Abdominal Pain and Vaginal Discharge: An Eye-Opening Simulation Case about Human Trafficking
Correspondence should be addressed to Nicole E Exeni McAmis, MD at nemcamis@gmail.com
DOI: https://doi.org/10.21980/J8.52150
ABSTRACT:
Audience:
The aim of this simulation case is to educate medical students, interns, junior residents, senior residents, nurses, and faculty on how to identify victims of human trafficking in the healthcare setting. This scenario is adaptable for emergency medicine, outpatient clinic settings, and prehospital settings, including EMS personnel as learners.
Introduction:
Human trafficking is a profound violation of human rights and a pressing local, national, and global health problem. Victims are reduced to objects for commerce, fueling a $150 billion-dollar industry and representing the second largest source of income for organized crime.1,2,3,4 Globally, an estimated 40.3 million people are victims of modern slavery, with more than 70% being women and girls, and one in four victims being children under the age of 18.3,4 While once perceived as a mostly international problem, prevalence estimates now show 5.4 victims per 1,000 people across the world, with 1.3 victims per 1,000 in the United States for forced labor.4
Healthcare providers are among the few professionals likely to encounter victims. Multiple studies show that 28-88% of victims sought medical care while being trafficked.6-9 These victims are most likely to seek medical care from emergency departments (63.3%), Planned Parenthood clinics (29.6%), private practices (22.5%), urgent care clinics (21.4%), women’s health clinics (19.4%), and neighborhood clinics (19.4%).8 Despite this, only a small fraction of emergency physicians report receiving formal training on human trafficking. This highlights the critical need for enhanced education in emergency medicine, where providers are frequently the first point of contact for victims.
Educational Objectives:
At the conclusion of this case, learners should be able to: 1) review red flags of identifying victims of human trafficking in healthcare settings, 2) identify common indicators and injuries associated with human trafficking, 3) demonstrate a trauma-informed care approach when interviewing potential victims, 4) list and provide patients with national resources for human trafficking, 5) understand federal and state mandatory reporting laws and the role of the healthcare provider, 6) determine best treatment options in patients with limited healthcare access, including counseling on empiric treatment of sexually transmitted infection (STI), 7) review management options for an undesired pregnancy according to local institutional policies and state laws for the senior case.
Educational Methods:
This simulation was designed to assess and improve the level of knowledge on identifying victims of human trafficking in the healthcare setting. This session was conducted using standardized patients portraying both the patient and father/trafficker, a faculty member in the nursing role, and a second faculty member in the control booth. The control booth faculty adjusted the displayed vitals, facilitated case progression, and could call in as registrationif needed to progress the case. Each case included approximately four to five learners. A pre-brief was provided to the residents prior to the start of the case, explaining the expectations for interacting with standardized patients (SPs) and emphasizing the importance of safety and professionalism. After each scenario concluded, a post-simulation debriefing was held focusing on the presentation, differential diagnosis, physical exam findings, and management of the targeted social and medical issues. This case scenario can also be adapted for use as an oral board examination case.
Research Methods:
The authors performed a knowledge assessment of the case using both pre-simulation and post-simulation surveys designed specifically for this project. These surveys measured participants’ knowledge of human trafficking prior to training and their knowledge after the session. Facilitators also provided informal feedback to the scenario developers after the case was piloted. These evaluations were reviewed after implementation. This case was trialed with emergency medicine residents across all training levels (PGY-1 through PGY-4).
Results:
Linear mixed models were used to compare pre-session to post-session knowledge of human trafficking, with means reported as descriptive statistics and Cohen’s standardized difference (d) used as a measure of effect size. For ordinal questions, a chi-square test compared pre- and post-session responses. Residents’ post-session perceptions of effectiveness were analyzed using frequency distributions. Statistical analyses were conducted using SPSS v29. Open-ended feedback responses were analyzed qualitatively using content analysis, with each author independently reviewing and categorizing key themes.
Participants reported gaining a deeper understanding of the complexities of human trafficking and greater confidence in their ability to recognize and intervene. A total of 29 residents participated across all four years of training (PGY-1 = 9, PGY-2 = 4, PGY-3 = 11, PGY-4 = 5; 51% female). Only 24% reported prior training, while 94% believed they would benefit from training on human trafficking. Knowledge scores improved significantly (Pre: 59.2 → Post: 65.1; Cohen’s d = 0.39, p < .05). Self-reported comfort recognizing victims increased from 35% to 64% (p < .05), and comfort managing victims increased from 28% to 69% (p < .05), with no differences by PGY level or gender. On the post-survey, 100% of participants agreed the simulation enhanced their knowledge.
Qualitative comments were gathered digitally through a QR code linked to Smartsheet as part of the standard process for resident didactic feedback. Resident responses were provided to case authors without any identifying information, except for PGY year. Prompts for qualitative comments were open-ended response questions of feedback for presenters and their most valuable learning points. Qualitative feedback (n = 27) emphasized increased awareness, the Human Trafficking Hotline as a valuable resource, and strategies for investigating concerns and providing medical management. Many also suggested smaller groups, additional pre-simulation training, and clearer integration of social work. Overall, residents highlighted that this simulation not only improved their base of knowledge but also provided practical tools to support victims in real-world clinical settings.
Discussion:
Simulation-based training on human trafficking in emergency medicine is a vital tool for preparing providers to recognize and respond to these complex cases. By engaging in highly interactive, standardized patient scenarios, learners can practice recognizing subtle red flags, applying trauma-informed communication, and balancing confidentiality with mandated reporting requirements. The debriefing sessions allow further reflection, knowledge integration, and discussion of best practices. Although standardized patients may be cost-prohibitive, faculty can serve as role players to reduce barriers to implementation. Through such training, healthcare providers enhance preparedness, empathy, and effectiveness in addressing the needs of trafficking survivors and contribute to broader efforts to combat exploitation.
Topics:
Medical simulation, emergency medicine, human trafficking, sex trafficking, sexually transmitted diseases, abuse, non-accidental trauma, domestic abuse.
