“Right Here is the Gateway”: Mobility, Sex Work Entry and HIV Risk Along the Mexico-U.S. Border

Abstract

Women comprise an increasing proportion of migrants. Many voluntarily migrate for sex work or practice survival sex, while others may be trafficked for sexual exploitation. To investigate how the context of mobility shapes sex work entry and HIV risk, we conducted in-depth interviews with formerly trafficked women currently engaged in sex work (n=31) in Tijuana, Mexico and their service providers (n=7) in Tijuana and San Diego, USA from 2010–2011. Women’s experiences of coerced and deceptive migration, deportation as forced migration, voluntary mobility, and migration to a risk environment illustrate that circumstances driving and resulting from migration shape vulnerability to sex trafficking, voluntary sex work entry, and HIV risk. Findings suggest an urgent need for public health and immigration policies that provide integrated support for deported and/or recently arrived female migrants. Policies to prevent sex trafficking and assist trafficked females must also consider the varying levels of personal agency involved in migration and sex work entry.

BACKGROUND

Globally and in Mexico, women comprise a large and increasing proportion of migrants(Marcelli and Cornelius, 2001, Kanaiaupuni, 2000, Massey et al., 2006). Female migrants often experience substantial health-related vulnerabilities, including violence, poor reproductive health, and risk of HIV and sexually transmitted infections (STIs)(Kendall and Pelcastre, 2010, Adanu and Johnson, 2009, Goldenberg et al., 2012b, Platt et al., 2012). Migrant women who exchange sex are at particularly high risk due to the social and structural circumstances they often face, including economic marginalization, social isolation, and extortion/abuse by authorities(Bautista et al., 2008, Bronfman et al., 2002, Goldenberg et al., 2012b). Although some women voluntarily migrate for sex work(Agustín, 2006) or practice survival sex, others may be trafficked(Chapkis, 2003). Different reasons for mobility – for example, forced versus voluntary – carry implications for HIV vulnerability, with the former often experiencing more pronounced risks(Grove and Zwi, 2006, Strathdee et al., 2008a, Goldenberg et al., 2012b). However, most research has insufficiently recognized how different reasons for and contexts surrounding migration can produce unique health consequences.

Trafficking for sexual exploitation (i.e., sex trafficking) is defined by the U.N. Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children (Palermo Protocol) as any act of recruitment, transportation, transfer, harboring or receipt of persons, using threat, force, coercion, abduction, fraud, or deception, for the purpose of prostitution or other forms of sexual exploitation…including all cases of sexual exploitation of minors (United Nations, 2000). In Asia, sex trafficking confers greatly elevated risk of HIV infection(Silverman et al., 2006, Silverman et al., 2007, Decker et al., 2011). Although migration is also associated with HIV risk(Mayer, 2000, Lippman et al., 2007, Coffee et al., 2007, Lyttleton and Amarapibal, 2002), few studies have assessed how mobility shapes HIV vulnerability among trafficked persons.

Migration, sex work, and sex trafficking along the Mexico-U.S. border

Mexico is a large source, transit, and destination for trafficked persons(U.S. State Department, 2012). Although accurate data on the magnitude of trafficking are lacking(Loff and Sanghera, 2004, Gozdziak and Collett, 2005), Latin America is believed to be one of the largest sources of persons trafficked across international borders, yet is among the most under-researched regions on human trafficking(Langberg, 2005). The border between Tijuana, Mexico and San Diego, USA, is the world’s busiest international land crossing(US Department of Transportation, 2009). Most individuals trafficked to the U.S. are moved from or through Mexico(Cicero-Domínguez, 2005).

In Mexico, organized sex tourism creates a market for trafficked females, especially in tourist areas, border cities, and areas hosting migrant workers(Langberg, 2005, U.S. State Department, 2012). The border city of Tijuana is a popular sex tourism destination(Shirk and Webber, 2004, Katsulis, 2010); in the Zona Norte, where the city’s sex work and drug use scenes are concentrated, most sex workers (>75%) are domestic or international migrants(Ojeda et al., 2009). Previous research in Tijuana has provided insights into the experiences of sex workers who voluntarily begin sex work due to economic motivations, including subsistence needs, to acquire drugs, and a desire for socioeconomic mobility(Katsulis, 2009), and has linked early sex work entry to increased HIV/STI risk(Goldenberg et al., 2012a). Given the paucity of data regarding the experiences of females who enter the sex industry due to fraudulent or coercive means, our study aimed to complement this literature by focusing on this under-represented facet of Tijuana’s sex industry.

