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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 37 Health care professionals play a vital role in assisting victims in a variety of health care settings and require education and training to understand the nature of trafficking, identify the signs, and refer victims for appropriate services (Ahn et al., 2013; Chisolm-Straker et al., 2012; Grace et al., 2014; Ross et al., 2015). Ahn et al. (2013) reviewed the literature on human trafficking and did not find evidence of rigorously evaluated educational modules for health care providers. In response, the Department of Health and Human Services (HHS) began evaluating Stop Observe Ask Respond (SOAR) to Health and Wellness training program in 2013 for health care and social service providers in the United States (U.S. Department of Health and Human Services: Office on Trafficking in Persons, 2016). The SOAR National Technical Work Group included health care providers, human trafficking survivors, and other content experts to develop and evaluate the training program. Implementing evidence-based training modules and guidelines to inform health care providers in the identification and management of trafficking victims is an essential step to improve care and health outcomes for these individuals. Physical Health Consequences Emerging evidence supports the profound physical and psychological health consequences as a result of exposure to violence, restricted movement, and deprivation while being trafficked (Baldwin et al., 2011; Clawson & Dutch, 2008; Decker, McCauley, Phuengsamran, Janyam, & Silverman, 2011; Lederer & Wetzel, 2014; Oram, Ostrovschi, et al., 2012; Ottisova, Hemmings, Howard, Zimmerman, & Oram, 2016; Peters, 2013). For those victims who survive the hazards of a trafficking situation, many will require medical and psychological health services (Kiss et al., 2015). Health problems experienced by labor trafficking victims in Southeast Asia include loss of body parts (0.7%), head injury (3.7%), persistent cough (9%), lacerations (11.3%), skin damage (12.5%), weight loss (13.7%), exhaustion (18.3%), and dizziness (20.1%) (Kiss et al., 2015). Findings from a systematic review on sex trafficking suggest that victims experience high levels of violence and associated physical symptoms over a prolonged duration (Oram, Stockl, Busza, Howard, & Zimmerman, 2012). In a survey of sex-trafficked women receiving posttrafficking services in Moldova (N = 120), physical symptoms include headaches (62%; n = 74), memory problems (44%; n = 53) with a strong association between duration of trafficking and severity of symptoms, and gynecological problems (16.5%; n = 16), whereas women in domestic trafficking circumstances described more back pain (38%; n = 51) and vision problems (22%; n = 15) (Oram, Ostrovschi, et al., 2012). Reproductive Health Issues and Infectious Disease Reproductive health issues from sex trafficking include STIs, pelvic inflammatory disease, unintended pregnancies, miscarriages, and forced or elective abortions (Baldwin et al., 2011; Doherty & Morley, 2013; Lederer & Wetzel, 2014). Studies conducted in Mexico, India, and Nepal estimated a 22.7%– 45.8% range of prevalence of HIV infection in women trafficked for sex (Goldenberg et al., 2015; Wirth, Tchetgen Tchetgen, Silverman, & Murray, 2013). The risk of HIV infection increases with sexual violence, forced entry into sex trafficking (Wirth et al., 2013), and longer duration of exploitation (Goldenberg et al., 2015). Although there is scarcity of research in the United States on the prevalence of HIV infection in sex-trafficked women, HIV infection has increased in female sex workers (FSWs) from 1% to 6% between 1999 and 2008 in Tijuana, Mexico (Collins et al., 2013; Strathdee & Magis-Rodriguez, 2008). The two largest Mexican cities along the U.S. border are Tijuana (south of U.S. metropolitan San Diego, CA) and Ciudad Juarez (south of U.S. metropolitan El Paso, TX). In a behavioral 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 38 Advanced Emergency Nursing Journal intervention study to increase condom use among FSWs (N = 924), more than two thirds