216 – Wisdom from a Sexual Assault Nurse Examiner

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Dr. Sandie Morgan and Dave Stachowiak are joined by Heidi Olson, a Sexual Assault Nurse Examiner (SANE) Program Manager at Children’s Mercy Hospital in Kansas City. Heidi has a wide range of experience in pediatric and forensic nursing and her role includes performing forensic exams on children who have been victims of sexual assault, communicating with law enforcement and child protective services, and serving as an expert witness in criminal trials.

Key Points

  • A SANE nurse collects evidence to corroborate the patient’s disclosure, makes sure the patient is safe and healthy and may testify in court.
  • There is a better way to identify possible victims of human trafficking other than looking for signs similar to over-sensationalized media.
  • Assess risk factors that address the patient’s reproductive system, substance abuse, mental health, physical abuse, and other risk factors.
  • Vulnerabilities and risk factors differ from children to adults, necessitating different screening tools.


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Dave [00:00:00] Hi, everyone, a quick disclaimer before this episode. As always, our content is serious and difficult. This episode is particularly challenging as we are talking about children who have been victims of sexual assault. This, as a result, may not be a good carpool episode as colleagues may experience being triggered and may not be able to ask to turn it off for a bit. It’s also not a good episode if you have kids or youth with you without an adult nearby to stop or explain and answer questions. Nevertheless, this is important content and you’re listening to the Ending Human Trafficking podcast. This is episode number 216 – Amy Looks like Everybody Else, Wisdom from a Sexual Assault Nurse Examiner.

Production Credits [00:00:42] Produced by Innovate Learning, Maximizing Human Potential.

Dave [00:01:03] Welcome to the Ending Human Trafficking Podcast. My name is Dave Stachowiak.

Sandie [00:01:08] And my name is Sandie Morgan.

Dave [00:01:10] And this is the show where we empower you to study the issues, be a voice, and make a difference in Ending Human Trafficking. Sandie, as I mentioned in the introduction here, a difficult topic today, of course, as we get into this and yet an important topic for us to all know more about. And so, I’m glad we get to speak to someone today who’s really an expert in this area that’ll help us to discover even more.

Sandie [00:01:35] So, we have with us today Heidi Olson, a registered nurse who is a specialist as a sexual assault nurse examiner, and she’s the program manager at Children’s Mercy Hospital in Kansas City. And her wide range of experience in pediatric and forensic nursing in her role includes performing forensic exams on children who have been victims of sexual assault. She communicates with law enforcement, child protective services, and serves as an expert witness in criminal trials. She has performed or reviewed over twelve hundred child sexual abuse exams in the last two years and has presented over 200 times about recognizing human trafficking, child on child sexual assault, pornography, and sexual violence trends. Heidi, I don’t know if welcoming you to the show is the appropriate next statement, but your work is really difficult and I am just in awe of your resilience. And meeting you in person, you are just the right person for this job. So, welcome to the Ending Human Trafficking podcast.

Heidi [00:02:54] Thank you so much for having me. It’s such an honor and just such a topic that I feel really passionate about. So, I’m really excited to be here.

Sandie [00:03:03] Alright. Well, first, you know, I’m a pediatric nurse background as well, although not with your level of specific experience. And I remember the first time I heard the term SANE. nurse and I thought I’m not so sure that’s very sane. So, do you want to, I know you’ve heard that like a thousand times, but for our listeners, can you give us a better idea of what a SANE. nurse does?

