AMA Journal of Ethics. October 2015, Volume 17, Number 10: 914-921.
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 .
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 . International human rights law has declared the “fundamental immorality and unlawfulness of one person appropriating the legal personality, labour or humanity of another” ; 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 .
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” . 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 . 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  to 87.8 percent . 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 . 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 . 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 . 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 , highlighting the need for trauma-informed care training.
Several studies [20-21, 23-26], including a randomized controlled trial , 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) . 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 . 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 . 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) . Recently introduced legislation in the US Senate would codify and further expand this training program on human trafficking .
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 .
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 .
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.
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.
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