U.S. deportation also shapes migration dynamics along the Mexico-U.S. border. In 2011, over 715,495 foreign nationals were deported from the U.S., of whom 69.8% were Mexican nationals(U.S. Department of Homeland Security, 2011). Most deportees are delivered to stations along Mexico’s northern border, including two in Tijuana. Deportation has been linked to HIV infection and risk among drug users and clients of sex workers in Tijuana(Strathdee et al., 2008a, Goldenberg et al., 2010), although its relationship to sex trafficking has not been empirically studied.

In addition to its role as a “hotspot” for trafficking and deportation, Tijuana is experiencing an emerging HIV epidemic, with as many as one in 116 persons aged 15–49 infected in 2006(Iniguez-Stevens et al., 2009). Female sex workers experience disproportionately high prevalence of HIV (6%), which is >12% among those who also inject drugs(Strathdee et al., 2008c). Pervasive drug use and gender-based violence in Mexico-U.S. border cities further exacerbates the vulnerabilities experienced by sex workers(Strathdee et al., 2008b, Beletsky et al., 2012).

While the confluence of mobility, sex work, and HIV-related risks create a high-risk environment, to our knowledge no prior studies have evaluated linkages between mobility, sex work entry and HIV infection among trafficked persons in this setting. We aimed to investigate how contextual factors related to mobility shape (1) sex work entry and (2) HIV vulnerability among formerly trafficked women. To understand how contextual factors related to migration and sex work impact health, we drew upon theoretical perspectives regarding the risk environment, defined as, ‘the space – whether social or physical – in which a variety of factors interact to increase the chances of harm occurring’(Rhodes, 2002, Rhodes, 2009). Employing this approach, our study conceptualized HIV vulnerability as a product of interactions between individuals and the contexts in which they participate.

METHODS

Data collection

We conducted ethnographic fieldwork in Tijuana, Mexico and San Diego, USA from November 2010-July 2011. Over the 9-month study period, we conducted 37 in-depth interviews with formerly trafficked women in Tijuana, as well as fieldwork (e.g., field observations; service agency tours) and in-depth interviews with service providers (n=7) in Tijuana and San Diego. During fieldwork, notes were recorded to understand the distribution of services, contextualize information gathered during interviews, and maintain a reflexive stance. IRBs at the University of California, San Diego and El Colegio de la Frontera Norte approved the study.

Formerly trafficked women (n=31) were recruited from an epidemiological study among 420 female sex workers and their male partners in Tijuana and Ciudad Juarez (Proyecto Parejas). As previously described(Syvertsen et al., 2012), participants completed a questionnaire and biological testing for HIV, syphilis, gonorrhea, and Chlamydia. Female sex workers were recruited through targeted sampling in areas where sex work and drug use occur (e.g., street, bars), where outreach workers unobtrusively approached them to explain the study. Eligible women for Proyecto Parejas were ≥18 years old, traded sex in the past month, reported lifetime use of heroin, cocaine, crack, or methamphetamine, had a stable partner for at least 6 months, had sex with that partner in the last month, and were willing to recruit their partner for the study. From this sampling frame, we conducted interviews with formerly trafficked women who lived in Tijuana.

Specific criteria used to identify formerly trafficked women included reporting at least one of the following: being <18 years old the first time that they sold/traded sex; forced, coerced, or deceived into selling/trading sex (e.g., sold/traded, kidnapped, forced, or tricked to exchange sex); or transported and forced to sell/trade sex (e.g., moved between cities as a sex worker and forced/coerced to sell/trade sex). These measures were assessed during the Projecto Parejas questionnaire; we subsequently developed a purposive sample(Strauss, 1998) of women whose survey responses met one or more of these trafficking criteria and who represented a range in age, nationality (e.g., Mexican vs. foreign-born), trafficking experiences (e.g., underage vs. forced), and migration experience (e.g., deportee, internal migrant). These women were invited to complete a qualitative interview regarding their sex work and migration history.

