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Using sexual assault training to improve human trafficking education

Scannell, Meredith PhD, CNM, MPH, MSN, CEN, SANE-A; Conso, Jonathan BSN, RN

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doi: 10.1097/01.NURSE.0000657028.81053.2f
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EDs ARE THE MOST common healthcare service utilized by human trafficking victims.1 One study found that 88% of human trafficking victims sought treatment in an ED while being trafficked, making emergency healthcare professionals key agents in helping these victims.2 Unfortunately, many healthcare professionals have had little education on human trafficking and miss many red flags.

One urban hospital sought to improve human trafficking education among its emergency staff by using a sexual assault simulation course, called the Sexual Assault Simulation Course for Healthcare Professionals (SASH). The hospital wanted to find out if the SASH course could help nurses identify victims of human trafficking, especially those who are being trafficked for sex exploitation. Developed by the primary author of this article, the course implemented human trafficking education with a focus on sex trafficking. Supported by an example from our hospital, this article discusses how the healthcare organization implemented SASH to educate its staff on human trafficking and describes postimplementation results.

Background and significance

Human trafficking is a pervasive problem that continues to grow each year.1,3 There were 8,524 cases of human trafficking reported in the US in 2017, with the most reports coming from California, Texas, and Florida.3 While the cited number of human trafficking cases is high, the actual number of people affected is believed to be much higher due to the lack of accurate human trafficking identification and reporting. Sex trafficking is the most common form of human trafficking and disproportionately affects women.3-6 Further, many victims of sexual assault are at risk for sex trafficking. (See Common causes of human trafficking.)

Because of the health consequences of human trafficking, many victims need to seek healthcare services at some point. Education about human trafficking is essential for nurses, particularly those who work in the ED, because they are often the first healthcare professional to interact with a victim. Nurses spend the most time with patients, thereby increasing the opportunity to identify signs of human trafficking.

However, human trafficking education needs improvement. Research has shown that ED nurses who reported regularly screening patients for domestic violence and other aspects of violence also reported not ever having screened, identified, or treated human trafficking victims.7 Human traffic education is crucial for nurses to fully understand the complexities of human trafficking, especially obstacles that may prevent victims from disclosing that they are in a trafficking situation.

Simulation course

SASH uses an interprofessional model, which allows for participants to assume their unique and combined roles throughout the course. This is fundamental in some aspects of the course, such as a healthcare practitioner performing a speculum examination and the ED nurse's role in evidence collection.

The SASH course is comprised of four components: didactics, skills stations, simulated experience with a standard actor, and debriefing. It includes a pre- and posttest as well as a course evaluation. See Explaining the four components of SASH for a description of the course.


The SASH course has demonstrated effectiveness among nurses in regard to knowledge level and perceived competency. The authors analyzed pre- and posttest scores using statistical analysis Mann-Whitney U test (1-tailed), with .05 as the level of significance. There were 36 participants on the pretest and 28 on the posttest. The pretest group scored a mean average of 64.27 and the posttest group scored 81.60 (P = 0.00023), demonstrating a significant increase in baseline knowledge.

One limitation was the lower posttest response. Nurses were allowed a window of 2 weeks to complete the posttest, which resulted in the lower rate of completion when compared with the pretest.

The SASH course offered a standardized approach in providing educational content on a topic that many nurses had not had previously. This gave nurses a better understanding of the scope of the problem and helped them build skills to identify human trafficking patients and provide the necessary resources.

Delivering results

Our hospital's use of the SASH program led to the identification of a trafficking victim a few months later. In this case, JC was required to attend the SASH program once he began working as a new graduate nurse in the ED at a Level I trauma hospital. He had no previous human trafficking education. Education on caring for sexual assault victims is not a core educational component of most nursing programs. Months after attending the course, JC relied on this educational training while working in the observational unit in the ED. He received a report on a patient who was homeless and had reported a sexual assault and declined evidence collection. The patient also reported suicidal ideation, stating she had consumed a bottle of acetaminophen, but specimens for toxicology were negative. The patient was being transferred into the observation unit while waiting for placement in a mental health treatment center.

Upon receiving the report, JC felt that there was more to the patient's chief complaint and went to speak to her. Having undergone the SASH training, JC was now empowered to ask sensitive questions that foster open dialogue.

After conversing generally with the patient for a period, JC asked the patient if she felt safe here in the hospital. The patient responded yes. Following up, JC asked if anyone was making her do anything that she may not want to.

“In the hospital, no,” the patient responded. This answer raised JC's suspicion for human trafficking, so he then asked if anyone was making her do anything outside on the street. She said yes. JC informed the patient of the services available to her. To this, the patient declined to talk further about it but agreed to talk later once she was ready to take the next steps.

JC then reached out to some of the available services for victims of human trafficking and informed them about the patient. When she was ready to talk further, JC facilitated an assessment by a sexual assault nurse examiner, who confirmed JC's suspicions that this patient was a victim of human trafficking.

JC picked up on several key red flags when interacting with this patient. Knowing the complexities and the need to be sensitive about asking personal questions, JC developed a therapeutic relationship with the patient. This allowed him to ask more personal questions and the patient to open up and have an honest dialogue with the nurse. The patient was able to disclose to the nurse being forced into activities against their will.