Heidi [00:03:28] Absolutely, SANE is an acronym for sexual assault nurse examiner and it’s a very unique type of nurse, and SANE. nurses were basically born out of a need that when sexual assault victims had been sexually assaulted, there’s forensic evidence that can be collected off of their bodies, but also they may have injuries or specific needs at that moment. So, victims who are presenting to ER, nobody knew how to collect evidence, they weren’t sure what to do with these victims, didn’t understand trauma. And so it just ended up being a really traumatic experience for everybody involved. So, SANE. nurses were born out of this need of we need specific medical people who understand forensic evidence, who understand what injuries look for, who understand trauma, and don’t make this more traumatizing for someone who’s just experienced something awful. So, essentially, our nurses were specific, the ones I worked with, we are specifically trained to see children. So, 0 through 18, and when a child has been sexually assaulted and comes into our health care system, one of our nurses will see them. So, they’re looking for DNA on a kid’s body, which would be skin cells, hair cells, saliva, semen, wherever we think we can find it on the child, which is typically their genitals if it’s been a sexual assault. And then we look for injuries on their bodies. Sometimes we’ll see, you know, signs of strangulation or other physical injuries. And then we look obviously for genital injuries as well. And then we make sure that they have resources for therapy. You know, a safe place to go. We make all the appropriate reports to the hotline and then occasionally we get subpoenaed to testify in court as well, since we kind of helped start the beginning of the criminal justice process. So, in a nutshell, that’s what SANE. nurses do for kids, and then there are adults SANE. nurses as well.

Sandie [00:05:29] So, in my world, the connection between sexual abuse as a child and trafficking has been recognized for a very long time. And when you presented at the conference in Washington, D.C., you talked about the sensationalized world of trafficking and how you see these kids. Could you explain that a little bit?

Heidi [00:05:55] Yes. So, when I became a sane nurse, believe it or not, I actually didn’t get a lot of training about human trafficking. I got maybe a little blurb of like, “there is a thing called human trafficking that you will encounter, good luck.” So, here was my context for human trafficking, the movies, social media, the news. And so sort of a common thread and all of those things is that you’re seeing these examples of people getting kidnaped, and tortured, and being held in a basement, and that’s sort of what everybody, who have not been educated on human trafficking, that’s their perception of sex trafficking- is people who are being kidnaped and being held, you know, physically held against their will somewhere. So, if, as SANE. Nurses, that’s what we are looking for, is someone coming in who’s been chained up, locked away, tortured, we’re never going to identify a trafficking victim. So, I started to realize, because that’s not actually what they look like. And so probably about three months into being a SANE. nurse, I took care of a girl who I knew in my gut was being trafficked. And after just hearing all of her risk factors and looking at her labs and her exam and her story, I’m like this kid is being trafficked, there is no doubt in my mind. But nobody knew what to do with her. And so I think for me, it was for me this moment when she presented as a sexual assault victim, she was clean, she was dressed, she was like the cute smiley little teenager. You would never look at her and think, oh, this kid is a sex trafficking victim until you start to look at the risk factors. And so I think for me, that was this catalyst of we’re doing this wrong. We’re looking at this the wrong way. And we’re missing a ton of kids that are coming in for care because we’re looking for sort of this version of like the movie Taken. And that’s not how these kids are presenting.

Sandie [00:07:48] You’re singing my song. And in fact, I noticed in your PowerPoint, you cited Dr. Laura Lederer. And we interviewed her and her research back in podcast number 106, where they identified 87 percent of trafficking victims have had contact with a health care provider while they were being trafficked. So, what you’re doing is so important to turn those kinds of statistics upside down. So, tell me a little bit about your hospital, because I live in a big city. You know, I’m in California. Kansas City, how is it that you have treated so many victims?

Heidi [00:08:30] Yeah, it’s alarming how many kids we’re starting to identify now that there’s increased awareness and education. And I agree with what you were saying earlier. With so many trafficking victims interacting with health care workers, I can think of victims I took care of as a brand new nurse. But now, looking back, I’m certain they were being trafficked and I had no clue. And so part of sort of our statistics, I think in seeing higher and higher numbers of trafficking victims at our hospital, a level of it is just awareness. But Children’s Mercy Hospital is a large children’s hospital in Kansas City, we’re the only children’s hospital really in that part of the Midwest. And so we kind of have a monopoly on pediatric patients in that sense that we get a lot of referrals from everywhere in the Midwest, not just Kansas City. But our specific sexual assault program sees one of the highest volumes of sexual assault victims in the United States. So, when we look at statistics of like adult programs, pediatric programs, and programs of the adults and pediatrics, we are ranked in the top five percent of the United States.

Sandie [00:09:42] That’s impressive.

Heidi [00:09:44] Yeah, it’s a terrible statistic to have. And it is probably multifactorial for why, but as we have educated our emergency department staff, and urgent care staff, and SANE nurses, we’re identifying more and more trafficking victims. So, in 2015, we only identified two trafficking victims the entire year, supposedly. I’m sure we saw way more, it was just there was not the same level of education. Moving over to 2019, where we identified 62.

