The clandestine and transnational nature of trafficking and the reluctance of those involved to discuss the topic make accurate assessments of the magnitude of CSE difficult 4. A recent government commissioned by the Department of Women and Child Development (India) estimated the number of persons trafficked for CSE in India to be around 2.8 million, an increase of 22% from an earlier estimate 56. The majority of trafficked persons are young women or children who have been forced into sex work as a result of poverty, often before they were 18 years old. Published literature further points to an increasing demand for younger children and virgins, partly fuelled by the fear of HIV/AIDS; the emergence of new sources and destinations for trafficked persons; and an increase in the overall sophistication of trafficking networks, many of which are controlled by organized crime syndicates or insurgent factions 378. This has been illustrated in Nepal where the traditional trafficking of Nepalese girls to Indian brothels had been taken over by Nepalese rebel groups in order to fund their fight against the state 9.

The magnitude of the problem may partly be accounted by the different forms of sexual exploitation in India (Figure 1) 1011121314151617181920. The most common form of sex work involves young women and girls from economically deprived and marginalized groups (e.g. Dalits) who have been 'recruited' by brokers, sold to pimps or brothel owners (most of whom are ex-prostitutes), and forced into prostitution. Brokers may be community members known to the victims or the victims' families pretending to help families; agents seeking the help of a local person to approach families and victims; individuals willing to kidnap potential victims; and family members (e.g., parents or husbands). Recruitment strategies include: false promises of employment; approaching debt-bonded families and persuading them to part with their children to pay for their debts; abduction; and arranged marriages whereby young women and underage girls are 'married' to grooms willing to pay poverty-stricken parents a dowry 3810. Once married (marriage makes this form of trafficking particularly difficult to challenge under the law), wives are either forced into prostitution directly by their husbands or abandoned/divorced and sold to a broker who resells them to a brothel 1011. This practice has been documented in Bihar, West Bengal, Chhatisgarh, Orissa, Uttaranchal, and Hyderabad. Common destinations for women and girls forced into 'arranged' marriages include Punjab, Haryana, Uttar Pradesh, and the United Arab Emirates 1112.

Customary prostitution is also prevalent in India. It includes socially (if not legally) accepted forms of prostitution, i.e., religious and tribal prostitutions 151617. Victims of religious prostitution are pre-pubertal girls from scheduled castes (e.g., Devadisi, Jogini, Nailis, Muralis, and Theradiyan) who are dedicated to different deities. After a few years of concubinage with temple priests, they are sold or auctioned to traffickers for CSE. The market value of girls tends to fall after puberty. This form of prostitution is mostly practiced in Karnataka, Maharahstra, and Andhra Pradesh. Tribal prostitution involves girls from different ethnic tribes (e.g, Bedia, Nats) who used to entertain feudal lords. Overtime, many of these tribal communities have been forced to engage in prostitution for economic reasons. Tribal prostitution is prevalent in Andhra Pradesh, Rajasthan, Maharashtra, West Bengal, Chhattisgargh, and Manipur. However, Orissa, Bihar, and Uttaranchal have also emerged as supply states for tribal prostitution. Victims of customary prostitution are generally forced into prostitution at a very young age (9–13) by family members (parents or brothers) who act as agents of the victims 31012. Approximately 16% of persons forced in the sex trade are in prostitution as a result of customary practices 18.

Another form of sexual exploitation includes sex tourism (ST). ST includes the sexual exploitation of young boys and girls by international and Indian tourists. Street children are particularly vulnerable to this type of sexual exploitation 1920. Costs per sexual act vary from 50 to 200 Indian Rs (about 1 to 5 US$) and can reach up to 1000 Rs (about 25 US$) when victims remain with their clients overnight or longer 19. Sex tourism is prevalent in the 'pink triangle', i.e., the Agra-Delhi-Jaipur belt, as well as south and south-west India: Goa, Maharashtra (Mumbai), Karnataka (notably, in some of the new tourist spots like Gokarna and Karwar), Kerala (in Kovallam, and other new popular destinations such as Cochin, Kumily, and Varkala), in Tamil Nadu (Mammallapuram), and in Orissa (particularly Puri). Himachal Pradesh and Rajasthan are emerging as new destinations for sex tourism. Sex tourism may be facilitated by travel agencies, tour operators, hotels, and associated business. There is also some evidence of young boys being imported from the Gulf countries into Southern India and forced into prostitution 3820.

