Hope G. Miller BSN RN CA-CP SANE
Sierra Medical Center
University Medical Center of El Paso
What is a SANE and How the Medical Forensic Sexual
Assault Exam Can Aid in Recovery and Mental Health
“But He’s My Boyfriend”
How Coercion and Manipulation Can Lead to Human
 As many as 2.8 million children run away each year in the
US. Within 48 hours of hitting the streets, one third of these
children are lured or recruited into the underground world
of prostitution and pornography.
The National Center for Missing and Exploited Children
 The average number of victims for non-incestuous
pedophiles who molest girls is 20, for pedophiles who prefer
boys 100.
The Association For the Treatment of Sexual Abusers (ATSA)
 An average serial child molester may have as many as 400
victims in his lifetime.
Child Sexual Abuse Prevention Study
 Child pornography is one of the fastest growing crimes in
the US right now. Nationally, there has been a 2500%
increase in arrests in 10 years.
What is a SANE? (Texas)
 A Sexual Assault Nurse Examiner is a registered nurse
who has been specially trained to provide
comprehensive care to sexual assault patients, who
demonstrates competency in conducting a medical
forensic exam and has the ability to be an expert
 Certified through the Texas Office of Attorney General to
conduct exams on Adult, Adolescent and Pediatric
patients – recertify every 2 years
 Acute exams within 96 hours of assault/abuse
 Exception would be if the patient has been sequestered
 Medical ALWAYS comes before forensic – a patient’s life
is more important than “evidence”
What is a Medical Forensic Exam?
 Four parts to a medical forensic sexual assault exam
 History of Assault
 Head to Toe Assessment
 Detailed Ano-Genital Exam
 Evidence Collection
 The medical forensic exam is not considered an
emergent or life saving procedure
 The patient must provide informed consent for an
exam to be conducted
 To force an exam on an non-consenting patient – even
a minor – would be to assault them again
How Can Having an Exam Help?
 It gives the patient an opportunity to have their story
documented in their own words
 Exception to Hearsay Rule – Medical diagnosis and treatment
 It gives the patient peace of mind to know that their body is
 It is normal for an adolescent/adult female to not have genital
injuries due to having an estrogenized hymen
 If there are injuries they usually will be minor and not need
intervention and will heal on their own
 It gives them the opportunity to be given pregnancy and
STI prophylaxis that day and also for future serial STI
 It can help to start the healing and recovery process
 The exam is patient centered and patient driven – we do not do
anything that they do not want to do
 As an active participant in the exam they do not feel like a
victim because they are in control of what happens to their
How Can Having an Exam Help?
 Assurance and verbal reinforcement that what happened to
them was not their fault – no matter the circumstances
 They will be connected to a local rape crisis advocate while
at the hospital (STARS – Sexual Trauma and Assault
Response Services)
 The advocate will serve as a support person for the patient both
during their visit and thereafter and can connect them to many
services as well as helping them to apply for crime victims
 The SANE should not have contact with the patient after the
 There is the possibility of collecting DNA or other evidence
in the kit that could help the case
 Known and Unknown Assailant – CODIS (DNA database)
 It is important to understand that the medical forensic
sexual assault examination is the beginning of the process
and is only one piece of the puzzle – no “evidence” does not
mean there is not a case
What Can YOU Do?
 Rape/Sexual Assault is the only crime in the United
States that is perpetually blamed on the victim
 Rape Culture - a concept where rape is pervasive
and normalized due to societal attitudes about
gender and sexuality
 When a person tells you that they have been
raped, sexually assaulted or sexually abused – no
matter if it happened yesterday or 20 years ago…..
What is Human Trafficking?
 A form of modern day slavery/involuntary servitude
 Adults and Children – Men and Women
 Rural, Suburban, Urban,
Local and International – Worldwide
 Sex Trafficking, Child Pornography
 Labor Trafficking: Nanny’s, Maids, Sweatshop Workers,
Janitors, Restaurant Workers, Migrant Farm Workers,
Fishery Workers, Hotel and Tourist Industry Workers,
 Debt Bondage – Working Off a Debt
How is a Person Trafficked?
 Force – physical restraint or physical harm: violence, rape,
beatings, physical confinement may be used to break down
victim’s resistance
 Fraud – False promises re: employment, wages, working
conditions. Better life, marriage, fame and fortune
 Coercion – Threat of serious harm to them or loved ones,
physical restraint or threat of abuse of the legal process
 These only apply if the person being trafficked is an adult
 When an individual under the age of 18 provides sexual
services in exchange for anything of value, human
trafficking has occurred regardless of whether force, fraud
or coercion were used.
Trafficking Versus Smuggling
 Force, fraud or coercion is used – victim may have
offered consent initially but was then exploited by
 Human trafficking is a crime committed against an
 A person does not need to be moved physically to be a
victim of human trafficking
 Consent is given by individual
 Crime is against a country and its borders
 Illegal transport across transnational border
Human Trafficking Statistics
 Estimated 27 million victims worldwide – more than any
other time in history
 Yearly profits generated by human trafficking worldwide
= 32 Billion. Unlike drugs - victims can be “sold” again
and again.