Data collection commenced with service provider interviews (n=7) in Tijuana and San Diego. Service providers were recruited during fieldwork at local agencies, and were selected to gain insights into trafficked women’s interactions with legal, social, and other forms of support in the Mexico-U.S. border region. Eligible providers were individuals who had direct contact with trafficked persons in San Diego or Tijuana and were selected to reflect a variety of institutional structures and services (e.g., legal assistance, counseling, shelters).

In-depth interviews were conducted in private offices by female interviewers, audiotaped and lasted approximately 1.5 hours. All participants provided written informed consent. Informed by ethnographic methods and WHO guidelines for interviewing trafficked women, interviews followed an open-ended guide, which was iteratively revised(Zimmerman and Watts, 2003, Fetterman, 2009). Numerous steps were taken to create an open, reciprocal interview environment, develop rapport, and mitigate our influence as researchers. For example, confidentiality protections were carefully explained, and interviews emphasized listening to participants’ experiences, rather than pressing for distressing information(Zimmerman and Watts, 2003). During interviews, women were invited to reflect upon the circumstances surrounding their migration history, sex work entry, and HIV risk. Providers were asked about services for and experiences working with trafficked females. All interviews explored contextual factors related to sex work entry and HIV risk. Women received condoms, HIV prevention information, and $20 USD, and were offered referrals to care. Member-checking interviews were conducted with a sub-group of formerly trafficked women (n=6), which built upon initial interviews and gathered feedback on preliminary findings.

Data analysis

Interview recordings were transcribed; all personal identifiers were removed. Using NVivo 9.0, SG led data analysis in consultation with co-authors. One participant was excluded from the analysis, whose trafficking experience occurred over 40 years prior and reflected a social and historical context sufficiently different from that of other participants to warrant exclusion.

The analysis began by reading through transcripts and fieldnotes to generate an initial coding scheme informed by formerly trafficked women’s experiences. Next, we drew upon service providers’ interviews to triangulate themes and regrouped codes to describe migration-related experiences shaping (1) sex work entry and (2) HIV vulnerability. Throughout the analysis, constant comparisons were made between data coded within and between categories(Crabtree and Miller, 1999).

RESULTS

Participant characteristics

Formerly trafficked women’s median age was 33 years old (Table 1). Twenty-five women began sex work as minors; eleven were forced, coerced, or deceived into sex work; and two reported forced movement for sexual exploitation. Sixteen participants were internal migrants from other parts of Mexico, twelve were born in Tijuana, and two were international migrants; three women had previously been deported from the United States. Eighteen women recently injected drugs, and five tested positive for HIV or an STI.

Table 1.

Characteristics of formerly trafficked women (N=30)^*

Variable	(n = 30)
Age, years**	33 (19–54)
Education, years**	6 (1–15)
Sex trafficking experiences
<18 years old at entry	25 (85.3%)
Forced, deceived, or coerced	11 (36.7%)
Transported for sexual exploitation	2 (6.7%)
Age when first traded sex, years**	16 (12–28)
Migration history
Born in Tijuana	12 (40.0%)
Born in another Mexican city (Internal Migrant)	16 (53.3%)
Born in another country (International Migrant)	2 (6.6%)
Deported from U.S. (Deportee)	3 (10.0%)
HIV Positive	2 (7.1%)
Positive for any STI/HIV	5 (16.7%)

^*Data are N (%) of women, unless otherwise indicated.

^**Median (range)

Of participating service providers, four worked in San Diego and three in Tijuana (Table 2). Providers worked in legal assistance (n=2), social services (n=3), and advocacy (n=2). On average, providers reported 10 years’ experience working at their current organization and previous contact with 50 trafficked persons (range: 3–300).

Table 2.

Characteristics of service providers (n=7)^*

Variable	(n = 7)
Age, years**	50 (35–62)
Place of residence
San Diego, USA	4
Tijuana, Mexico	3
Provider type
Legal	2
Social services	3
Advocacy	2
Years worked at current organization**	10 (1–16)
# of trafficking victims had contact with**	50 (3–300)

^*Data are N (%) of women, unless otherwise indicated.