Sandie [00:10:15] Wow.

Heidi [00:10:16] So. I think we probably were seeing a ton of kids before. It’s just that our perception has shifted. And so now we’re starting to sort of see the result of that is that we’re identifying more and more kids who are really high risk or are definitely confirmed trafficking victims.

Sandie [00:10:32] So, we have a lot of nurses that listen to this podcast, many of them, especially if they’re in Southern California, sit in traffic. So, they listen to the whole thing. So, let’s take kind of a walk through your experience. And first of all, identify the five aspects of assessment that you address when you’re seeing a patient.

Heidi [00:10:55] Sure so, hello, fellow nurses. And these are based on what we’ve seen with children specifically. So, it could be a little different with adult victims. But I do think there’s a lot of overlap with both populations. But what we see pretty much without fail with every child who is being trafficked is their reproductive system is going to be affected. Of course, when there’s multiple sexual contacts over and over and over again. And so a lot of these kids coming in have multiple sexually transmitted infections in multiple parts of their body. And in the past, I would hear, you know, that a kid would come, say, a 15-year-old came into an E.R. and they had gonorrhea and chlamydia. And instead of anyone asking more questions like, are you safe? You know, tell me about where you’re living, that type of thing. It was here are some condoms, you need to stop being so promiscuous. And so it’s not assessing those red flags. So, the reproductive system is huge. We see a lot of kids who are trafficked who have genital injuries, they may have a positive pregnancy test, they’ll admit to having elective or spontaneous abortions, or maybe have something impacted in their vaginas, things like that that are just absolutely not normal for a teenager or, you know, a younger kid would be extremely huge red flags. Then the other thing that we see that are really common is that there’s some history or current use of substances. So, maybe a parent is addicted to drugs, and that automatically makes that child vulnerable. Or we’ll see a lot, especially of the teenagers who test positive for some type of substance. And a lot of times its meth, here in the Midwest. So, we see that quite a bit. I took care of a trafficking victim last year and she was taking cough medicine and she actually brought it in her purse with her to the hospital. So, I mean, we see all various types of substance abuse. Then mental health is another huge one that comes up almost every time with trafficking victims, of course, because of all of the trauma that’s associated with this. So, sometimes maybe it’s their parent who has a mental health diagnosis that’s making this child vulnerable or it’s the kid who’s been diagnosed with something because of all of this trauma and sexual abuse that they’ve experienced. So, we see a lot of anxiety, a lot of kids who are actively suicidal. I think kids who are, you know, disassociating right in front of me as we’re doing their exams or they’ll just be really flat and disengaged as we’re interacting with them. And then we see a lot of physical abuse and injuries that kind of go hand-in-hand with being trafficked as well. So, cigaret burns, bruises where they don’t tell us “I don’t remember where that came from”, that is really concerning, strangulation. Sometimes they’re coming in and they’re malnourished. They’ll say, I got to eat Wendy’s, you know, at midnight every night and that’s it. Or traumatic brain injuries. Of course, they’re not going to have well-child checkups or anything like that.  And then kind of in its own other categories, other risk factors that we see as a lot of these kids, at least presented in the Midwest, are kids who are runaways, who have had some type of have either been in foster care or in state custody at some point. And a lot of times they’re presenting alone. That’s sort of the commonality that we’re seeing, at least here with our patients.

Sandie [00:14:16] So, what you went from identifying three trafficking victims to 60 plus. So, how do we learn to identify kids who are being sexually exploited?

