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exploit the desire to migrate due to poverty, political strife, oppression, gender violence, social instability, human rights violations, or perceived opportunities to ensnare victims and gain cooperation and control (UNODC, 2008). Traffickers often prey on the emotional needs and vulnerability of others, especially children and adolescents who are easily coerced, manipulated, and terrorized into compliance (De Chesnay, 2012; Greenbaum & Crawford-Jakubiak, 2015; Varma, Gillespie, McCrackenb, & Greenbaum, 2015). Childhood sexual abuse nearly doubles the odds of later entry into prostitution, and 80%– 90% of trafficked youth have a history of childhood sexual abuse (Siskin & Sun Wyler, 2013; Williamson, 2009). Characteristics and inequities that predispose victims to all forms of trafficking include poverty, early childhood trauma or abuse, substance abuse or addiction disorders, and housing insecurity (MaciasKonstantopoulos et al., 2013). Family dysfunction, domestic violence (DV), mental illness, and familial substance abuse increase vulnerability to trafficking. Frequently, women are recruited into labor or domestic work and subsequently sold into the sex trafficking trade (Zimmerman, Hossain, & Watts, 2011). Sex trafficking is considered a complex form of gender-based violence, with its root cause in subordinate societal and cultural norms, objectification of women and girls, childhood sexual abuse, poverty, gender inequality, and oppression (Macias-Konstantopoulos et al., 2013). 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 35 The rapid evolution of digital technologies such as social networking sites, mobile phones, websites, anonymizing networks and applications, and the Internet has added unique opportunities to exploit victims (Latonero et al., 2012). In 2010, the estimated number of Internet users exceeded 2 billion and hundreds of millions of people use social networking sites (Latonero, Berhane, Hernandez, Mohebi, & Movius, 2011). These technologies are used to recruit, market, communicate, transact, and exploit victims across broad geographical areas (Latonero et al., 2012). Traffickers leverage social networking and online classified sites such as Craigslist, Facebook, Tinder, and Backpage to conduct illicit activities (Latonero et al., 2011). Digital technologies are also used by law enforcement, service providers, and antitrafficking agencies to monitor illicit activity, locate and rescue victims, communicate between agencies, collect data, and report suspected trafficking (Latonero et al., 2011). Table 2 provides additional examples of risk factors. Exposure to Violence and Abuse A large, quantitative, cross-sectional study (N = 1,015) of men, women, and children receiving posttrafficking services in Southeast Asia (Cambodia, Thailand, and Vietnam) evaluated the health effects of various forms of violence and occupational exposures on survivors’ health (Kiss et al., 2015). Most children (281 of 344; 82%) were girls trafficked for sex work (n = 201), whereas boys (n = 63) were Table 2. Social determinants and risk factors for trafficking in persons Social determinants of health Poverty Gender (low societal and familial value of women and girls) Lack of formal education (illiteracy and low levels of education reduce employment options) Limited English proficiency Food and housing insecurity Responsibility for dependents Limited support systems Low self-esteem Violence and trauma Childhood sexual abuse Childhood trauma/adverse childhood events/domestic violence Previous physical, sexual, or emotional abuse Substance abuse and/or addiction disorders Parental drug abuse Juvenile justice system exposure Globalization Migration, refugee displacement, and victims in conflict zones Digital technologies and social networking sites Marginalized populations Runaway or homeless youth Gay, bisexual, and transgender youth Persons with disabilities Rural populations Migrant workers American Indians/Alaskan Natives/Native Hawaiians and Pacific Islanders Foreign national domestic workers Note. Data obtained from Farley et al. (2011); Gibbons & Stoklosa (2016); Goldenberg et al. (2015); Latonero et al. (2012); Macias-Konstantopoulos et al. (2013); Shandro et al. (2016). 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 36 Advanced Emergency Nursing Journal trafficked for begging, fishing, factory work, or construction (Kiss et al., 2015). Women (n = 288) were trafficked for sex work (n = 127; 44%), for factory work (n = 40; 13.9%), as brides (n = 38; 13.2%), for agriculture work (n = 36; 12.5%), or domestic work (n = 26; 9.0%); men were typically exploited for the fishing trade (n = 262; 68.4%) or factory work (n = 76; 19.8%). Nearly half of the survivors reported physical violence (n = 388; 38.3%), sexual violence (n = 204; 20.2%), or both (n = 481; 47.6%) while being trafficked (Kiss et al., 2015). In a qualitative, multisite (seven countries), posttrafficking European study, women trafficked for forced sex work (N = 192) reported high levels of physical violence (n = 145; 76%), sexual violence (n = 172; 90%), or both (n = 182; 95%) while being trafficked (Zimmerman et al., 2008). These data obtained from different regional and cultural studies expose the high rate of trauma and violence experienced by victims during various forms of trafficking. Trafficked victims routinely endure extreme forms of physical and emotional trauma through systematic “seasoning” tactics involving coercion, force, fraud, and physical and sexual violence for the purpose of control and cooperation (Baldwin, Fehrenbacher, & Eisenman, 2014; Logan et al., 2009; NHTRC, n.d.). Often victims of human trafficking remain trapped through the use of physical and psychological confinement, as traffickers use methodical tactics designed to reduce the victim’s resistance and increase dependence (Logan et al., 2009). Psychological confinement is associated with abuse, shame, and degradation to achieve submission (ILO, 2012a). Although victims may escape a trafficking situation, psychological entrapment will prevent some victims from leaving even if the opportunity arises (Logan et al., 2009). HEALTH CONSEQUENCES OF HUMAN TRAFFICKING Role of Health Care Practitioners In a mixed-method study conducted in the United States across a broad geographical, racial, and ethnic range, 87.8% (N = 98) of sex-trafficked victims sought treatment within the health care system while in captivity but were neither identified nor offered assistance by health care practitioners (Lederer & Wetzel, 2014). Clinical areas accessed by victims of trafficking in the United States include the emergency department (ED), family planning clinics, urgent care, primary care clinics, community health centers, health departments, pediatrics, obstetrics and gynecology, and private offices (Lederer & Wetzel, 2014; Stevens & Berishaj, 2016). The most common health care setting reported by 63% of trafficked respondents was the ED (Lederer & Wetzel, 2014). The concealed nature of human trafficking makes identification in the clinical setting challenging (Oram, Ostrovschi, et al., 2012; Peters, 2013). Research suggests that victims present to the health care system with injuries, evidence of neglect, STIs, addiction disorders, pregnancy, and advanced disease states but are often not identified as victims of trafficking (Baldwin, Eisenman, Sayles, Ryan, & Chuang, 2011; Lederer & Wetzel, 2014). In a study of health care providers in England (N = 792), 13% (n = 102) of the respondents reported actual or suspected contact with persons trafficked in a variety of clinical settings. Maternity ward providers reported suspected or prior contact rate of 20.4% (n = 28/137) (Ross et al., 2015). While 91% of the study respondents (n = 697) felt they had an obligation to assist suspected victims of trafficking, 80% (n = 613) cited lack of training as a barrier to assist these individuals. Lack of knowledge regarding their role in identifying and appropriately responding to human trafficking is cited as the primary reason for not intervening (Ross et al., 2015). In a study of 180 ED providers in the United States, 95% (n = 171) reported they have not received formal training on the management of trafficking victims (ChisolmStraker et al., 2012). Few health care professionals understand how to identify victims and appropriately manage the care of a suspected victim (Stoklosa, Grace, & Littenberg, 2015).