^**Median (range)

Findings

Coerced and deceptive migration, deportation as forced migration, and voluntary mobility for sex work emerged as themes illustrating how circumstances leading to and resulting from mobility shape voluntary sex work entry and sexual exploitation. The theme migration to a risk environment describes the impact of migration on participants’ vulnerability to HIV infection.

“He brought me over here”: Coerced and deceptive migration

Many participants were tricked, coerced, or deceived into migrating to Tijuana by third parties, especially intimate partners. Some were attracted by the prospect of U.S. migration, but had changed their plans or been unable to secure safe passage. Most women had mixed feelings about their reasons for migrating, with experiences of exploitation and personal agency often factoring into their migration histories. For example, one internal migrant attributed her decision to migrate to coercion by an abusive partner and her desire for new opportunities:

“My oldest daughter’s dad, he brought me over here…I’d never been here before. My mom had just come to the United States and I wanted to know what it was like. Maybe travel the world, no? It was in my best interest. I came here and left him and stayed here in Tijuana…He used to beat me up and he still hit me when we got here. I got out of there, but he kept looking for me.”

[Internal Migrant, age 34]

In some cases, women who experienced forced migration were subsequently forced to exchange sex in Tijuana:

“I couldn’t go back…he [her partner] set my papers on fire, so I wouldn’t leave…Once we got here, he took me to the Callejon [sex work strip] where there were a lot of women…He said, ‘Look, this is where you are going to work’…From the time I got here, the next day he wanted to send me off to work…he first charged and then he sent them here…He said he was going to call immigration so they would take me away, because I wasn’t from here.”

[International Migrant, age 34]

Service providers contextualized such accounts by describing their experiences working with sex trafficked women and girls. Providers typically described trafficked persons as victims of manipulation by intimate partners:

“It’s the boyfriend who has known her for 6 months and they fell in love and all that. He brought her to live with him in another city; he doesn’t have a job and asks her for help. How? He has a friend at a bar, a massage parlor or [by] accompanying clients…It is difficult to work with them, because it is the partner who is exploiting them but you [the victim] don’t see it as exploitation.”

[Service provider, Tijuana]

Formerly trafficked women described their perceptions of peers who had been deceived into migrating to Tijuana, only to be trafficked into the sex industry. As one woman described:

“This happens a lot here. A lot of them [traffickers] go to places that are far away…Chiapas and places nearby, where people are very needy…They tell their parents and the girls that they’re going to send them money, or they threaten and bring them…I’ve met chicks here that have gone through that…I’ve already gone through that, but thank God I wasn’t under as much pressure….there are women that fall into the lies of bad people…A lot of chicks like the ones here, they come to work with a black eye or whatever, but they’re being sent to work.”

[Internal Migrant, age 34]

Service providers also emphasized the importance of more subtle forms of coercion and trickery involved in the trafficking of women and girls. Although providers’ often acknowledged ‘push’ factors such as poverty and violence, they generally did not discuss trafficked women’s agency in their migration:

“They have always arrived by the most usual means of exploitation, which is by being tricked. They [the traffickers] offer a more comfortable situation…a good job, good pay, a house…It’s really easy to get a victim who has a precarious economic situation, especially if someone is an acquaintance…They say, ‘Look, I’ll take you to Tijuana.’ Ultimately they don’t bring you the classic way – tie up your wrists, cover your mouth, kidnap you. Exploitation no longer works like that. It’s by trickery…that way the traffickers don’t struggle with the victims.”

[Service provider, Tijuana]

Some participants had previously exchanged sex in other cities. These women often described nuanced ways in which they had been convinced by intimate partners, friends, and family members to migrate to Tijuana. Many had experienced violence in their home communities and environments, which they perceived as rendering them vulnerable to coerced migration. One participant who began sex work in Ciudad Juarez explained that she had sought to leave due to escalating violence, and was convinced by a friend to migrate to Tijuana, who brought her to the Zona Norte for sex work:

“In Ciudad Juarez, they started killing addicts…I have a friend who worked here at the Coahuila [sex work strip] and she’s the one who told me, ‘let’s go’…she introduced me; you could say she sent me…She took me to the Coahuila. I didn’t have that much money and there was an agreement for fifty pesos [$4 USD]…She told me, ‘come on, just think that you’re going to sleep with your husband…I’ll give you some drops [heroin]’…I started working here for what would be the first time.”