[00:14:29] So, for us, what we realized is that a lot of rules have been developed to identify kids who are being trafficked, were geared towards adults. So, the questions that you may ask an adult trafficking victim is going to make no sense to a 12-year-old coming in for a sexual assault. For example, if we’re saying, “well do you have to meet a quota every day?” You know, a twelve-year-old is going to stare at you like what is a quota, like what on earth are you talking about. And so those types of screening tools didn’t really make sense to our patient population. So, thankfully, about a year ago, Jordan Green Bomb, who’s an amazing physician. She and a whole list of other people published a tool to help identify kids in a medical setting that are being sexually exploited. And so essentially what this screening tool does is it asks about risk factors, which for us more than anything if we start to see that kids are saying yes to multiple risk factors, there is a high likelihood that there’s some level of exploitation going on. So, we obviously, I’m sure, everyone knows like you can’t ask a child, “are you being trafficked?” They have no idea what that means, have no context. But when we say, you know, “have you ever had problems with the police? Have you ever been arrested for anything?” Well, they are much more inclined to answer those questions. So, we’ve been doing the screening tool, which has helped us be able to positively identify a lot more trafficking victims. So, the screening questions that are on this poll that was published are: have you been seen by a health care provider in the last year? Have you ever run away from home or been kicked out of your home? Have you used drugs or alcohol in the last twelve months? Have you had problems with the police? Has a boyfriend or girlfriend in a relationship ever physically hurt you or threaten to hurt you? Have you ever had sex? And then if they say yes- what kind of sex did you have? How many sex partners have you had? What were the genders of your partners? How would you describe your sexual orientation? And have you ever had a sexually transmitted infection? If they say yes to two or more of those it’s considered positive, which doesn’t necessarily mean they’re being trafficked. It means we need to ask more questions about the kind of their safety and what’s going on in their life. But then at the end of the screening question, there are four more questions where if a kid said yes to any of them, we would flag it for sexual exploitation. So, have you ever been in a position where you needed to trade sex for something? Has a boyfriend or girlfriend ever forced you to have sex with someone else? Has anyone ever asked you to do some kind of sex act in public? Have you ever had to pose in a sexy way for a photo or video? So, those are sort of the questions that we, I mean those are the questions that we have started asking our teenage patients. And they don’t know that we’re assessing for trafficking. You know, when they’re answering these questions, they might feel kind of awkward answering some of them, but they have no idea the intent behind it. They probably don’t realize the cascade that’s going to happen is like, OK, well, now we’re really concerned about your safety and we probably need to intervene and, you know, we need to ask more questions. But most kids are very honest. I mean, I’ve had kids, right? I typically will physically ask them questions, but sometimes they want to fill it out on their own and they’ll write notes and they’ll tell us all kinds of things we didn’t know when they came into the E.R., which can be very heartbreaking but it also helps us be able to say this child was very high risk or is being trafficked.

Sandie [00:17:58] So, how is this screening tool different than a screening tool for adults?

Heidi [00:18:05] I think the difference is that it’s assessing vulnerabilities in kids that a trafficker would prey on or that would point to exploitation, whereas with adults, some of these behaviors might be considered normal. You know, an adult might have a sexually transmitted infection from a consenting partner or, you know, an adult may have been arrested for shoplifting and that maybe isn’t as much of a risk factor as it is with a child. For us, it’s helpful to see the different ways that they are vulnerable.

Sandie [00:18:35] OK, so you’ve given us a really good foundation and now you’re going to walk us through how this works with a patient. Because the title of your presentation is “Amy Looks like everybody else.” So, Amy is not a real person but is a nice case study for us to learn how to apply this. So, walk us through that.

Heidi [00:18:57] Alright. So, Amy is a healthy-looking teenager. If you glance at her, you would not think this child’s been held in a basement or anything like that. She comes into an emergency department with her grandmother and she wants to test for sexually transmitted infections. So, she’s currently in state custody and was previously living in a group home. She ran away from her group home six months ago with an older female that she met online. The police found her in another state last night and brought her back to her grandmother’s. So, when her assessment was done, she was found to have four sexually transmitted infections, she had cigaret burns to her inner thighs, she had genital injuries, she does have a history of childhood sexual abuse, she denies that she is being trafficked or exploited.

Sandie [00:19:44] Alright. So, now what do we do?

