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depersonalization (19.8%), multiple personality disorder (13.2%), and borderline personality disorder (13.2%) (Lederer & Wetzel, 2014). The cumulative risks associated with repetitive traumatic events during trafficking are consistent with the extensive long-term psychological health problems noted in the literature on complex trauma and PTSD (Ottisova et al., 2016). Poor mental health outcomes appear to be associated with exposure to violence before trafficking, restricted freedom, and poor living conditions (Kiss et al., 2015; Ottisova et al., 2016). IDENTIFICATION AND MANAGEMENT OF THE TRAFFICKING VICTIM Often, there is an overlap between DV and trafficking in which the perpetrator and the trafficker are the same person (parents, boyfriends, or husbands). While abusers and traffickers use similar tactics, traffickers exert total control over their victims for economic exploitation. Victims of both trafficking and DV may experience traumatic bonding with the abuser or trafficker, a response to the simultaneous fear of death and relief for being allowed to live (Barasch & Kryszko, 2013, p. 84). Victims of DV and trafficking experience physical, psychological, and sexual trauma that requires similar services to escape and restore their lives (Barasch & Kryszko, 2013, p. 83). Similar to victims of DV, victims of trafficking have been groomed to conceal their abuse, with fabricated or ambiguous presentations inconsistent with the injury or illness (Baldwin et al., 2011; Gibbons & Stoklosa, 2016; Munoz, 2012; Shandro et al., 2016). Because of the extreme nature of trafficking, victims may require more comprehensive social, legal, and mental health services than victims of DV. Evidence-based guidelines from sexual abuse, intimate partner violence, and child abuse provide useful strategies to guide assessment and intervention in human trafficking situations (Alpert et al., 2014). Clinical Indicators Medical care is often delayed, and victims present with severe injuries or advanced illnesses. However, the clinical presentation will be unique to the individual patient (Baldwin et al., 2011). Because traffickers often threaten and condition victims to conceal the trafficking situation, fear of further abuse by the trafficker is a powerful deterrent to disclosing the situation (Peters, 2013). Additional barriers include the fear of being reported to immigration, inability to pay for services, shame and stigma, prior criminal record, and judgmental or discriminatory treatment by health care personnel (Alpert et al., 2014; Gibbons & Stoklosa, 2016; MaciasKonstantopoulos et al., 2013; Ross et al., 2015). These challenges in victim identification reinforce the critical role advanced practice registered nurses (APRNs) have in the recognition and support of trafficking victims (Hardy, Compton, & McPhatter, 2013). Potential warning signs and/or clinical health indicators of trafficking may include evidence of physical and/or sexual violence, discrepancy between suspected and reported age, self-inflicted injuries, addiction use disorders, chronic medical conditions, multiple or recurrent STIs, and the presence of a controlling person (partner, employer, or family member) (Alpert et al., 2014; Baldwin et al., 2011; Doherty & Morley, 2013; Dovydaitis, 2010; Gibbons & Stoklosa, 2016; Isaac, Solak, & Giardino, 2011; Lederer & Wetzel, 2014; Munoz, 2012; NHTRC, 2016b). Responses of PTSD may range from extreme fear with an exaggerated startle response to a submissive, emotionless, and withdrawn posture. Disruptive, aggressive, or combative behaviors as a protective measure may be suggestive of trauma and victimization (Peters, 2013). Although some symptoms may be subtle, any patient with multiple or new STIs or signs of physical, emotional, or sexual trauma should be screened. If an individual does not have access to valid identification or is unable to state a verifiable residential address, screening should be conducted. Any of these clinical indicators warrant sensitive verbal screening. 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 40 Advanced Emergency Nursing Journal Trauma and the Victim Mind-Set Although rescue and rehabilitation are the ideal outcomes of screening, the primary focus during an encounter is to establish trust, provide a safe environment, manage the presenting complaint(s), offer available options and resources, and facilitate empowerment and validation so that the patient feels safe to discuss her or his situation without judgment (Alpert et al., 2014; Borland & Zimmerman, 2009; Shandro et al., 2016). Trauma victims develop protective mechanisms and are able to sense signs of real or perceived danger that could elicit intense feelings of fear, vulnerability, and loss of control in different environments (Alpert et al., 2014; Peters, 2013). Many exploited patients do not recognize or self-identify as a victim of trafficking and may not be in a position to leave the trafficker (Gibbons & Stoklosa, 2016; Shandro et al., 2016). Given the complexity of physical and psychological trauma, a patient-centered, culturally aware, and trauma-informed approach creates a safe clinical environment sensitive to the needs of trauma victims while in a health care setting (Alpert et al., 2014; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Trauma-Informed Care Trauma-informed care is defined by SAMHSA (2014) as a method of caring for people with a history of trauma that acknowledges the presence of trauma symptoms and its effect on lives of survivors. A trauma-informed approach emphasizes the need for health care practitioners and organizations to recognize the effects of violence and victimization on an individual’s health, behavior, and development (Elliott, Bjelajac, Fallot, Markoff, & Glover-Reed, 2005). Disruptive, withdrawn, or combative behaviors often provide relevant clues indicative of trauma and victimization that may be overlooked by health care practitioners. If a patient chooses to divulge a trafficking situation, each will disclose the information differently and may not present the details in a linear fashion. It is essential to establish rapport, remain flexible while screening, respect the person’s decisions, and focus on the individual’s needs and safety (Gibbons & Stoklosa, 2016; Shandro et al., 2016). Although a person’s decision may be in contrast to the provider’s, a trauma-informed approach empowers the individual with a sense of personal choice, control, and respect. The dynamics of exploitation are complex and multifaceted. By establishing a foundation of trust and safety, the patient may return prepared to leave the trafficking situation at some point. Screening and Physical Examination A thorough history focused on the presenting concern(s) and guided by the individual’s responses should be conducted with consent (Lederer & Wetzel, 2014; Shandro et al., 2016). Separate the patient from anyone accompanying her or him and refrain from screening for trafficking or violence if the person refuses to leave (Shandro et al., 2016). Refusal of a person to leave may indicate that the patient is a victim of trafficking and alert the APRN. Use a certified translator or translator phone service if there is a language barrier. Ask the patient if she or he has a preference for a male or female provider. Direct, open-ended questions with age- and culturally appropriate language are essential. The practitioner should strive to be familiar with cultural backgrounds and viewpoints that influence a person’s perception of heror himself, others, and the world (Hopper, 2017). Potential cultural differences may include avoidance of eye contact or the belief the trafficking situation is predetermined by position or status in life. These cultural differences could be interpreted as avoidance, withdrawal, helplessness, or hopelessness from a Western frame of reference. Alleviate fear of answering questions and support the patient’s right for nondisclosure of information. A thorough sexual history may be uncomfortable and trigger traumatic experiences. Assess for consensual and nonconsensual sexual experiences (Coppola & Cantwell, 2016). Maintain patient privacy 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 41 during encounters. Assure the patient she or he is