[Internal migrant, age 34]

“It was a whole new world for me:” Deportation as forced migration

Three participants arrived to Tijuana by way of deportation. As is common among deportees in the Mexico-U.S. border region, these women had often migrated to the U.S. with their families as young children and spent most of their lives in California. They described their transition to life in Tijuana as abrupt and traumatic, having arrived with no plans, money, or social ties. Their narratives suggested that deportation could act as a form of structural violence, fostering circumstances that rendered them vulnerable to harms such as coerced sex work. As one deportee explained,

“I got deported 4 or 5 years ago…I didn’t have anywhere to stay, no family or friends…When I got deported, the first night here I didn’t have a penny, a dollar, a peso. I had nothing in Mexico. And someone was telling me, ‘you should do this…I know this guy and he’ll give you $20 to be with him, it’s just ‘gonna be real quick.’ I had no other way. It was either stay on the streets and be moneyless, or go with his friends and get money to be well.”

[Deportee, age 29]

Other participants also described pathways through which deportation led to their involvement in sex work. Recent migrants described quickly becoming aware of the opportunities posed by local sex and drug trades as a temporary strategy to obtain resources such as money, shelter, and drugs. One participant who initiated sex work as an adolescent in Los Angeles explained that limited work opportunities available to her after being deported resulted in her involvement in sex work in Tijuana, which she perceived to be a higher-risk environment than the U.S.:

“It was a whole new world for me. I didn’t come to TJ [Tijuana] voluntarily, you know? This place is completely different. It changed my life completely. My education doesn’t mean shit here. I didn’t know what I was going to do, I didn’t have money or a roof over my head…I started working as a waitress and then I moved on…I work the streets and go run [drug] connections. It all goes to my roof over my head and other things I need.”

[Deportee, age 41]

Some service providers linked the socio-economic impacts of deportation to sex trafficking. One provider expressed concern regarding the limited protections offered to deported youths:

“It’s linked to economics…A person who is living here and is deported back to their country of origin, they can’t find a way to sustain themselves and end up meeting the wrong people, getting duped and end up in these kinds of scenarios…Children especially are susceptible. If children are turned back and there is no place for them, if there’s no infrastructure to protect them…there is always that possibility.”

[Service provider, San Diego]

“I came blind”: Voluntary mobility

Sixteen participants were voluntary migrants from other Mexican states, many of who traveled to Tijuana and entered sex work during adolescence. Although women who experienced forced migration described high levels of past exploitation and violence, voluntary migrants also experienced unanticipated health and social risks post-migration.

Voluntary migrants described the need to support children and other family members as a key driver of migration and sex work entry. For instance, one participant moved to Tijuana seeking employment to meet her family obligations. Although she did not perceive herself as forced into sex work, she described being misled into working at a sex work establishment as a minor:

“I was born in Ciudad Juarez, Chihuahua and I came here to work because of an emergency, a sickness my oldest daughter had. I didn’t have enough [money] from my normal job…A friend of mine invited me to work here at a bar…She told me as a waitress; but when we got there she explained it…’You’re not going to make money like that,’ she said, ‘You have to go out and dance.’ ‘Oh no’ I told her.”

[Internal Migrant, age 29]

Three participants knowingly migrated to Tijuana for sex work, seeking social mobility and adventure, or to escape circumstances of exploitation or intimate partner violence; for example, one participant fled Ciudad Juarez to escape a pimp who had threatened her life. Although these women previously engaged in sex work in other Mexican or U.S. cities, they did not anticipate the risks they faced in Tijuana, highlighting how the realities that awaited them did not correspond to their expectations:

“I came blind. Well, because of what I heard about Tijuana…What does Tijuana have that makes the whole world want to go over there?”

[Internal Migrant, age 40]

Upon their arrival, some women suffered exploitation by individuals who initially offered them support. Social isolation and economic desperation positioned female migrants as targets for men who sought to take advantage of them. Such exploitation was said to be common in the Zona Norte, due to its large concentration of marginalized populations, including male deportees. Formerly trafficked women’s narratives indicated the far-reaching impacts of migration – especially deportation – on broader socio-economic dynamics characterizing the neighborhood:

“People see you when you arrive and cheat you really easily…people live here off catching the people who come, to steal from them, to convince them, to put them to work, more for the underage girls. There are people who live just by waiting at the line [border], in the bars, listening to people to see where they come from.”

