AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. October 2015, Volume 17, Number 10: 914-921.
doi: 10.1001/journalofethics.2015.17.10.medu1-1510.

Medical Education

  • Print
  • |
  • View PDF

Medical Education on Human Trafficking

Training for health care professionals on human trafficking should be informed by a human rights perspective and include prevention and identification of trafficking and treatment of trafficking-related health conditions.

Hanni Stoklosa, MD, MPH, Aimee M. Grace, MD, MPH, and Nicole Littenberg, MD, MPH

Human trafficking occurs in all 50 US states and in at least 124 countries worldwide [1, 2]. The US Trafficking Victims Protection Act (TVPA) of 2000 defines “severe forms of trafficking in persons” as

(A) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or (B) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion, for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery [3].

The physical and mental health impacts of human trafficking have been described widely [4-8]. They include infectious illnesses and their sequelae, such as HIV/AIDS, sexually transmitted infections (STIs), pelvic inflammatory disease (PID), viral hepatitis, respiratory illnesses, and dental infections; exacerbations of chronic conditions such as asthma, heart disease, and diabetes; noninfectious conditions such as head injuries, fractures, lacerations, malnutrition, hearing loss, and gastrointestinal illnesses; and mental health disorders such as depression, anxiety, posttraumatic stress disorder (PTSD), substance abuse, and suicidality.

Victims of human trafficking interact with the health care system before, during, and after the period of victimization [5, 9, 10]. These encounters provide health care professionals the opportunity and the responsibility to play a critical role in identifying and preventing human trafficking and treating conditions resulting from it. For these reasons, health care professionals must be trained about human trafficking from a human rights perspective.

Education on Human Trafficking in Medical Training: A Human Rights Framework

Human trafficking is a human rights issue [11]. International human rights law has declared the “fundamental immorality and unlawfulness of one person appropriating the legal personality, labour or humanity of another” [12]; arguably, there is no act more dehumanizing and exploitative than the trafficking of another human being. The particular human rights violated in cases of trafficking include the right to liberty and security; the right not to be submitted to slavery, servitude, forced labor, or bonded labor; the right not to be subjected to torture, punishment, or cruel, inhumane, or degrading treatment; the right to be free from gendered violence; the right to freedom of movement; the right to the highest attainable standard of physical and mental health; and the right of children to special protection [11].

Accordingly, training for health care professionals on human trafficking should be informed by a human rights-based framework. Fundamental to a rights-based approach is the core concept of “strengthening the capacities of rights holders [the trafficking survivors] to secure their rights” [13]. Therefore, the medical education of health care professionals should be grounded in a victim-centered, culturally relevant, evidence-based, gender-sensitive, trauma-informed perspective and include the essential components of prevention and identification of trafficking and treatment of trafficking-related health conditions.

Prevention. According to a US Department of Justice report, the majority (83 percent) of confirmed sex trafficking victims in the United States are US citizens [14]. Victims of sex or labor trafficking may be of any gender, age, or sexual orientation. Many victims have experienced prior trauma. Risk factors for future trafficking victimization include sexual abuse, physical abuse, emotional abuse and neglect, intimate partner violence, homelessness, and social marginalization [4, 15, 16]. Health care professionals who screen for and recognize these overlapping forms of violence and trauma have the opportunity to intervene and potentially prevent future trafficking victimization.

Identification. Studies have found that the percentage of victims in the United States who encounter health care professionals while under the control of the trafficker ranges from 28 percent [5] to 87.8 percent [17]. Traffickers may bring or allow the victims to obtain medical care either when their illnesses or injuries are interfering with their ability to work or for routine care such as STI testing and contraception [18]. In many of these cases, health care professionals may be the only professionals who interact with a victim while he or she is still being controlled. Even in the presence of a clinician, however, victims may not disclose their situation for numerous reasons, including language and cultural barriers, fear of the criminal justice system or of deportation, fear of repercussions from the trafficker (to themselves or to loved ones), distrust of health care professionals, and doubt that anyone can help them [9, 19]. Health care professionals must have an understanding of the “red flags” for trafficking and the barriers to disclosure in order to appropriately interview, identify, and assist victims [19]. Identifying and assisting trafficking victims brings trafficking survivors closer to the end of their cycle of violence.

