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substance use/addiction, nutritional deprivation/starvation, unsanitary living conditions, stress/anxiety, infectious disease Genitourinary/ reproductive Pelvic pain, dyspareunia, labial/vulvar/vaginal/cervical trauma, mutilations, ecchymosis or hematomas, untreated or recurrent STIs, PID, UTIs, retained vaginal sponge/cotton fibers, unintended pregnancies, purulent/foul vaginal discharge, multiple abortions Sexual trauma, gang rape, nonconsensual sex, multiple sex partners; recent, multiple, forced, and/or unlicensed abortions, sponge or foreign body use while on menses (nonconsensual sex or heavy vaginal discharge) (continues) 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 44 Advanced Emergency Nursing Journal Table 5. Potential examination findings associated with the trauma of human trafficking (Continued) System Subjective complaints and objective clinical findings Associated physical and psychological trauma Endocrine/metabolic Diabetes, asthma, anemias Lack of preventive and routine care, unmanaged chronic medical conditions, stress, environmental exposures Infectious disease Malaise, febrile, HBV infection, HCV infection, HIV/AIDS Unprotected, nonconsensual, forced sex, multiple partners, substance use disorders, intravenous drug use, high-risk behaviors Psychiatric/ behavioral health Depression, anxiety, hostility, depersonalization, hypervigilance, PTSD, traumatic bonding, normalized sexual violence, self-inflicted injuries, suicide attempt, shame, emotional dysregulation Coercion, physical and psychological violence, intimidation, social isolation, deception, frequent relocation, sexual humiliation, sleep deprivation, restricted movement, unpredictable events, forced pornography, coercive or coping drug use Note. Data obtained from Alpert et al. (2014); Baldwin et al. (2011); Doherty and Morley (2013); Gibbons and Stoklosa (2016); NHTRC (2016b); Stoklosa et al. (2015). AIDS = acquired immunodeficiency syndrome; HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus; IBS = irritable bowel syndrome; PID = pelvic inflammatory disease; SOB = shortness of breath; PTSD = posttraumatic stress disorder; STI = sexually transmitted infection. Safety and Referral Once a patient is identified as a victim of trafficking, prioritize safety, health care, and psychological needs (Stevens & Berishaj, 2016). An important aspect of safety is the patient’s assessment of immediate risks (Alpert et al., 2014). Law enforcement will need to be notified if imminent danger to the patient, staff, or others is a concern (Borland & Zimmerman, 2009). Safety measures may include a review of emergency protocols, restriction of access to doors in clinical areas, and an established relationship with local law enforcement (American College of Obstetricians and Gynecologists, 2011). The National Human Trafficking Hotline is available 24/7 to assist with posttrafficking placement resources and identification of law enforcement with human trafficking training. Developing partnerships with organizations and community stakeholders is essential to access resources that meet the needs of trafficking victims. Many victims of trafficking have an array of needs that include medical and psychological care, substance abuse treatment, trauma recovery treatment, housing, transportation, legal assistance, and financial support (Alpert et al., 2014; Borland & Zimmerman, 2009; Gibbons & Stoklosa, 2016). The initial response of a health care organization is to meet the immediate basic and crisis needs of the patient, which may include medical conditions, safety, emergency psychiatric evaluation, nutrition and hydration status, rest, HIV and hepatitis screening, STI treatment, pregnancy, contraception, clothing, and shelter (Greenbaum & Crawford-Jakubiak, 2015; Macy & Graham, 2012). Enlisting additional comprehensive, multidisciplinary services such as social work, case management, and mental health services may be appropriate. Often, the needs of trafficking victims are extensive and beyond 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 45 Table 6. Human trafficking education and referral resources Resource name Information provided Contact Coalition Against Trafficking in Women NGO to combat trafficking of women and children http://www.catwinternational .org DHS Legal assistance, T-visa, and victim support 1-866-347-2423 DHS Blue Campaign Awareness, education, shoe cards, victim-centered investigation https://www.dhs.gov/bluecampaign/about-blue-campaign 1-866-347-2423 https://www.dhs.gov/bluecampaign/resource-catalog Department of Health and Human Services: Rescue and Restore Campaign Toolkits including literature and posters http://www.acf.hhs.gov/ programs/endtrafficking/ trafficking ECPAT-USA “Leading anti-trafficking policy organization in the United States.” http://www.ecpatusa.org HEAL Trafficking Interdisciplinary health professionals connect to end trafficking through referral, education, advocacy, and support https://healtrafficking.org Local police department Immediate assistance for safety and protection 911 or local contact number National Human Trafficking Resource Center Hotline Education, information, and local referral sites 1-888-3737-888 NHTRC SMS Short code for victims Specialized Text Service Confidential crisis support, referrals, tip reporting, and general information through SMS text message https://polarisproject.org/ services-hours Text “BeFree” (233733) 3 p.m.–11 p.m. EST (provide information to victims) Polaris Project website and Resource Center Online reporting, education, and information www.polarisproject.org S.O.A.P. Outreach and education rescue victims trafficked at hotels; educate motels on trafficking signs https://www.traffickfree.com/ soap SafeHorizon Victims’ services agency— Antitrafficking Program only for New York http://www.safehorizon.org/ page/human-trafficking-whatwe-do-346.html Note. DHHS = Department of Health and Human Services; DHS = Department of Homeland Security; ECPAT = End Child Prostitution and Trafficking; HEAL = Health, Education, Advocacy, Linkage; NGO = nongovernmental organization; NHTRC = National Human Trafficking Resource Center; SMS = Short Message Service; S.O.A.P. = Save Our Adolescents from Prostitution. the scope of a single provider or clinical site (Gibbons & Stoklosa, 2016; Peters, 2013). Table 6 provides resources for locating assistance. Reporting and Documentation The U.S. Department of Homeland Security (DHS, 2015) is responsible for providing sanctuary to noncitizen victims of human 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 46 Advanced Emergency Nursing Journal trafficking, immigration relief in the form of a T-visa, U-visa, or Continued Presence (CP)- visa, and facilitating the prosecution of traffickers. A CP-visa allows victims to remain in the United States for 1 year, access to government benefits, and authorization for employment. The Trafficking Victims Protection Act of 2000 created a new class of visa (T-visa) that allows trafficking victims to remain in the United States for 3 years with work authorization, access to benefits, medical care, and services offered by HHS. At the end of 3 years, T-visa holders may apply for permanent residence. The U-visa is for victims with nonimmigrant status who have suffered substantial physical and/or psychological trauma from qualifying criminal activity and are willing to assist law enforcement with the investigation and prosecution of criminals (U.S. DHS, n.d.). After 3 years, these victims can apply for a permanent resident card, also known as a Green Card, and permanent status if cooperation with authorities is established. The Green Card status allows the victim to be eligible for employment in the United States. Otherwise, the U-visa is valid for a period of 4 years, with the option for an extension. Mandated Reporting All states have mandated reporting for suspected child abuse to appropriate state agencies such as child protective services, legal authorities, or a state child abuse