[International Migrant, age 32]

“My daughter’s father was my pimp…He came to Tijuana because he was deported…he didn’t want to work and wanted me to keep supporting him financially. He wanted money for drugs…he beat me up on the streets once…I left to work at a casa de citas [brothel] after that.”

[Local resident, age 19]

Among Tijuana-born participants, movement from other neighborhoods to the Zona Norte preceded their sex work entry. Local residents typically moved to this neighborhood as youth and initiated sex work to escape abuse at home and in search of income-earning opportunities:

“I was looking for a way to get out…I came to el centro [downtown]…People told me about this place…that there was a lot of prostitution. But it’s not the way others told me about…I never thought I’d come to this place to do what I do. “

[Local resident, age 23]

“I just came to the Zona [Norte] to look, to see if getting money was easy. And well, I started doing things at the bars nearby, and that’s how I got some money.”

[Local resident, age 30]

These participants typically began sex work in the absence of coercion. The following quotes illustrate many women’s histories of moving to the Zona Norte as youth, where they began survival sex and drug use:

“I came here to the Zona Norte when I was 19 years old. When I came here I was very different…I met guys, friends, and they invited me to hang out, smoke [drugs] and finally I’d give them my body…I started running out of money, drugs…I had to start prostituting myself.”

[Local resident, age 23]

Migration to a risk environment: Implications for HIV vulnerability

Health impacts of forced migration and forced sex work

Women’s migration histories generally represented a continuum of health impacts. Those who were forced to migrate and exchange sex often reported more severe risks, including forced unprotected sex and violence, which typically occurred during or following migration. As an HIV-positive participant who had been trafficked and forced to exchange sex in migrant camps described the violence that was inflicted upon her during her trafficking experience:

“We’d go from town to town, from California…all the way to Oregon, to Mexican towns where they worked the fields. We’d get there and he charged…he only gave us food, clothes and a place to live…They [the traffickers] would get us in the room at night. The first time I said, ‘No, that’s not how the business went.’ The only ones we didn’t use protection with were with him or his friends; he hit me too.”

[International Migrant, age 32]

Service providers described health impacts of sex trafficking within California’s agricultural camps, highlighting the connections between labor migration, sex trafficking, and STIs:

“Young girls were being prostituted into migrant camps in North County [San Diego]. And that’s how I came across my first victim… The number one thing since then, that I knew with this type of crime was the STD checking and behold, she was positive for herpes.”

[Service provider, San Diego]

“You have migrant men who themselves might be abused or victims of trafficking for labor, living in these camps. On top of that, these young girls are being brought in, forced to service them.”

[Service provider, San Diego]

Migration contexts as determinants of health-related harm

In addition to the direct health impacts of being forced to migrate and exchange sex in high-risk settings such as migrant camps, contextual features of Tijuana’s Zona Norte shaped participants’ vulnerability to exploitation, drug use, and HIV. Women frequently discussed the risks of migrating to a setting where such risks were normalized. For instance, many situated their first use of drugs such as heroin and methamphetamines in this neighborhood as recent migrants, illustrating the potential impacts of migration on drug use initiation:

“Right there by the arch [a landmark welcoming tourists]…It was like a hidden world…in my mind I said, ‘This is a secret world of the drug dealers.’ I made a lot of friends, they smoked heroin, and I started to get hooked.”

[International Migrant, age 32]

“Once I’d been working here for a month…she [a friend] showed me how to use crystal [meth]…She said, ‘If you want to last here, I have a remedy, a trick’…From there I started. With the drugs at the bar, that’s where I learned a little about everything.”

[Internal Migrant, age 29]

In addition to the normalization and widespread availability of illicit drugs in Tijuana’s Zona Norte, migrants implicated the stress and loneliness they experienced upon moving to the city as contributing to addictions and related HIV risk behaviors:

“People don’t use heroin in Guadalajara…I met people that sold [drugs] in the Zona [Norte], and those people brought me here, I got into that environment…My family was very far away, well, it was hard…the fact that I didn’t have anyone here in Tijuana was a big influence.”

