Opinion
VIEWPOINT
Aimee M. Grace, MD, MPH Children’s National Health System, Washington, DC. Roy Ahn, MPH, ScD Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts. Wendy Macias Konstantopoulos, MD, MPH Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts.
Viewpoint page 791
Corresponding Author: Aimee M. Grace, MD, MPH, Children’s National Health System, 111 Michigan Ave NW, Washington, DC 20010 (agrace@stanfordalumni .org). jamapediatrics.com
Integrating Curricula on Human Trafficking Into Medical Education and Residency Training Today in the United States , human trafficking occurs in cities, suburbs, and rural areas across all 50 US states.1 “Severe forms” of human trafficking are defined under the US Trafficking Victims Protection Act of 2000 as the following: (1) 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 (2) 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. According to data collected by the US Human Trafficking Reporting System between January 2008 and July 2010, 83% of confirmed sex trafficking victims were US citizens, and 95% of confirmed labor trafficking victims were foreignborn nationals. Moreover, 87% of sex trafficking victims were younger than 25 years, compared with 38% of labor trafficking victims.2 Health outcomes associated with human trafficking include infectious diseases such as tuberculosis and human immunodeficiency virus (HIV)/AIDS, noninfectious diseases such as dental disease and malnutrition, reproductive health problems, substance abuse, mental health problems including posttraumatic stress disorder, depression, and suicidal ideation, and physical injuries from violence experienced during enslavement.3,4 From a public health perspective, trafficking may be an important means of HIV transmission, as suggested by one study that found a 38% HIV prevalence among repatriated sex-trafficked Nepalese women and girls, with a 60% infection rate among girls trafficked prior to 15 years of age.5 The health care profession may be one of the few professions likely to interact with trafficking victims while enslaved. A 2011 study found that 50% of trafficking survivors interviewed reported having visited a physician while trafficked.6 Key informants working closely with trafficking survivors were also interviewed and 100% described additional clients who had received medical care while under their trafficker’s control.6 Low awareness and a lack of guidance or protocols for responding to human trafficking in the health care setting are particularly salient barriers to a more effective health sector response in the United States.3 A recent study demonstrated that a brief educational intervention for health professionals increased their knowledge about human trafficking, as well as selfreported recognition of human trafficking victims.7 In the same study, an overwhelming majority of respondents— 79% preintervention and 92% postintervention— agreed or strongly agreed that it was important for them to know about human trafficking for their professions.7
Calls for Educational Training About Human Trafficking Multiple health professional organizations have issued calls for their member physicians to receive educational training about human trafficking. These organizations—including the American College of Obstetricians and Gynecologists (2011), the American Medical Association–Medical Student Section (2012), the Christian Medical & Dental Associations (2013), and the American Academy of Pediatrics (2014)—have been joined by similar calls from allied health professions, including nursing and social work. Following the January 2014 release of the US government’s Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States: 2013-2017, the US Department of Health and Human Services launched the SOAR to Health and Wellness Network, a pilot initiative to educate health care professionals on how to identify and serve victims of trafficking. For more information, please refer to the US Administration for Children & Families website at http: //www.acf.hhs.gov/press(press release dated January 14, 2014).