Treatment. The wide range of acute and chronic medical and psychological conditions that affect trafficking survivors can be addressed through ongoing medical and psychiatric care. Many will require months, years, or even decades of intensive care to recover from their traumas [8, 9].

In the care that survivors receive, a trauma-informed approach is crucial to avoid retraumatizing patients. Chronic trauma and its mental health sequelae can lead to somatization, distrust, and difficulty developing therapeutic relationships. Furthermore, lack of reliable housing, transportation, and employment, combined with frequent appointments with other social service providers and law enforcement personnel, can all contribute to medical noncompliance. If clinicians do not have an appropriate understanding of survivors’ experiences and needs, the patients are at risk of being labeled “difficult,” and clinicians risk burnout. Linking survivors to critical medical and psychological care, as well as to legal and social services, will provide them the protection and support they require for restoration and healing [6, 8, 9]. Because each interaction with a victim of trafficking is complex and critical, health care professionals must be thoroughly trained to engage in a multidisciplinary response that addresses the effects of trauma on victims’ physical and mental health.

The Need for Education on Human Trafficking in Medical Training

Gaps in knowledge of human trafficking identification, care, and response are apparent among medical students, residents, physician assistants, attending physicians, nurses, and social workers [20-26]. For example, in a New York City-based study, only 4.8 percent of emergency medicine clinicians reported feeling confident about their ability to identify a victim of human trafficking [24]. A survey of survivors about their interactions with health care professionals demonstrated that, in addition to not being identified, they had been hurt, humiliated, and, in some cases, harmed by the actions of clinicians [27], highlighting the need for trauma-informed care training.

Several studies [20-21, 23-26], including a randomized controlled trial [22], have demonstrated that simple training can have a significant impact on clinicians’ knowledge of trafficking and ability to recognize and care for trafficking victims. For example, prior to training, a majority of the students in a Michigan medical school either believed that the correct number to call to report a victim of human trafficking was 911 or were uncertain of whom to call. Following the presentation, a vast majority of students correctly identified the number 1-888-373-7888 (the National Human Trafficking Resource Center) [25]. Various modalities, including Grand Rounds-style didactics and online training, have shown promising results in increasing clinician knowledge of human trafficking for medical students and physicians. Core topics include definitions of trafficking; scope and scale of the problem; prevention; health consequences; a trauma-informed, multidisciplinary approach to identification based on trafficking indicators; and resources for response at the national level (i.e., the National Human Trafficking Resource Center hotline) and the local level (i.e., physical and psychological medical care, hospital or clinic social work services, and other resources for shelter, substance abuse treatment, or legal services, based on survivor needs) [26, 28].

Progress and Resources

The state governments of Michigan and Illinois have recognized and addressed the lack of awareness of human trafficking among health care professionals by enacting laws that require or encourage training about trafficking [29, 30]. On the federal level, the US Department of Health and Human Services (HHS) launched the Stop, Observe, Ask, and Respond (SOAR) to Health and Wellness Training program in 2013 to provide human trafficking training to health care and other related professionals [31]. The training is part of the five-year Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States, 2013-2017 [32]. To inform the development and evaluation of the pilot training, HHS appointed a national technical working group comprising health professionals, survivors of human trafficking, and other subject matter experts. The trainings were held in September of 2014 in six cities across the United States. One hundred and eighty health care professionals, including physicians, nurses, dentists, and clinical social workers, were trained and received a three-month follow-up evaluation (results forthcoming) [31]. Recently introduced legislation in the US Senate would codify and further expand this training program on human trafficking [33].

The American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the American Medical Association (AMA), the American Medical Women’s Association (AMWA), the American Nurses Association (ANA), the American Psychological Association (APA), the American College of Emergency Physicians (ACEP), and other medical, nursing, and social welfare organizations have encouraged their members to receive training in and increase their awareness of human trafficking [34].

Additionally, a network of professionals called Health Professional Education, Advocacy, and Linkage (HEAL) Trafficking unifies and mobilizes interdisciplinary professionals in combating human trafficking and serves as a centralized resource on health care for the broader anti-trafficking community. HEAL Trafficking convenes multiple working groups that address various aspects of health and trafficking, including protocol development, education and training, direct services, prevention, and media and technology [35].