[Internal Migrant, age 34]

Deportees were particularly likely to attribute HIV risk behaviors to social isolation. Unlike many internal migrants, deportees often arrived in Tijuana with pre-existing addictions; however, their narratives suggested that deportation may exacerbate HIV risk behaviors (e.g., drug use; unprotected sex). Deportees were often fatalistic during their initial years in Tijuana, framing HIV as an inevitable risk:

Q: “How did you feel, being here by yourself?”

A: “Desperation and fear…stress, but you can’t do anything; you do what you need to do to survive”

Q: “What did you do when you got here and knew no one?”

A: “Well, what was I going to do? Just try and live here. I rented a room and I started to work here at the bars, doing what I could, but I started getting into the habit of doing drugs…I lost touch with my family…I started working like that [sex work].”

[Deportee, age 36]

Service providers’ perceptions regarding drug use focused on drugs as a means of luring trafficking victims and the development of addictions as a consequence of trafficking. Whereas migrant women suggested that migration to Tijuana and its social ramifications (e.g., social isolation, exposure to illicit drugs) fostered or exacerbated drug use, service providers often perceived trafficked women as forced by traffickers to use drugs:

“They’re given drugs, and then they become young girls that are addicted to drugs and cannot quit by themselves, and this is also another factor.”

[Service provider, Tijuana]

“I don’t think they get addicted to drugs until they’re introduced to it by the traffickers. Yeah, these are poor villagers out in rural areas…I don’t think they fall into it [trafficking] because they’ve got some drug habit…Not only can you not say no, but probably it does numb the pain of the situation.”

[Service provider, Tijuana]

Impacts of overlapping sex work and drug dependence

Formerly trafficked women frequently discussed the pervasive influence of drug use on their HIV risk. Within the context of extreme marginalization and isolation, participants often acquiesced to known risk behaviors, such as unprotected sex, especially during drug use:

“I knew about diseases and that I should use condoms…Most of the customers wouldn’t use condoms. I needed the money and I had nowhere else to get it…I would worry about it, but I had, like, submitted myself to that risk.”

[Deportee, age 29]

“My friend told me, ‘I have a client [for you], with a condom,’ but when you’re high you don’t care.”

[Internal migrant, age 34]

Despite their histories of forced or underage sex work, most women continued working in the absence of coercion. Most felt entrenched in sex work due to stigma, shame, and addictions. Participants often expressed frustration at their dependence on the neighborhood’s sex work and drug use scenes, noting these to be co-dependent vulnerabilities:

“I wanted to go back, but I knew that, you know…I got myself into it. I was just waiting for my mom to tell me ‘come back home.’”

[Local resident, age 25]

“As an addict, a prostitute…we’re like cows, branded, that’s life and that’s the way it is.”

[Internal migrant, age 34]

DISCUSSION

Our data indicate that migrant women’s vulnerability to sex trafficking and its associated harms are strongly shaped by migration drivers (e.g., coercion; involuntary repatriation; voluntary mobility), as well as characteristics of migration destinations. Although forced mobility appeared to confer the greatest harms, voluntary migrants also experienced unanticipated risks after migrating, including sexual exploitation, addictions, and HIV.

Characteristics of Tijuana as a risky migration context strongly influenced susceptibility to exploitation and HIV. Despite some participants’ (e.g., deportees) prior involvement in risk behaviors in other settings, their narratives indicated that HIV risks (and likely infection) predominantly occurred during or following migration. This was often attributed to violence, the normalization of exploitation and drug use, exposure to drugs, and psychosocial stressors. This study contributes to a growing body of literature indicating the salience of contextual features of migration destinations in determining the health consequences of migration(Acevedo-Garcia et al., 2012, Goldenberg et al., 2012b), especially with regards to HIV risk(Platt et al., 2012, Goldenberg et al., 2010, Goldenberg et al., 2011).