Integrating Human Trafficking Into Educational Training Resources currently exist to educate health care professionals about human trafficking,4 and some could be incorporated into medical education and residency training. These resources include online PowerPoint (Microsoft) presentations and training modules, handbooks, articles, tool kits, issue briefs, and websites, some of which provide continuing medical education credits.4 However, there does exist a need for further development of formal, evidence-based curricula. In its delineation of the core functions and structure of a medical school, the Liaison Committee on Medical Education defines the following core educational objective: “ED-20. The curriculum of a medical education program must prepare medical students for their role in addressing the medical consequences of common societal problems (e.g., provide instruction in the diagnosis, prevention, appropriate reporting, and treatment of violence and abuse).”8 Additionally, the National Board of Medical Examiners and the Federation of State Medical Boards of the United States define the following as necessary content for the US Medical Licensing Examination Step 1 examination: “Psychopathologic disorders, processes, and their evaluation…[including] physical and sexual abuse of children, adults, and elders.”9 Given these definitions, educational training on human trafficking fulfills both the Liaison Committee on Medical Education medical school core requirement, as well as the content for the US Medical Licensing ExamiJAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 05/30/2015
793
Opinion Viewpoint
nation Step 1 examination, making human trafficking an appropriate subject for incorporation into national medical school education. In residency training, the Accreditation Council on Graduate Medical Education lists the following for Common Program Requirements: “Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care,”10 a category in which human trafficking would certainly fall. Additionally, various specialty boards include violence and abuse in the content requirements for their certification examinations, including the American Board of Emergency Medicine, the American Board of Pediatrics, the American Board of Family Medicine, and the American Board of Internal Medicine. Ideally, an appropriate curriculum on human trafficking and health care would include information about the prevalence, health effects, and signs of human trafficking, appropriate interviewing techniques using a trauma-informed approach, and potential responses to disclosures, including referral to any needed services and provision of appropriate resources (including the telephone number to the National Human Trafficking Resource Center). In the case of minors younger than 18 years, education would additionally enARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamapediatrics.2014.999. Conflict of Interest Disclosures: None reported. Funding/Support: Drs Ahn and Macias Konstantopoulos receive grant support from Give Way to Freedom, a private foundation. Dr Grace's time on this project was supported by Health Resources and Services Administration grant D55HP23194 (Ivor Horn, MD, MPH, principal investigator) as part of the Health Resources and Services Administration Physician Faculty Development in Primary Care program. Role of the Sponsor: Give Way to Freedom and the Health Resources and Services Administration had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. REFERENCES
tail a review of mandatory reporting responsibilities. This information, when efficiently delivered, could be done as a 1-hour lecture. For medical students, this 1-hour lecture could be integrated into the equivalent of the first-year “physician and society” course and could form the basis for a simulation case to practice patient-physician communication. An alternative would be to include it in an elective course on violence and abuse. For residents, this could be a 1-hour lecture during residency didactic conference, delivered once yearly or every other year, as part of other lectures addressing social, ethical, or mandatory reporting issues. Health care professionals are well positioned to be first responders for victims of human trafficking who present to the health care setting. The opportunity exists for medical schools, residency programs, health professional organizations and societies, and national regulatory bodies to ensure that human trafficking education becomes part of medical school instruction and residency training. Integrating curricula on human trafficking into medical education and residency training, as well as encouraging research that will provide the evidence base for continually informing and updating the content of these curricula, are examples of ways in which health care professionals can respond to human trafficking today.
2. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010. Special report, US Department of Justice. http://www .bjs.gov/content/pub/pdf/cshti0810.pdf. Published April 2011. Accessed May 5, 2014. 3. Macias Konstantopoulos W, Ahn R, Alpert EJ, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: achieving a more effective health sector response. J Urban Health. 2013;90(6):1194-1204. 4. 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. 5. Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA. 2007;298(5):536-542. 6. 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):36-49.
7. Grace AM, Lippert S, Collins K, et al. Educating health care professionals on human trafficking. Pediatr Emerg Care. In press. 8. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. http://www .lcme.org/publications/functions.pdf. Published June 2013. Accessed May 5, 2014. 9. Federation of State Medical Boards of the United States, Inc; National Board of Medical Examiners. 2013 USMLE step 1 content description and general information. http://www.usmle.org/pdfs/step-1 /2013content_step1.pdf. Published 2013. Accessed May 5, 2014. 10. Accreditation Council on Graduate Medical Education. ACGME common program requirements. http://www.acgme.org/acgmeweb /Portals/0/PFAssets/ProgramRequirements /CPRs2013.pdf. Most recently effective: July 1, 2013. Accessed December 1, 2013.
1. Human trafficking: the victims. Polaris Project Web site. http://www.polarisproject.org/human-trafficking /overview/the-victims. Accessed May 5, 2014.