Human trafficking victims interface with the health care system every day and often leave undetected. Victims have numerous physical and psychological needs that require unique and compassionate care. A human rights framework should inform a medical education trafficking curriculum that is victim-centered, culturally relevant, evidence-based, gender-sensitive, and trauma-informed and that includes the essential components of prevention, identification, and treatment. By properly training health care professionals, we can make our health care system a place of healing for victims of this egregious human rights abuse.


  1. United Nations Office on Drugs and Crime. Global report on trafficking in persons. 2014. de5fs23hu73ds/progress?id=MV2s1g53Jw&dl. Accessed July 20, 2015.
  2. UNICEF. Child trafficking. trafficking?gclid=CI39oNGjqMMCFQeRaQod5RcA0w. Accessed July 20, 2015.
  3. Victims of Trafficking and Violence Protection Act of 2000, Pub L No. 106-386, 114 Stat 1470. Accessed July 15, 2015.
  4. Raymond JG, Hughes DM. Sex Trafficking of Women in the United States: International and Domestic Trends. New York, NY: Coalition Against Trafficking in Women; March 2001. Accessed July 15, 2015.
  5. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-91.
  6. Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS Med. 2012;9(5):e1001224.
  7. Kiss L, Pocock NS, Naisanguansri V, et al. Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study. Lancet Glob Health. 2015;3(3):e154-e161.
  8. Baldwin SB, Fehrenbacher AE, Eisenman DP. Psychological coercion in human trafficking: an application of Biderman’s framework [published online ahead of print November 4, 2014]. Qual Health Res. doi: 10.1177/1049732314557087.
  9. Macias-Konstantopoulos WL, Munroe D, Purcell G, Tester K, Burke TF, Ahn R. The commercial sexual exploitation and sex trafficking of minors in the Boston metropolitan area: experiences and challenges faced by front-line providers and other stakeholders. J Appl Res Child. 2015;6(1):4.
  10. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):e36-e49.
  11. United Nations Human Rights Office of the High Commissioner. Human rights and human trafficking. 2014. Accessed July 15, 2015.
  12. United Nations Human Rights Office of the High Commissioner, 4.
  13. United Nations Human Rights Office of the High Commissioner, 8.
  14. Banks D, Kyckelhahn T. Special report: characteristics of suspected human trafficking incidents, 2008-2010. US Department of Justice Office of Justice Programs Bureau of Justice Statistics. April 2011. Accessed July 15, 2015.
  15. Institute of Medicine; National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: National Academies Press; 2013. Accessed July 15, 2015.
  16. Estes RJ, Weiner NA. The Commercial Sexual Exploitation of Children in the US, Canada, and Mexico. Philadelphia, PA: University of Pennsylvania School of Social Work Center for the Study of Youth Policy; September 18, 2001. Exploitation%20of%20Children%20in%20 the%20US,%20Canada%20and%20Mexico.pdf. Revised February 20, 2002. Accessed July 15, 2015.
  17. Family Violence Prevention Fund. Turning pain into power: trafficking survivors’ perspectives on early intervention strategies. 2005. file/ImmigrantWomen/Turning percent20Painpercent20intoPower.pdf. Accessed July 15, 2015.
  18. Tracy EE, Konstantopoulos WM. Human trafficking: a call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012;119(5):1045-1047.
  19. International Organization for Migration. Caring for Trafficked Persons: Guidance for Health Providers. Geneva, Switzerland: International Organization for Migration; 2009. Accessed July 15, 2015.
  20. Wong JC, Hong J, Leung P, Yin P, Stewart DE. Human trafficking: an evaluation of Canadian medical students’ awareness and attitudes. Educ Health (Abingdon). 2011;24(1):501.
  21. Beck ME, Lineer MM, Melzer-Lange M, Simpson P, Nugent M, Rabbitt A. Medical providers’ understanding of sex trafficking and their experience with at-risk patients. Pediatrics. 2015;135(4):e895-e902.
  22. Grace AM, Lippert S, Collins K, et al. Educating health care professionals on human trafficking. Pediatr Emerg Care. 2014;30(12):856-861.
  23. Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: what do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Health. 2015;3:6.
  24. Chisolm-Straker M, Richardson LD, Cossio T. Combating slavery in the 21st century: the role of emergency medicine. J Health Care Poor Underserved. 2012;23(3):980-987.
  25. Yankovich T. Human trafficking education and assessment for medical students. Poster presented at: 143rd Annual Meeting of the American Public Health Association; November 1, 2015; Chicago, IL.
  26. Titchen KE, Loo D, Berdan E, Rysavy MB, Ng JJ, Sharif I. Domestic sex trafficking of minors: medical student and physician awareness [published online ahead of print May 20, 2015]. J Pediatr Adolesc Gynecol. doi: 10.1016/j.jpag.2015.05.006.
  27. Miller C. Child sex trafficking in the health care setting: recommendations for practice. Paper presented at: 25th International Nursing Research Congress; July 27, 2014; Hong Kong.
  28. Ahn R, Alpert EJ, Purcell G, et al. Human trafficking: review of educational resources for health professionals. Am J Prev Med. 2013;44(3):283-289.
  29. Illinois State Medical Society House of Delegates. Resolution 19 Educating medical providers as first-line responders to stop human trafficking. 2012.
  30. S 597, 97th Leg, Reg Sess (Mich 2014). 2013-2014/publicact/pdf/2014-PA-0343.pdf. Accessed June 30, 2015.
  31. US Department of Health and Human Services Administration for Children and Families Office on Trafficking in Persons. SOAR to Health and Wellness Training. Accessed June 27, 2015.
  32. US Departments of Justice, Health and Human Services, and Homeland Security. Coordination, collaboration, capacity: federal strategic action plan on services for victims of human trafficking in the United States, 2013-2017. January 2014. Accessed June 27, 2015.
  33. SOAR to Health and Wellness Act of 2015, S 1446, 114th Cong, 1st Sess (2015). Accessed June 30, 2015.
  34. HEAL Trafficking. Medical societies. linkagesresources/medical-societies/. Accessed July 20, 2015.
  35. Stoklosa H, Grace A, Chisolm-Straker M, Baldwin S, Chang K, Littenberg N. Network of health professionals combatting human trafficking—HEAL Trafficking. Paper presented at: 142nd Annual Meeting of the American Public Health Association; November 17, 2014; New Orleans, LA.