In the last 15 years, CSE has been characterized by two changes. Females from upper castes are increasingly becoming victims of CSE 6. Prostitution is no longer primarily confined to traditional brothels and can be found in new venues, such as mobile brothels, dance bars, escort services, friendship clubs, massage parlours, and huts or bath establishments along the national highways (e.g., the Kolkata,-Siliguri-Guwahati-Shillong highway, the Dehli-Kolkata-Chennai-Mumbai highway, the Solapur-Hyderabad highway; the Grand Trunk Road between Bangaldesh and Pakistan) 312131415.

India is a source, transit, and destination country for women and girls trafficked for CSE 378. Interstate trafficking represents 89% of trafficking for CSE in India. Figure 2 presents the main supply, transit, and destination states. The biggest supply states include: Andhra Pradesh (16/23 districts affected by trafficking for CSE), Bihar (24/38 districts affected by trafficking), Madhya Pradesh, West Bengal, Karnataka (16/27 districts affected by CSE), Tamil Nadu, Maharashtra, and Uttar Pradesh. They are followed by the states of Orissa, Rajasthan, Assam, and Jharkhand. Bihar, Maharashtra, and Madhya Pradesh have also the dubious distinction of being the states that procure the largest number of minor girls. The biggest buyers of minors include West Bengal and Maharashtra 7812. Main destinations include Delhi, West Bengal (Kolkata), Maharashtra (Mumbai), Gujurat, Punjab, and Haryana (the last 2 states being particularly popular for 'arranged' marriages). Cities like Mumbia, Dehli, Kolkata, Bangalore, Hyderabab, and Chennai have the largest concentration of prostitutes 10. Table 2 describes some of the characteristics of brothels in the most prominent red lights areas of India.

Trafficking from neighbouring countries into India account for about 10% of trafficking for CSE. Bangladesh and Nepal are the biggest suppliers, respectively accounting for 2.17% and 2.6% of the international traffic for CSE into India 378. An estimated 10,000–20,000 Bangladeshi women and girls are trafficked every year into India. Total estimates of Bangladeshi persons trafficked for CSE into India vary between 200 000–300 000. Trafficked victims are initially kept in West Bengal, Assam, Orissa, or Tripura. There, they are 'graded' according to their age, beauty (e.g., light or dark skin), and sexual status (e.g., virgin), initiated into commercial sexual customs, and sent to new destinations, including New Delhi, Agra, Mumbai, Kolkota, Goa, or Pakistan (Karichi and Lahore).

Estimates of Nepali persons trafficked into India vary from 100 000 to 200 000 6. Human Rights Watch (2005) estimated that 6,000–10,000 Nepalese were trafficked into India annually. Other studies have suggested similar numbers (5,000–11,000) 21222324. Seventy per cent of trafficked victims, most of them under 16, come from ethnic minority groups (e.g., Tamang, Gurung, Magar, and Sherpa) who live in remote hill villages or poor border communities. Trafficked victims are sold to brokers from amounts as small as 200 Nepali Rs. 200 (US$4.00) who then deliver them to Indian brothels for amounts ranging from 15,999 to 40,000 Rs (US$ 500–1300) 2224. India is also a transit country for Nepalese and Bangladeshi women trafficked to Pakistan, Western Asia, and the Middle East and for women trafficked from the Russian Federation to Thailand 25.

Table 3 shows the data available on women trafficked from Bangladesh and Nepal into Indian brothels. It does not include non-brothel based prostitution or prostitution into small urban and rural red light areas. The literature also indicates that India is a destination country for women trafficked from Bhutan, Myanmar, Kyrgyzstan, Pakistan, Europe, Russia, and Thailand 1225.

Data on India as an international supply country are scarce 7. However, evidence suggests that children from Karnataka, Andhra Pradesh, and Madhya Pradesh are trafficked to the Gulf States, England, Korea, and the Philippines for CSE 3. As well, the United Nations reported trafficking for CSE from India to Western Asia (the most prevalent), Kenya, The United Arab Emirates, The United States of America, and to a lesser extent to Bahrain, Bhutan, Canada, France, Germany, Kuwait, Malaysia, Netherlands, Pakistan, Saudi Arabia, Singapore, Thailand, Turkey, The United Kingdom, and The United Republic of Tanzania 25.