794
JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 05/30/2015
jamapediatrics.com
VIEWPOINT
Aimee M. Grace, MD, MPH Children’s National Health System, Washington, DC. Roy Ahn, MPH, ScD Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts. Wendy Macias Konstantopoulos, MD, MPH Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts.
Viewpoint page 791
Corresponding Author: Aimee M. Grace, MD, MPH, Children’s National Health System, 111 Michigan Ave NW, Washington, DC 20010 (agrace@stanfordalumni .org). jamapediatrics.com
Integrating Curricula on Human Trafficking Into Medical Education and Residency Training Today in the United States , human trafficking occurs in cities, suburbs, and rural areas across all 50 US states.1 “Severe forms” of human trafficking are defined under the US Trafficking Victims Protection Act of 2000 as the following: (1) 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 (2) 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. According to data collected by the US Human Trafficking Reporting System between January 2008 and July 2010, 83% of confirmed sex trafficking victims were US citizens, and 95% of confirmed labor trafficking victims were foreignborn nationals. Moreover, 87% of sex trafficking victims were younger than 25 years, compared with 38% of labor trafficking victims.2 Health outcomes associated with human trafficking include infectious diseases such as tuberculosis and human immunodeficiency virus (HIV)/AIDS, noninfectious diseases such as dental disease and malnutrition, reproductive health problems, substance abuse, mental health problems including posttraumatic stress disorder, depression, and suicidal ideation, and physical injuries from violence experienced during enslavement.3,4 From a public health perspective, trafficking may be an important means of HIV transmission, as suggested by one study that found a 38% HIV prevalence among repatriated sex-trafficked Nepalese women and girls, with a 60% infection rate among girls trafficked prior to 15 years of age.5 The health care profession may be one of the few professions likely to interact with trafficking victims while enslaved. A 2011 study found that 50% of trafficking survivors interviewed reported having visited a physician while trafficked.6 Key informants working closely with trafficking survivors were also interviewed and 100% described additional clients who had received medical care while under their trafficker’s control.6 Low awareness and a lack of guidance or protocols for responding to human trafficking in the health care setting are particularly salient barriers to a more effective health sector response in the United States.3 A recent study demonstrated that a brief educational intervention for health professionals increased their knowledge about human trafficking, as well as selfreported recognition of human trafficking victims.7 In the same study, an overwhelming majority of respondents— 79% preintervention and 92% postintervention— agreed or strongly agreed that it was important for them to know about human trafficking for their professions.7
Calls for Educational Training About Human Trafficking Multiple health professional organizations have issued calls for their member physicians to receive educational training about human trafficking. These organizations—including the American College of Obstetricians and Gynecologists (2011), the American Medical Association–Medical Student Section (2012), the Christian Medical & Dental Associations (2013), and the American Academy of Pediatrics (2014)—have been joined by similar calls from allied health professions, including nursing and social work. Following the January 2014 release of the US government’s Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States: 2013-2017, the US Department of Health and Human Services launched the SOAR to Health and Wellness Network, a pilot initiative to educate health care professionals on how to identify and serve victims of trafficking. For more information, please refer to the US Administration for Children & Families website at http: //www.acf.hhs.gov/press(press release dated January 14, 2014).