The nurse also gave the patient space and time to open up. This demonstrates a trauma-informed approach, which is essential in caring for victims of sexual trauma. The trauma-informed approach recognizes that patients experience and recover from trauma differently. Core components include empowering patients and allowing them to make decisions regarding their healthcare. JC was able to do this by giving the patient space and allowing her to choose when she would be ready to fully disclose her situation.

Lessons learned

The SASH course teaches valuable lessons for ED nurses. For one, it provides an understanding of the scope of human trafficking as well as specific patient populations at risk, such as victims of sexual assault. Understanding the problem raises awareness of this problem and increases identified cases of human trafficking. The nurses also learn how to enable patients to discuss topics that are private and often difficult to talk about.

Finally, nurses learn how instrumental they are in helping victims of human trafficking. They develop skills to identify cases of human trafficking with the knowledge gained in the SASH course, thereby enabling these patients to get the resources and support they need.

Demonstrated effectiveness

Nurses can be key agents in identifying victims of human trafficking because they are most likely to meet a victim who is being trafficked. Implementing human trafficking education in different aspects of current educational materials is one method to start to address the educational gap identified among healthcare professionals.9 The SASH course has demonstrated effectiveness in nurses with no previous human trafficking education, improving their ability to successfully identify a human trafficking victim and provide necessary services.

Common causes of human trafficking

Victims of human trafficking may have become exploited due to the following reasons.

  • Some victims enter into human trafficking after escaping an abusive home situation. If they have limited money and life skills, entering into human trafficking is one method of survival.
  • Some victims are lured into sex trafficking under the guise of a romantic relationship with the trafficker who they believe is a boyfriend. These victims develop feelings of love and trust in a short period of time and are soon afterward coerced or forced into human trafficking and sexual exploitation.10
  • In some cases, the victim's friend(s) may have deceived the victim by organizing travel to a different country or area for a better life opportunity.5
  • Parents, relatives, or caregivers may be directly involved in having their child trafficked or sexually exploited.4

Explaining the four components of SASH

The didactics portion of the SASH course includes information on the latest evidence-based approach in caring for sexual assault victims. Key aspects include the need to first address any critical and life-threatening medical issues, followed by assessment for psychological issues, the medical forensic examination, and evidence collection. Some fundamental aspects to the educational content include emerging healthcare issues seen more frequently with victims of sexual assault. In-depth information is provided on signs and symptoms to assess for as well as relevant hospital policies, procedures, and resources. A trauma-informed framework, which considers the traumatic experiences patients may currently have or have had in the past that may impact how they seek care, is utilized throughout the course so that the patient's needs and preferences are met. It promotes shared decision-making, giving patients choices so that they can make the best healthcare decisions for themselves and their situation.

The second portion consists of six hands-on skills stations that cover the components of evidence collection:

  • Station 1 includes an overview of the forensic evidence collection kit and instructions, with participants practicing specific evidence collection techniques such as head hair combings and fingernail scraping on a manikin.
  • Station 2 offers a case scenario in which a sexually assaulted victim was strangled. This scenario requires the use of an alternative light source to find evidence on the victim not seen in daylight.
  • Station 3 reviews principles of forensic photography and proper documentation.
  • Station 4, which also involves a case scenario, covers vaginal and anorectal assessment. The advanced practitioner assumes the lead in the speculum exam and the nurses assist with equipment and identifying landmarks necessary for evidence collection.
  • Station 5 reviews the techniques of preserving, packaging, and documenting clothing collection and the legal process of how to maintain the chain of custody.
  • Station 6 reviews the components of the separate toxicology kit and the limitations and extent of testing.

The next section is a simulated experience with a standardized actor who plays the role of a sexual assault victim requesting medical care and declining forensic evidence collection. When the actor declines forensic evidence collection, the participants are required to address other aspects of care, such as using a trauma-informed approach to ask questions, addressing the need for the prevention of sexually transmitted infections and pregnancy, and connecting the patient to services such as social work.

The final portion is a debriefing period in which the participants discuss the case scenario and their role. In addition, participants discuss any areas of improvements or areas that went well. They also have an opportunity to ask questions and share experiences.

What is human trafficking?9

Human trafficking was defined in 2000 as the recruitment, transportation, transfer, harboring, or receipt of people by means of threat, the use of force, or other forms of coercion, abduction, fraud, deception, the abuse of power, or a position of vulnerability. Human trafficking may also involve the giving or receiving of payments or benefits in exchange for exploitation. Exploitation includes prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude, or the removal of organs. Human trafficking can be divided into three components: the act, the means, and the purpose. Human trafficking does not require the movement of persons; many victims are trafficked in their own homes, communities, or in cities within their countries of origin. Human trafficking is also referred to as modern slavery. It affects nearly every country in the world, regardless of level of economic development. As awareness of human trafficking has evolved, victims have been found and assisted in leaving exploitative situations within a variety of industries including agriculture, manufacturing, hospitality, healthcare, domestic service, and commercial sex work.


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