Trafficking for CSE is a demand-driven phenomenon, facilitated by traffickers, who find trafficking highly profitable and low risk, and the availability of vulnerable populations. Vulnerability results from a range of inter-related economic, social, political, and familial factors (e.g., poverty, lack of sustainable livelihoods, structural inequities) and creates the supply needed by traffickers to meet the nature of the demand. In most cases, trafficking results from the interface of multiple risk factors 2378101920262728293031323334. For example, trafficking in Manipur has been fueled by years of civil unrest, the presence of armed forces, drug trafficking from neighbouring Myanmar, and poverty. Factors that facilitate trafficking for CSE are included in table 4.

There is little evidence on the morbidity and mortality of persons engaged in commercial sex. Overall, adult HIV prevalence in India is 0.36% (2–3.1 million people infected) 3536373839, with 85% of HIV transmitted via heterosexual contacts, except in the northeastern states (Nagaland, Manipur, and Mizoram) where the primary mode of transmission is injection drug use 36. Estimated HIV prevalence is greater among males (0.43%) than among females (0.29%) 39. HIV in India continues to be primarily concentrated in high risk populations (i.e., females or males in prostitution and injecting drug users). Estimated adult HIV prevalence was greater than 1% in Manipur (1.67%) and Nagaland (1.26%) in 2006 39. HIV prevalence among women in prostitution (WP) in 2003, 2004, 2005, and 2006 was respectively 10.3%, 9.4%, 8.4%, and 5.4 3536373839. In 2006, HIV among WP was very high in Nagaland (16.4%), followed by Maharashtra (12.8%), Manipur (11.6%), Mizoram (10.4%), Karnataka (9.6%), and Andhra Pradesh (8.8%). Overall, 8 states had greater than 5% HIV prevalence among WP, while 9 states had HIV prevalence between 1 and 5% 39. Figure 1 shows HIV prevalence among women in prostitution (WP) from 2002 to 2006 in specific states 3637383940.

Other studies on specific sub-populations found higher HIV prevalence rates than the ones previously mentioned. For example, a recent study on 287 repatriated Nepalese who had been trafficked in Indian brothels indicated that 38% of the study population was HIV+ 41. In other studies, HIV prevalence among WP ranged between 43 to 54% of the study population 424344. However, the higher HIV prevalence rates in these studies may be due to the small sample size or the selected sample (e.g., WP attending STI clinics).

The aggregate data mask the heterogeneity of the epidemic. This heterogeneity reflects the influence of multiple factors, such as the types of prostitution in different states (e.g., brothel versus non-brothel based), the age at which trafficked persons had their first sexual contacts and/or were forced into CSE, the clients (e.g., regular vs. one-time clients) and broader contextual variables (e.g., the ability of regional and local health care systems to prevent and respond to STIs). HIV prevalence among WP was 45% and 26%, respectively in Mumbai (Maharashtra), and Mysore (Karnataka), and 13%, 27% and 44% in Kolkata, Siliguri, and Panjipara in West Bengal in 2004–2005 3637383940. However, there are rural districts (e.g., in Rajasthan and Karnataka) where the epidemic is just as advanced as in urban areas 45. Furthermore, younger WP (25 years of age or less) are more at risk of acquiring STIs than older ones 4146. Higher infection rates among younger WP may be associated with the integrity of the genital lining when they are subjected to repeated trauma during sexual intercourse, facilitating higher HIV transmission. Additionally, younger WP may find it more difficult to negotiate condom use with their clients, leading to unprotected sex 4146.

A limited number of studies have looked at STIs other than HIV among WP (Table 5) 37424347484950515253. These studies (N sizes ranging from 118 to 5574) also suggest that 48–80% of WP have symptoms of STIs. Most common symptoms include vaginal discharge (13–83%), vaginal warts (3–14%), vaginal ulcer (4–25%), Trichomonas (3–40%), Candidiasis (9%), and Gardenella (3%). Overall, brothel-based WP reported less signs of STIs than non-brothel-based WP, except in one study 54. Interestingly, this study also found that home-based WP were less at risk of acquiring HIV than brothel- or street-based WP.