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begging, peddling, massage parlors, nail salons, construction, janitorial, agriculture, textile, commercial fishing, restaurants, fairs, carnivals, or circus, health or elder care, and/or hospitality industries. Forced child labor The entrapment of children under the age of 18 years old in forced, bonded labor, or slavery-like conditions for a third party without an economic benefit for self, family, or the option to leave. Child soldiering The unlawful recruitment of children for labor, sexual exploitation, or combatants in conflict areas. Children may be forced to work as cooks, porters, guards, spies, or suicide bombers for government or rebel groups. Both boys and girls may endure forced sexual abuse. Debt bondage/bonded labor The use of a debt or bond to hold a person in subjugation by traffickers or recruiters to unlawfully exploit an initial debt the worker assumed as part of the terms of employment. An inherited debt in traditional systems of bonded labor includes debt passed from generation to generation. Organ trafficking The recruitment, transportation, or harboring of a person for organ removal through force, fraud, or coercive means, including the abuse of a position of vulnerability. Cases in which a person’s personal, situational, or circumstantial vulnerability is used or the person believes that submitting to the will of the abuser is the only real and acceptable option available. Note. From U.S. Department of State (2014, 2015). Used with permission. TVPA = Trafficking Victims Protection Act of 2000. Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Article: AENJ-D-16-00027 Date: January 18, 2017 Time: 0:13 January–March 2017 Vol. 39, No. 1 Human Trafficking Victims in the Emergency Department 33 2013; UNODC, 2014). Weitzer (2015) contends that the number of victims and the magnitude of trafficking have been overestimated (Macias-Konstantopoulos et al., 2013), whereas others believe that the conservative estimates are only the tip of the iceberg (ILO, 2012a). The wide variation of reported estimates has been the subject of debate, in part, due to the methods employed to determine the scope of the problem. Nonetheless, there is clear evidence that human trafficking affects numerous people, in many forms, and in every region of the globe (MaciasKonstantopoulos et al., 2013; U.S. Department of State, 2014; Weitzer, 2014). To date, the ILO has conducted the most robust estimate of forced labor at the global and regional levels using a statistical model of estimation known as “capture–recapture” (ILO, 2012b). These estimates are extrapolated from data over a 10-year period of time (2002–2011) from 5,491 total reported cases of “forced labor” using algebraic formulas to calculate the number of cases (ILO 2012b). From the ILO’s extrapolated data, the global incidence of trafficking is approximately three per 1,000 persons and considered to be a $150 billion a year industry (ILO, 2012b). Of the 20.9 million people estimated to be in forced labor or sex trafficking situations, 11.4 million are women and girls, of which 22% (4.5 million) are victims of forced sexual exploitation (ILO, 2012b). The highest concentrations of trafficked people are in the Asian-Pacific Rim region (56%) and Africa (18%), whereas the lowest is in the Middle Eastern countries (3%) (ILO, 2012b). Although the actual number of trafficking victims in the United States is unknown, the U.S. Department of State (2006) estimated that between 14,500 and 17,500 foreign nationals are trafficked into the United States annually. The actual number of trafficked individuals is most likely higher because this estimate does not take into account U.S. citizens or residents, those trafficked within the United States, or those individuals trafficked in previous years (Chisolm-Straker, Richardson, & Cossio, 2012). The National Center for Missing and Exploited Children (n.d.) has estimated that between 100,000 and 300,000 children are at risk for commercial sexual exploitation annually. With the exception of child soldiering, trafficking patterns in North America (the United States, Canada, and Mexico) mirror all forms of trafficking in other developing nations (Reid, 2012). The extremes of wealth and poverty in North America contribute to the problem of trafficking in this region. Canada and the United States are primarily considered destination countries for sex and labor trafficking (Reid, 2012; U.S. Department of State, 2016). Canada is also a transit country used to relocate foreign nationals into the United States. Large segments of the populations within Canada and the United States are economically disadvantaged and socially marginalized, placing them at risk to be trafficked into the flourishing commercial sex industry (Reid, 2012). Mexico is largely considered a source and a transit country. Cross-border migration between Mexico and the United States is associated with deceptive and/or coercive tactics, forced migration through deportation, forced sex in high-risk environments, violence, drug use, and Sexually transmitted infections (STIs; Goldenberg, 2015; National Human Trafficking Resource Center [NHTRC], 2016c). Trafficking in the United States has been reported in rural, urban, and suburban areas in all 50 states, Washington, DC, and U.S. Territories (NHTRC, 2015), with the highest number of victims identified in California (NHTRC, 2016a). As of June 30, 2016, the NHTRC (2016a) has reported 130,485 total calls, e-mails, and online tip reports to the hotline since 2007. Of the 21,947 calls to the hotline in 2015, a total of 5,541 cases were reported for sex trafficking (n = 4,136), labor trafficking (n = 721), or both (n = 178) (NHTRC, 2016a). Although trafficked victims can be of any gender, race, ethnicity, age, or socioeconomic status, the risk of trafficking increases in cities or regions with fewer economic opportunities and the social determinants associated with poverty (e.g., homelessness, food Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Article: AENJ-D-16-00027 Date: January 18, 2017 Time: 0:13 34 Advanced Emergency Nursing Journal insecurity, and violence; Gibbons & Stoklosa, 2016; Shandro et al., 2016; Stevens & Berishaj, 2016). In 2015, the U.S. Department of Justice (DOJ) initiated 257 human trafficking cases (248 sex trafficking) involving 377 defendants and convicted 297 traffickers (291 sex traffickers) (U.S. Department of State, 2016). Between 2008 and 2010, the U.S. DOJ reported that 83% of domestic sex trafficking victims were U.S. citizens whereas 67% of domestic labor trafficking victims were undocumented aliens (Banks & Kyckelhahn, 2011). The victims of sex trafficking were more likely to be White (26%) or Black (40%), whereas labor trafficking persons were identified as Hispanic (63%) or Asian (17%). According to Shared Hope International (2009), age is the greatest vulnerability and risk factor for sex trafficking of girls, with risk increasing with a history of sexual abuse and an unstable home life. The average age of entry into the commercial sex trade in the United States is approximately 12–14 years for girls and 11–13 years for boys (Estes & Weiner, 2001; Gibbs, Walters, Lutnick, Miller, & Kluckman, 2014). Data support that women and girls are at greater risk for sex trafficking than men or boys, both internationally and within the United States (MaciasKonstantopoulos et al., 2013; UNODC, 2014; U.S. Department of State, 2016). The proportion of boys and men trafficked for sexual exploitation may be underestimated because of cultural norms, taboos, underreporting, and misperceptions regarding male victimization (U.S. Department of State, 2013). Rather than being viewed as victims of objectification and coercive sexual exploitation, male victims are perceived as being willing participants, gay, bisexual, or transgender, traffickers, or buyers within the commercial sex trade (Dennis, 2008; End Child Prostitution and Trafficking–United States of America, 2013). Risk Factors for Exploitation of Victims Human trafficking occurs in every region of the world, with victims identified from 124 different countries and 152 nationalities around the world (UNODC, 2014). Globally, victims tend to be trafficked within the same region or subregion, typically from poor to more affluent countries. More than six of 10 victims are foreigners in another country and have crossed at least one international border (UNODC, 2014). The origins of human trafficking are complex, multifaceted, and influenced by economic, social, and cultural factors from both the country of origin and the country of destination (Macias-Konstantopoulos et al., 2013; Organization for Security and Co-operation in Europe, 2005). Traffickers