Hanni Stoklosa, MD, MPH, is an emergency physician at Brigham and Women’s Hospital, an instructor at Harvard Medical School, and a Human Trafficking and Forced Labor fellow at the T.H. Chan School of Public Health Center for Health and Human Rights at Harvard University in Boston. She is also an Institute of Medicine, American Board of Emergency Medicine fellow in health sciences policy and co-founder of HEAL (Health, Education, Advocacy, Linkages) Trafficking, an international network of professionals combating human trafficking from a public health perspective. Her work seeks to advance research and policy on the health needs of human trafficking victims, globally and locally.

Aimee M. Grace, MD, MPH, is the health legislative assistant for Senator Brian Schatz (D-HI) and an adjunct assistant professor of pediatrics at The George Washington University in Washington, DC. Dr. Grace was previously a Children’s National Health System General Academic Pediatrics fellow in association with the Division of General Pediatrics and Adolescent Medicine at Johns Hopkins University School of Medicine, where she studied pediatric benefits in the Affordable Care Act. She received her MD from the University of Hawaii John A. Burns School of Medicine, her residency training in pediatrics at Stanford University, and her MPH from the T.H. Chan School of Public Health at Harvard University.

Nicole Littenberg, MD, MPH, practices internal medicine at Kokua Kalihi Valley Comprehensive Family Services and serves as the clinical director of the High Risk Victim Clinic at the Sex Abuse Treatment Center in Honolulu. In 2007 she co-founded the nonprofit Pacific Survivor Center to provide forensic evaluations, health care, and social services for victims of human trafficking, torture, and immigrant domestic violence. Over the past decade, Dr. Littenberg has provided care to hundreds of survivors and has conducted trainings on the investigation, documentation, and treatment of torture and trafficking victims for health care providers, attorneys, and judges in Hawaii and internationally. She is researching the health needs and access to care of labor trafficking survivors in Hawaii.

The Team Approach to Management of the Polytrauma Patient, July 2009

Human Rights and Advocacy: An Integral Part of Medical Education and Practice, January 2004

Integrating Human Rights into Medical Education, September 2004

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.