Heidi [00:19:47] So, if we refer back to that screening tool that I was talking about. We’ll just quickly go through the questions again. Has she been seen by a health care worker in the last year? Not that we know of. Has she run away from home? Yes, her group home. Has she used drugs or alcohol in the last twelve months? She denies it. Has she had problems with the police? Yes, obviously, the night before. She says she’s never been in a relationship where she was hurt or threatened. She does admit to having sex. She says she’s had penile to vaginal sex, but she’s had six to 10 partners, which that screens positively if it’s higher than five. She would describe herself has been straight, she says, but obviously she’s had a sexually transmitted infection. She is positive in the ED. She is screening very, very positive on the screen. So, even though she’s saying, “no, I’m not being trafficked, nobody’s doing anything to hurt me.” She’s had multiple yeses on this screening tool. So, when we go through the next questions, you know, have you ever had to trade sex, anything like that? She says no to all of those questions.

Sandie [00:20:51] Did that surprise you?

Heidi [00:20:54] No, it didn’t. She actually, with some kiddos I think they are smart enough to know when we get into more of those exploitation questions like I probably shouldn’t say yes to any of these questions.

Sandie [00:21:07] Ok.

Heidi [00:21:07] But it’s the risk factors that just like glaringly bright that I felt a lot of red flags. So, we reported this just of, hey, we’re really concerned, you know, considering all of these things that are going on the way she would even brought into the ER, that she was found with a stranger. You know, all these things, it was investigated and she actually was a victim of human trafficking.

Sandie [00:21:30] And so take us back to when you reported it. How did you report it? To local law enforcement?

Heidi [00:21:37] We did. So, we report it to Child Protective Services, and obviously in whatever state this child is in. We reported it to law enforcement where the crime was happening, so it was actually in a different state. And then we report it to the human trafficking hotline. And then we also have a really good relationship with the FBI here in Kansas City. So, we’ll typically call those agents directly to say, hey, we have a kid here that we think is being trafficked and they kind of take it from there. So, there are multiple people that we report to and obviously it’s mandated reporters.

Sandie [00:22:11] One of the things that people often ask me is why should I call the human trafficking hotline when I already have the victim in a safe place? And so I’d love to hear your answer to that question first. I totally agree with doing it.

Heidi [00:22:27] Sure! One thing, I know this is not like the top of anyone’s priority list when you’re taking care of a trafficking survivor, but if they are attempting to streamline statistics for trafficking. So, I think that’s very helpful. The more calls that we make when we suspect trafficking, we’re going to have real-time data of where we think trafficking victims are in the United States. But then I think another part of it is when I’ve talked to the FBI, so when we make a hotline, that same hotline goes to the FBI agents we’re already calling. So, some of our nurses are kind of like we’re just doing the same thing twice. But the FBI was like we actually recommend calling the hotline on top of us because it starts to piece together sort of a picture for us from the hotline tips. So, maybe Children’s Mercy is calling about a kid, but then three other people are as well calling the hotline. The FBI can start to say like, oh, three people called about this kid, like there’s something going on. So, it is actually really helpful, according to investigators.

Sandie [00:23:25] It does give us bigger statistics to look at than if we keep everything local. So, OK, kudos to you for that. So, then Amy got help?

Heidi [00:23:36] She did, yes. Actually, that’s a really sad ending, as far as I know, Amy is on the run again after that exam she was with grandma for a little bit and then she ran. A far as I know she hasn’t been found.

Sandie [00:23:47] And that’s tragically a very frequent story. Which is the previous episode on the podcast was about the very long journey to healing and how committed we have to be for that. But still identifying people and the idea that eventually they run, but then we find them again and each time there’s a better prospect for a really complete restoration. Let’s look at another case study, I wish we had time to go through all of the ones that you did at the conference, but I was really intrigued by your case study on Whitney. Can you talk about Whitney?

Heidi [00:24:33] Sure, so Whitney is a toddler and her history is that her mom has a history of substance abuse and her mom has a history of gang involvement as well. So, grandma had brought Whitney into the emergency department and she told our nurse that she had overheard a conversation where Whitney’s mom admitted to holding Whitney down and allowing her to be sexually assaulted in exchange for drugs. So, of course, she was extremely concerned, did the right thing brought her into the E.R. And Whitney is as verbal as you can be for a toddler, but she’s not disclosing anything about her assault in the emergency department, which is not uncommon. Our nurse didn’t see any injuries on her exam, which again, is also not uncommon. Actually, a lot of sexual abuse victims don’t typically have injuries. So, we absolutely were concerned that something was going on, exploitation wise. So, how do you do a screening tool with a 3-year-old? You can’t. So, the limitation to this streaming screening tool is that it really only works with like the tween, teen population. And so we already knew there was a disclosure of exchange, that there was a sexual assault in exchange for drugs, and that meets the definition of sex trafficking with minors. And so we went ahead and hotlines it and reported it, and all of those types of things and safety plan for her to not be around mom.