Integrating Human Trafficking Into Educational Training Resources currently exist to educate health care professionals about human trafficking,4 and some could be incorporated into medical education and residency training. These resources include online PowerPoint (Microsoft) presentations and training modules, handbooks, articles, tool kits, issue briefs, and websites, some of which provide continuing medical education credits.4 However, there does exist a need for further development of formal, evidence-based curricula. In its delineation of the core functions and structure of a medical school, the Liaison Committee on Medical Education defines the following core educational objective: “ED-20. The curriculum of a medical education program must prepare medical students for their role in addressing the medical consequences of common societal problems (e.g., provide instruction in the diagnosis, prevention, appropriate reporting, and treatment of violence and abuse).”8 Additionally, the National Board of Medical Examiners and the Federation of State Medical Boards of the United States define the following as necessary content for the US Medical Licensing Examination Step 1 examination: “Psychopathologic disorders, processes, and their evaluation…[including] physical and sexual abuse of children, adults, and elders.”9 Given these definitions, educational training on human trafficking fulfills both the Liaison Committee on Medical Education medical school core requirement, as well as the content for the US Medical Licensing ExamiJAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 05/30/2015
793
Opinion Viewpoint
nation Step 1 examination, making human trafficking an appropriate subject for incorporation into national medical school education. In residency training, the Accreditation Council on Graduate Medical Education lists the following for Common Program Requirements: “Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care,”10 a category in which human trafficking would certainly fall. Additionally, various specialty boards include violence and abuse in the content requirements for their certification examinations, including the American Board of Emergency Medicine, the American Board of Pediatrics, the American Board of Family Medicine, and the American Board of Internal Medicine. Ideally, an appropriate curriculum on human trafficking and health care would include information about the prevalence, health effects, and signs of human trafficking, appropriate interviewing techniques using a trauma-informed approach, and potential responses to disclosures, including referral to any needed services and provision of appropriate resources (including the telephone number to the National Human Trafficking Resource Center). In the case of minors younger than 18 years, education would additionally enARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamapediatrics.2014.999. Conflict of Interest Disclosures: None reported. Funding/Support: Drs Ahn and Macias Konstantopoulos receive grant support from Give Way to Freedom, a private foundation. Dr Grace's time on this project was supported by Health Resources and Services Administration grant D55HP23194 (Ivor Horn, MD, MPH, principal investigator) as part of the Health Resources and Services Administration Physician Faculty Development in Primary Care program. Role of the Sponsor: Give Way to Freedom and the Health Resources and Services Administration had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. REFERENCES
tail a review of mandatory reporting responsibilities. This information, when efficiently delivered, could be done as a 1-hour lecture. For medical students, this 1-hour lecture could be integrated into the equivalent of the first-year “physician and society” course and could form the basis for a simulation case to practice patient-physician communication. An alternative would be to include it in an elective course on violence and abuse. For residents, this could be a 1-hour lecture during residency didactic conference, delivered once yearly or every other year, as part of other lectures addressing social, ethical, or mandatory reporting issues. Health care professionals are well positioned to be first responders for victims of human trafficking who present to the health care setting. The opportunity exists for medical schools, residency programs, health professional organizations and societies, and national regulatory bodies to ensure that human trafficking education becomes part of medical school instruction and residency training. Integrating curricula on human trafficking into medical education and residency training, as well as encouraging research that will provide the evidence base for continually informing and updating the content of these curricula, are examples of ways in which health care professionals can respond to human trafficking today.
2. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010. Special report, US Department of Justice. http://www .bjs.gov/content/pub/pdf/cshti0810.pdf. Published April 2011. Accessed May 5, 2014. 3. Macias Konstantopoulos W, Ahn R, Alpert EJ, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: achieving a more effective health sector response. J Urban Health. 2013;90(6):1194-1204. 4. 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. 5. Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA. 2007;298(5):536-542. 6. 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):36-49.
7. Grace AM, Lippert S, Collins K, et al. Educating health care professionals on human trafficking. Pediatr Emerg Care. In press. 8. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. http://www .lcme.org/publications/functions.pdf. Published June 2013. Accessed May 5, 2014. 9. Federation of State Medical Boards of the United States, Inc; National Board of Medical Examiners. 2013 USMLE step 1 content description and general information. http://www.usmle.org/pdfs/step-1 /2013content_step1.pdf. Published 2013. Accessed May 5, 2014. 10. Accreditation Council on Graduate Medical Education. ACGME common program requirements. http://www.acgme.org/acgmeweb /Portals/0/PFAssets/ProgramRequirements /CPRs2013.pdf. Most recently effective: July 1, 2013. Accessed December 1, 2013.
1. Human trafficking: the victims. Polaris Project Web site. http://www.polarisproject.org/human-trafficking /overview/the-victims. Accessed May 5, 2014.
794
JAMA Pediatrics September 2014 Volume 168, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 05/30/2015
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