Welcome back to our Colpo Corner, where we explore various aspects of colposcopy. In this edition, Dr. Judy Norman shares her experience in treating sex workers in Cambodia, where the situation reaches the level of public health crisis.

Human trafficking affects up to 21 million people worldwide, of which international sex trade accounts for about 22%.   

In South Asia, 60% of human trafficking victims are trafficked for sexual exploitation. Sex workers experience numerous healthcare issues, especially those working against their will and enter the trade at a young age. Dr. Judy Norman works extensively with current and former sex workers in her women’s health practice at the Mercy Medical Center Cambodia. Dr. Norman shares experience and suggestions for best practice in serving sex workers women’s health needs.

Mercy Medical Center Cambodia works with 50 to 60 different anti-trafficking and support organizations that serve different areas, from combating human trafficking at the source to serving the reproductive needs of active sex workers and providing shelter. The sex trade is rampant in Cambodia with up to 80% of Cambodian men paying for sex.  This creates a significant public health challenge, even beyond those directly involved in the sex industry. As a result of male involvement in the sex trade, all Cambodian women remain at high risk of contracting HPV, even those with only one sexual partner.

 

Women’s health for sex workers

 

The program at MMCC addresses these issues with a combination of direct screening, patient education and an extensive clinician training program designed to extend cervical cancer screening throughout the country.  The holistic approach addresses the range of needs of sexually exploited/trafficked women and girls. Assessment and treatment are designed to identify and address substance abuse, mental health challenges, and a range of sexual and reproductive health issues that include sexually transmitted infections, HIV, contraception, and other gynecological challenges.  We also act as advisors for shelters and other rehabilitation centers dealing with human trafficking victims for any service we can’t provide at the point of care.

Learn to recognize the signs of human trafficking. Read more >>

Given the frequency and need in urban Cambodia, sex workers make up a significant percentage of patients in the MMCC Women’s Health program. Almost all these women and girls are victims of human trafficking.

“As a physician, the scope and real horror of the sex industry has a human face. Our patients have survived almost unimaginable abuse. The youngest survivor I have treated was trafficked at just 18 months old.”

Human trafficking has many possible health consequences besides contracting sexually transmitted diseases including:

  • Mental health issues
  • Poor general physical health
  • Substance use
  • Legal and security issues
  • Financial instability
  • Social isolation

 

Sex workers are at a higher risk of HPV

 

As the greatest risk of contracting high-risk HPV is within the first 6 months after the onset of sexual activity, sex workers experiencing multiple partners are at an exponentially greater risk than the general population. With so many being forced into the sex trade in childhood, instances of aggressive cervical cancer in early adulthood are frequent, that may be different than other regions in the world where cervical cancer mortality is rare before the age of 30.

Sex workers in Cambodia do not have the autonomy to enforce condom usage, putting them at constant risk for infection. The sometimes traumatic sex they experience adds to the physical damage to the vagina and cervical mucous membranes, increasing the instance and severity of infection that can develop into cervical cancer if left untreated.

 

HIV and HPV

 

Globally, sex workers are more likely to carry HIV than the general population. The deficiency in the immune system caused by HIV compounds the effects of any HPV infection.  As frequent carriers of both infections, sex workers as a group are at an increased risk of cervical cancer due to these factors. In fact, HIV increases the risk for any person to develop cervical cancer 3,000 fold.

HIV positive sex workers have a 73.3% likelihood of also becoming HPV carriers.

 

Presumptive treatment program

 

The MMCC program is built on presumptive and symptomatic treatment following the WHO guidelines with the goal of decreasing the physical effects of the sex worker’s experience as quickly as possible. We recommend that all active sex workers receive presumptive treatment for gonorrhea and chlamydia every three months, plus treatment for any other related infections such as trichomonas and bacterial vaginosis. Newly rescued women receive single dose presumptive treatment. Treating co-infection is important as it helps create a more robust immune system, helping the body fight the HPV virus.

 

Colposcopy under 21 years old

 

As a result of the high infection rates in this population, we will perform VIA. Unlike the standard practice in other settings, we will provide treatment when necessary for patients under 21 years of age. Based on consultation with others working with high-risk women, we start VIA three years after the first sexual exposure. Even after many years of working with this population, it can still be shocking to see developed cancer in such young patients. I recently treated an 18-year old presenting with CIN3. Several years ago we had a 24-year-old with stage 3 HPV related vulvar cancer.

 

Patient inclusion

 

Patient inclusion is one of our top priorities. The IOM guidance for health providers in caring for trafficked persons stresses the need to include patients in their healthcare.  Beyond explaining and receiving consent for any medical procedures, this also includes the ability to have a third party accompany the patient during all visits.

“The provision of STI care for female sex workers improves their health and the health of the community. As sex workers are usually among the most vulnerable members of the community, their needs extend far beyond health care.” – World Health Organization

 

For women who have suffered some of the worst types of abuse, the experience of receiving care from a supportive staff represents the first step in the psychological healing process. At MMCC, women are treated by local Khmer speaking physicians who have the linguistic and societal sensitivity needed to put patients at ease. For some of these women, visiting MMCC is the first time they are treated with dignity by a person in a position of authority (as doctors are seen in Cambodia.)

 

Conclusions:

 

Sex workers have a much greater risk of developing cervical cancer. It is imperative that they receive presumptive treatment as soon as possible. Standard procedures need to be adapted to fit the needs of this population, including performing exams under the age of 21.

Our experience treating Cambodian sex workers and trafficked victims have shown that providing a safe supportive environment is as important for overall healing as following the correct clinician procedures.

 

Check out this resources to learn more:

 

About the collaborating author: 

Judy Norman, MD, OB/GYN

Dr. Judy Norman is a missionary gynecologist from the US working at the Mercy Medical Center in Cambodia, a unique organization focused on providing women’s health services. They provide cervical cancer screening, medical training and community education for the poorest and more vulnerable.

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