Sandie [00:26:06] Oh my goodness, that’s a harrowing story. And understanding what to do, though, is the key to success for the future of that child. And I think that’s one of the things that every hospital and every health care facility should have a protocol and an algorithm in place. So, do you kind of have a system that is programmed for everyone to follow the same guidelines?

Heidi [00:26:35] We do, yes. So, whenever there is some type of suspicion of sexual exploitation or trafficking or even sexual abuse, I mean, just anything falling in the category of some type of sexual exploitation. The first person that anyone in our health care system is supposed to contact is our social workers. So, kind of each department has a social worker assigned to them. And our social workers have all been trained on then here’s what you do next. So, sometimes that involves getting a SANE nurse, you know, to do an exam. Of course, it’s going to involve hot lining, reporting, safety planning, that type of thing. So, social work is actually kind of our go-to person. And then if we need someone to collect evidence to do a physical assessment, then SANE is kind of the next person who gets involved.

Sandie [00:27:23] So, you’re not the first person that they call?

Heidi [00:27:26] I’m actually not, no. Which is fine with me because I’d be spending all day, every day making hotlines. So, social workers are amazing, and they’ve been willing to take that on.

Sandie [00:27:38] So, what recommendation do you have for health care providers at other hospitals and especially pediatric health care providers?

Heidi [00:27:48] So, I think that one of the biggest barriers that we have faced in the last few years is just the perception that people have of trafficking survivors. I think they’re often dismissed, or misidentified, or the right people aren’t like, you know, social workers or SANE aren’t even activated in the first place because there’s such a lack of awareness or we’re labeling a kid as being, you know, a truant or promiscuous or not asking enough questions even really see there is some level of exploitation. So, I think for health care providers to start to sort of question what we’ve been told and changed our perception about what trafficking really looks like and how survivors are presenting because we know they are. And I think really that the perception piece of it has probably been one of the hardest things to overcome in our health care system.

Sandie [00:28:39] Okay, you heard it from an expert witness. So, we’re gonna share this podcast as widely as we can with pediatric nurses and emergency room staff that work with children, because this is a really important message. We’ll do another podcast later on, on screening for adults. We’ve done some in the past, but at this particular point, we really want to challenge health care providers to begin to reach into their particular community to find out who is doing what. What are the best practices? Are there written protocols, policies, guidelines and procedures? Because the statistic that we talked about at the beginning, that 87 percent of victims who were interviewed after they’d been rescued had seen a health care provider and the health care provider had not realized that they had a trafficking victim right in front of them. So, we’re going to change that, right Heidi?

Heidi [00:29:44] Absolutely.

Sandie [00:29:44] Okay. Thank you so much for being on this show with us. And we look forward to having you right here in Orange County with us, March 6th and 7th for Ensure Justice. And if you haven’t registered yet, go to Ensurejustice.com.

Dave [00:30:03] Thank you so much to you both. Sandie, as we mentioned early on, such a difficult topic, but such an important one for all of us to be aware of, especially those of us in our listening community who are in health care. And we challenge you to go and take the next step, go over to endinghumantrafficking.org. If you haven’t already visited there, it will allow you to download a copy of Sandie’s book, The Five Things You Must Know, a Quick Start Guide to Endinghumantrafficking.org. It’ll teach you the five critical things that Sandie has identified that will help you in your efforts to join the fight against human trafficking. Get access right now by going to endinghumantrafficking.org. And as Sandie mentioned, the Ensure Justice conference is coming up March 6th of 7th, 2020. EnsureJustice.com is where to go for that registration and all the details for joining us out here live in Southern California. And we will be back for our next conversation in two weeks. Thanks again, Sandie.

Sandie [00:31:03] Thanks, Dave.

Dave [00:31:03] Take care.

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