of interviewed FSWs (n = 634) from these two Mexican cities along the U.S. border reported having sex with at least one U.S. male client (Strathdee, Lozada, et al., 2008). These FSWs who reported having sex with U.S. male clients were significantly younger (median = 31 vs. 36 years, p < 0.0001; odds ratio [OR] = 0.95 per year), spoke English (25% vs. 7%, p < 0.001; OR = 4.33), were more educated (OR = 1.21), and entered sex work at a younger age (25 vs. 28 years; OR = 0.94) (Strathdee, Lozada, et al., 2008). In addition, they were more likely to have injected drugs (16% vs. 5%, p = 0.001; OR = 3.68), more likely to use drugs before sex with their clients (18% vs. 7%, p = 0.001; OR = 3.4), and more likely to report their U.S. clients used drugs (81% vs. 55%, p < 0.001; OR = 3.55) or injected drugs (36% vs. 21%, p < 0.001; OR = 2.20) (Strathdee, Lozada, et al., 2008). The FSWs were more likely to test positive for gonorrhea (8% vs. 2%, p < 0.001; OR = 4.38) or syphilis with titers of 1:8 or more (16% vs. 10%, p < 0.008; OR = 1.81), to have more than 250 clients in the past 6 months (OR = 1.54), and to be paid more for sex without a condom (OR = 1.07 per U.S. $10 increase) (Strathdee, Lozada, et al., 2008). Prevalence of HIV infection among FSWs increased to 6% (95% CI [4.5, 7.7]), whereas prevalence of HIV infection among FSWs who inject drugs increased to 12% (Strathdee, Philbin, et al., 2008). These data highlight the potential increased risk of cross-border HIV infection, blood-borne pathogens, and STI transmission for FSWs, their clients, and the general population in both countries (Strathdee, Lozada, et al., 2008). In addition to the immediate risk of genderbased violence, women subjected to the trauma of sex trafficking experience high levels of physical symptoms that often persist for decades (Lederer & Wetzel, 2014; Oram, Ostrovschi, et al., 2012). Neurological problems frequently reported (91.5%) include headaches or migraines (53.8%) and memory problems, insomnia, and poor concentration (82.1%) (Lederer & Wetzel, 2014). Contrary to findings in previous studies, physical injuries (69.2%) described by victims while in the trafficking situation most commonly were inflicted to the head and the face (Lederer & Wetzel, 2014). Psychological Health Consequences Poor mental health has been identified as a persistent and severe health effect of trafficking. Traffickers use intimidation to control victims, including violence, deportation, threats against family, and death (Oram, Stockl, et al., 2012). The psychological trauma experienced by victims of trafficking is associated with the severe mental devastation noted in survivors (Hossain, Zimmerman, Abas, Light, & Watts, 2010; Lederer & Wetzel, 2014). Lederer and Wetzel (2014) explored the violence faced while being trafficked and the subsequent health consequences reported by women and girls exploited for commercial sex in the United States. In addition, these researchers analyzed the interactions within the health care system experienced by persons trafficked (N = 106) both during and after a trafficking situation. The most frequently reported psychological problems include depression (88.7%), anxiety (76.4%), nightmares (73.6%), flashbacks (68.0%), low self-esteem (81.1%), and feelings of shame and guilt (82.1%) (Lederer & Wetzel, 2014). The devastating extent of the psychological trauma in this U.S. study is evident in the attempted 41.5% (N = 106) suicide rate during trafficking and 20.5% (N = 83) after trafficking (Lederer & Wetzel, 2014). Formerly trafficked women continued to struggle with posttraumatic stress disorder (PTSD) following societal reintegration (Abas et al., 2013; Baldwin et al., 2014; Lederer & Wetzel, 2014; Ottisova et al., 2016). Poor mental health and psychological comorbidities can manifest as depression, anxiety, substance abuse disorder, insomnia, eating disorders, and other severe psychological conditions following trauma (Hossain et al., 2010; Lederer & Wetzel, 2014). Psychological 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 39 disorders experienced by survivors (N = 106) include acute stress (38.7%), bipolar disorder (30.2%),