 More than 70% of victims are female and half are
 Up to 800,000 persons are trafficked each year across
international borders – 20% of those people pass
through Texas = 160,000 year
 Texas OAG estimates that one out of every 5 human
trafficking victims travels through Texas – major
destination and transit state
Interstates, US/Mexico Border,
Fort Bliss
Child/Adolescent Statistics
 In the US: 300,000 children/adolescents are at risk each
year for sexual exploitation – at least 100,000 of them
are being used for prostitution
 Average age of child/adolescent entering prostitution =
12 to 14 years old
 Life expectancy of child/adolescent exploited for
prostitution = 7 years
 Only 1% of child victims are rescued
 These numbers are probably lower than actual fact
Prostitution Versus Trafficking
 Trafficking may be hard to prove or prosecute if the victim is
legally old enough to provide consent for sex
 A victim who is underage cannot legally provide
consent for sex (even if they say it was consensual)
 There is no such thing as a child (adolescent) prostitute –
there is only prostitution of a child which is trafficking
and always against the law
 Victims can be difficult to identify – 43% of reported HT
cases investigated by LE occurred in private residences.
 Understanding, preventing and identifying victims will require
that people change the way they view the crime
 The best way to prevent, identify and rescue is through
awareness and education
Who is at Risk?
 Human trafficking, like sexual abuse knows no
socioeconomic boundaries
 Persons who have been sexually abused are more
likely to be targeted
 Sexual abuse and Interpersonal Violence (DV) are
huge push factors for human trafficking
 Persons who tend to be on the periphery of society
 Foster Home
 Runaways/Throwaways
 Developmentally Disabled
 Psychological Illness
Adolescents and Risks
 Adolescents are more at risk due to several factors:
 Identity vs. Confusion (Erickson’s Psychosocial Stages):
Trying to find out who they are and where they fit in
 Tend to be risk takers
 Focused on peers – less parental interaction, supervision
 Lack the knowledge and judgment skills that come with
age and experience – If it seems too good to be true, it
probably is!
 Traffickers will frequent places where adolescents go without
 Mall
 Social Media
American Adolescents & HT
 Adolescent girls are especially at risk for being drawn in
by a male who will pretend to be their boyfriend (Romeo
pimp) and then use coercion and manipulation to exploit
the relationship for their personal and financial gain
o “Love addiction” – they may view their trafficker/pimp as
their boyfriend and/or their protector, “Baby daddy”
o Trauma Bonding, Stockholm Syndrome – “brainwashing”
 Traffickers/Pimps are master manipulators
 Maslow’s Hierarchy of Needs (for pimps)
 A large percentage do not see themselves as victims and
believe that they are there by choice
Adolescent Mental Health
 Victims may be subjected to physical, sexual and psychological
abuse – they could require multiple services depending on the
length of time and severity of abuse they have endured
 Safety, Shelter, Basic Necessities
 Counseling – Months or Years
 Medical Care – Possibly Extensive
 Legal Services
 Transitional and/or Long Term Housing
 Advocacy
 Education
 Financial Assistance
 Job Skills/Job Training
 Life Skills Training
 Child Care
 Translation Services
 Etc.
Identifying Traffickers/Pimps
 Warning Signs – If 3 or more apply to a relationship = Red Flag
 Fancy Cars, Clothes or Jewelry
 Frequently spends nights away or out of town
 Acts out the hip hop or gang/pimp culture
 Claims to own a business or has a job that you cannot visit
 He has dreams of making it big and being successful – he will
encourage her to become part of HIS dream
 Her dreams and goals for life will be put on hold for his
 He pulls her in and everything becomes “we” in her conversation –
when a person internalizes a dream they will work harder to achieve it
 Secludes her from family and friends by moving her away
 Attempts to fast track the relationship – moving away and talking of
marriage within a short time frame
 Decreasing healthy relationships with others – her circle becomes
smaller and smaller
 Gets to know HER dreams and goals and dangles them like a carrot
 Carries multiple cell phones
Identifying Victims
 Tired during the day from working all night
 Suddenly has expensive things – high end name brand
purse, diamond bracelet, name brand clothes or nails and
hair done on a regular basis
 Increasingly interested in or talks a lot about his dream –
“we’re going to….”
 Older boyfriend, usually one not in school
 Morals and values have slowly expanded
 New tattoo, barcodes or branding of initials – his name,
“Daddy” or saying showing ownership “property of”
 Carries multiple cell phones
 Keeps eyes down while in public, avoids eye contact
 Starts to become secluded – you see her less and less
 Signs of physical abuse
 Submissive or appears fearful, anxious or nervous
Screening Questions
 Have you ever exchanged sex for food, shelter, drugs or
 Have you ever been forced or asked to have sex against
your will?
 Have you been asked to have sex with multiple
 Do you have to meet a quota of money before you can
go home?
 Have you or a family member been threatened in any
 What are your working and living conditions like?
 Can you come and go as you please?
What Can You Do?
 It is only through education and awareness that human
trafficking may be prevented
 It is also through education and awareness that victims
may be identified and rescued – they are “hiding” in
plain sight
 Educate yourselves and your peers/colleagues about
human trafficking and help spread awareness
 If you are in a position to do so – ask questions
 Use extreme caution
 Do not confront a pimp/trafficker
 Do not try to rescue a victim
 You may need to involve security or call 911
 If the person is under 18 and you suspect they are being
abused or trafficked you do not need the patient’s
permission to report it or to call law enforcement – you
must move to protect them - the burden of proof is not ours
Rebecca Bender – Survivor
 Rebecca Bender.mp4
National Human Trafficking
Resource Center
24/7/365 170 Languages
Thank You!

But He’s My Boyfriend”