Previously, contextual factors such as social disruption and marginalization have been linked to migrants’ HIV risk(Lyttleton and Amarapibal, 2002, Lippman et al., 2007, Bronfman et al., 2002). In this study, the normalization of risks such as exploitation, drug use and unprotected sex contributed to migrants’ health and social struggles. The normalization of harm among marginalized groups has been previously described as the reproduction of structural violence – that is, the ways that institutional and social forces shape the distribution of health and social harm(Bourgois, 2003, Rhodes, 2009). This study furthers this evidence by highlighting how trafficked women’s health and vulnerability to exploitation are impacted by structural forces (e.g., deportation; absence of health/social safety net for migrants). Our data situate formerly trafficked women’s exposure to HIV as an outcome of structural conditions within Tijuana’s risk environment, supporting conceptualizations of risk as dependent on local context(Rhodes et al., 2012, Rhodes, 2009).

Although immigration policies are recognized drivers of migrant health(Morin et al., 2004), our findings highlight deportation as a potential factor perpetuating women’s vulnerability to sex trafficking and HIV. Our study complements previous research articulating the health consequences of U.S. deportation among vulnerable populations(Brouwer et al., 2009, Goldenberg et al., 2010, Strathdee et al., 2008a). This evidence highlights the need to improve coordination of public health and immigration policies, including those aimed at combatting trafficking in persons and undocumented migration, to ensure that these are not at odds with one another. Despite recent programmes providing transportation for deportees to Mexico City and/or their home communities, these policies are ultimately aimed at curbing migration, rather than protecting migrants’ wellbeing(Los Angeles Times, 2012). Given that most migrants invest large sums of money to travel to the border and typically intend to re-attempt crossing(Cornelius et al., 2010), the health and social consequences of deportation to Mexico-U.S. border cities are likely to persist.

Public health and immigration policies that provide support for recently arrived migrants and trafficked persons may be needed to reduce the health concerns described herein. Programs integrating HIV prevention and related support (e.g., vocational placements, shelter, counseling) for migrant females could reduce vulnerability to exploitation and health-related harms, while minimizing stigmatization associated with a sole focus on HIV(Vijeyarasa and Stein, 2010).

Unfortunately, policies to prevent and address sex trafficking have often emphasized punitive approaches, such as laws preventing single women from travelling across international borders and raids on brothels(Busza et al., 2004, Jana et al., 2002). Evidence-based intervention development and evaluation of existing programmes are needed; intervention components could include providing employment opportunities, social support, and harm reduction services, as well as efforts to reduce gendered discrimination and violence. Above all, policies to assist trafficked females should be based on existing evidence regarding the range of agency involved in migration and sex work entry; overly victimizing approaches may not resonate with voluntary sex workers, including those who may be previously trafficked. Situating the concerns of women who have been involuntarily involved in sex work and who voluntarily exchange sex at the forefront of intervention development is recommended.

Since studies with trafficking survivors are suggested means of safely gathering such data(Zimmerman and Watts, 2003), our sample was restricted to current sex workers participating in a larger epidemiological study. Rather than attempting to document all trafficked women’s experiences, this study provides an in-depth account of participants’ migration and trafficking experiences, situating these within a geopolitical context highly impacted by trafficking(Brunovskis and Surtees, 2010). Despite our best efforts to recruit them, certain sub-groups (e.g., deportees; international migrants) may be under-represented. Additional studies focused on these sub-populations and more diverse samples of service providers are recommended. Mixed-methods research is particularly needed to assess linkages between deportation, sex trafficking, and HIV.

Although we interviewed women screened for former trafficking by operationalizing the Palermo Protocol definition, their experiences depicted a nuanced relationship between migration and sex work entry, which entailed both forced and voluntary experiences. Different sampling strategies may yield distinct representations of trafficking, with previously trafficked women who remain in sex work often reporting greater agency than those accessed through anti-trafficking services(Brunovskis and Surtees, 2010). Such discrepancies also highlight challenges in operationalizing the Palermo Protocol definition, which is underpinned by criminal justice rather than victim-assistance priorities(Chapkis, 2003).

Study findings support conceptualization of sex trafficking as a non-linear process of cumulative harm(Zimmerman et al., 2011) and highlight the tension between participants’ agency and victimization. Policies to prevent sex trafficking and HIV infection should recognize the spectrum of agency among sex workers and migrants, including those who have been previously trafficked. Meaningfully engaging trafficked and migrant women in the sex industry in empirical research can inform appropriate research methodologies, clearer trafficking definitions, and culturally appropriate interventions tailored to trafficked females and migrant sex workers’ priorities and needs.