“My wounds are inside. They are not visible.”
— survivor of human trafficking
In the five years that have passed since I met the 14-year-old girl who opened my eyes to the terrible crime of sex trafficking in the United States, much has changed. We have made strides in state and federal legislation to protect survivors, national human trafficking prevention months have been declared, and victims are no longer treated as criminals. More health care workers have joined the cause leading to the creation of health-centered advocacy groups, numerous peer-reviewed publications, and countless training and conferences around the country. There is a baseline awareness among health care professionals that trafficking exists in our own communities and is an important issue that needs our attention. Many media posts emphasize that health care providers have the unique power to recognize people who have been trafficked in the clinical setting. But is awareness enough? Would you recognize a survivor if they were sitting right in front of you tomorrow in clinic or on the floors?
In medical school when we learn the art of the differential diagnosis, we are taught that we need to have an index of suspicion of certain issues or we may miss them completely. This is no different when recognizing human trafficking, as I learned when recently speaking with a survivor about her prior healthcare experiences. This survivor told me that she had many physical symptoms after leaving her trafficking situation that doctors could not diagnose despite extensive lab tests and imaging. From headaches to muscle cramps to GI symptoms, her problems were very real and debilitating. Unfortunately, over the course of her medical work-up she faced impatience, condescension and one time even frank laughter from her healthcare team. Her symptoms eventually subsided years down the line after extensive mental health therapy and counseling. As I pieced together her history of complex trauma while trafficked with the physical ailments she described, I thought of somatic symptom disorder.
My heart sank as I processed her story not only because of the terrible care this woman had received, but also because her story brought to mind a patient I had seen that year on the floors. She was a teenager with somatic symptom disorder and, similar to the survivor’s experience, was subject to much frustration from the team caring for her. More often than not, providers find patients with somatic symptom disorder difficult to care for. My thought is that these attitudes result from the team’s inability to find a good solution or sound explanation for the patient’s experiences. We are usually at a loss of what to offer them to remedy their genuine physical symptoms. In the face of our own frustration we miss opportunities to make a difference in the life of someone who has potentially experienced repeated abuse, violence, and manipulation. We let survivors slip through the cracks, just like the woman I met.
In cases of somatic symptom disorder it is important that we think about any type of trauma or abuse, including human trafficking. One of the largest studies to date on the health ailments of human trafficking survivors stresses the importance of physician education on somatic symptoms in survivors and the severe impact symptoms can have on quality of life. It is therefore vital that we have this index of suspicion so that complex trauma and human trafficking end up on our differential. Further, we should be educated about the many different presentations and common health ailments of trafficking survivors if we hope to make a difference in their lives as future physicians. I know that I will never fail to consider human trafficking the next time I meet a patient who is somaticizing.