirrors applying the make-up of their nightly personas. Husbands would then drive their wives out to lonely roadway stops where customers would arrive without fail. While they earned far more than they would with a menial labor job, these people were isolated from society and subject to intense stigma. Sexually transmitted infections were prevalent, domestic abuse was permitted, and psychiatric illness was undiagnosed and ignored. Worst of all, women were not able to accept that they were victims of abuse—they attributed it to tradition and culture. There were many times when it was all too overwhelming—where does one even start?

And yet, start we did. Having experience in traditional Indian folk dancing, I began teaching the children of the community who eventually performed for their parents and relatives. They were soon featured on national television in India and performed in competitions in the city of Delhi. In addition, we helped girls market clothing items that they sewed by hand. They have since sold several of these garments through the efforts of various non-profit organizations, and have avoided entry into sex work through their earnings. Through my gradual rapport with the families, I also began to uncover a number of underlying health issues which had never been spoken about previously—some women had never heard of HIV; several explained the difficulties associated with obtaining and using condoms, as well as getting tested while coping with stigma; others divulged that doctors in the community often refused to treat them. I then was able to strategize with NGOs and local physicians to deliver better medical care. The efforts in these communities are ongoing.

Working in a major academic medical center, I often see patients who are at the end of the line and a similar question crosses my mind: where do we start? There have been many cases of extremely rare diseases, where there is no certain solution in sight. I have seen patients in need of organ transplants, patients with end-stage diseases, and some for whom there is no medical treatment available at all. At these times, I think back to my afternoons in the slum. I think about my students and remember the hardship they faced growing up in the community that they did, as well as the determination and perseverance they showed when they danced. I also think back to the women who, despite suffering immense abuse from clients and in-laws, found the will to be loving mothers and caring wives. It is from them I have gained immense courage, and it is this courage I have drawn upon to confront the trials and tribulations of medicine. I approach every clinical problem with the same fortitude I learned from the women and children I met in India—no problem is too large when you believe in yourself.

And so, when I am asked what my year in India working to dismantle the sex trafficking industry taught me about medicine, I can reply with certainty that medicine is only partly about medications, diseases, and hospital outcomes. Medicine is about people. It is about understanding the complexity of every individual and how it manifests itself in the form of health and disease. It is about listening, accepting, believing, and challenging. At the heart of our profession, we will find ourselves carried not by our clinical acumen, but by our courage and humanity. I’ve never learned more about these ideals than I did that year.


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Acknowledgment: I would like to acknowledge the hard work of the non-profit organizations that are working to combat sex trafficking in India, including Prajwala, Apne Aap, and Sewing New Futures. I would also like to thank the Yale Parker Huang Travel Fellowship for supporting my research in India.