Diagnosis Challenges when Substance Use and Trauma are Part of the Narrative: A Review of Human Trafficking Cases Among Women and Critical Points of Learning for the Mental Health Community

doi:10.21203/rs.3.rs-3443349/v1

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Diagnosis Challenges when Substance Use and Trauma are Part of the Narrative: A Review of Human Trafficking Cases Among Women and Critical Points of Learning for the Mental Health Community

https://doi.org/10.21203/rs.3.rs-3443349/v1

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Human trafficking survivors often have a myriad of complex mental health issues because of their experiences. Research has shown there is a high correlation between substance use and post-traumatic stress disorder among survivors. The mental health challenges can become more complex when trauma and/or substance use is misdiagnosed or underdiagnosed. The results of this study show the prevalence of both situations among a program serving adult female survivors from within the US. The study documents the more common inaccurate diagnoses for this population of women, and the change in diagnosis after a dedicated period of assessment was completed. The discussion includes lack of understanding of how trauma and substance use present in a clinical or medical setting, an overfocus on other symptoms, lack of education and training among law enforcement, courts, and community service providers, and the exacerbated problems for survivors because of the incorrect or inaccurate diagnoses.

Substance Use

Trauma

Human Trafficking

Diagnosis

Mental Health

Providers

Human trafficking, involving both labor and sex, and forms of sexual exploitation are a domestic and international problem of magnitude. Sex trafficking is a form of modern-day slavery in which individuals perform commercial sex under force, fraud, or coercion (National Human Trafficking Hotline, 2021). Estimates of the frequency of human trafficking are difficult to accurately obtain given the hidden and stigmatizing nature of the crimes. According to the National Human Trafficking hotline, in 2021, 50,123 signals were received by the hotline (signals include texts, calls, online chats and tips). The reported numbers are staggering, but the physical and psychological impact cannot be adequately measured.

Sexual exploitation and sex trafficking disproportionately affects women with higher rates of reported sexual violence as children, adolescents, and adults (Rainn, 2022). Survivors have reported they do not seek support and services for fear of being stigmatized against or criminalized (Rajaram & Tidball, 2018). Sex trafficking and sexual exploitation are extremely complex. As a result, survivors often have numerous needs and mental health struggles. Service providers in some locales are sparce, and in others, more are available, but the needs often outweigh availability of resources. Additionally, treatment providers may not ask questions that elicit a client’s history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program’s clinical orientation, or their agency’s directives (Center for Substance Use Treatment, 2014). Subsequently, survivors often go undiagnosed, or inaccurately diagnosed, when their trauma and/or substance use is not recognized.

A more critical understanding of the intersections between sex trafficking victimization and substance use disorders (SUDs) is necessary to implementing survivor-centered and trauma-informed approaches, including accurate assessment and diagnosis of mental health and SUD disorders. The intersection between sex trafficking victimization and SUDs is common (see Figure 1, Polaris Project, 2019). Several studies have found a strong association between SUDs and increases in the risk of being trafficked (Hopper, 2017; National Human Trafficking Training and Technical Assistance Center and Administration for Children and Families, 2018; Smith et al., 2016). The top form of force or coercion used against victims identified through the hotline was exploitation of an individual’s SUD.

Traffickers use drugs and alcohol as tools to lure potential victims, groom them, and ultimately control them. They exploit individuals’ opioid use or SUDs to coerce them into trafficking, knowing that they are more vulnerable than individuals without SUDs. Furthermore, traffickers use drugs and alcohol to maintain control over victims. After introducing drugs and creating dependency, they may further exploit victims by forcing them to use drugs or controlling their supply in order to maintain control over the victims. In other situations, substance use becomes a coping mechanism for victims to deal with the activities and trauma that they are forced to endure (Langton et al., 2022).

The second highest risk factor/vulnerability for a potential trafficking victim is being a runaway or homeless youth. In the internal data set we examined, 87 percent of victims had experienced significant adverse childhood experiences (ACES) prior to trafficking. This percentage is consistent with other national statistics that show that between 70% - 90% of commercially sexually exploited youth have a history of child sexual abuse (American SPCC, 2023). Childhood sexual abuse (CSA) is a profoundly traumatic experience that leaves its victims with lasting emotional and psychological scars. When we delve into the complex issue of human trafficking, we can see a clear connection between CSA and vulnerability to exploitation in adulthood. CSA involves any form of sexual exploitation or assault experienced by a child. The effects of such abuse are profound and can impact a survivor's emotional well-being, self-esteem, and overall mental health. These scars often persist into adulthood. One of the most significant vulnerabilities to adult trafficking is being a runaway or homeless youth. Recognizing and addressing this connection is crucial in developing strategies to prevent trafficking and provide support and healing for survivors (Franchino-Olsen, 2019).

To more closely examine the extent that trauma and substance use is not recognized in survivors of trafficking, research was collected as secondary data from a non-profit organization that serves adult women who have experienced sex trafficking and/or sexual exploitation. The program is a 90-day emergency shelter state licensed and nationally accredited to provide behavioral health services for mental health and substance use. Located in the southern region of the US, the program serves female clients from any state as they work with national partners from across the US to receive referrals.

The data was collected through the clinical intake paperwork and assessments that were recorded on the agency’s electronic health record (EHR). The data was anonymized and contained no identifiable information. There was no recruitment process for this research because secondary data was utilized. The parameters of the search within the EHR were set to exclude any client who had not stayed in the program at least 30 days (time frame was chosen to allow for accurate diagnosis), did not have an intake diagnosis of either SUD or PTSD (post-traumatic stress disorder) listed, or did contain a diagnosis that changed between intake and discharge from the program. The initial sample size was 91 clients spanning the course of 2 years (June 2020 – June 2022) of the program’s operations. The assumptions at the beginning of the research were that a statistically significant percentage of the client records would reveal a lack of diagnosis altogether or a diagnosis that was not consistent with the historic and current problems the client was reporting having experienced. Within the 91 initial client records, 53 were identified as meeting the criteria of the study and analysis: having been in the program 30 + days, no SUD or PTSD diagnosis listed at intake, or at discharge having a different diagnosis from their reported intake diagnosis.

As shown by Figure 2, the demographic breakdown of the client charts reviewed show little diversity and are not significant to suggest a racial or ethnic barrier to inaccurate diagnosis. However, there is surplus of evidence that reveals racial disparities in treatment and access to services, which may be an indicator of lower numbers of BIPOC/minority clients served. This is a potential area of further research needed.

The average length of stay for the client records indicate over 70 days for an average stay (Figure 3). This length of time is sufficient for accurately diagnosing a client given the residential nature of the program, and the day to day contact of the mental health professionals assessing for diagnoses.

An additional factor that provides a point for discussion is the average age of the 53 clients. As indicated in Figure 4, the average age was 41 years. This is a significant statistic because these are not clients who were new to the mental health or substance use systems of care. As shown by Figure 5, 55% of the client records indicated a history of suicide attempt, and 87% having experienced childhood sexual abuse. Both clinical indicators would suggest the 53 clients had been seen in a medical, mental health, psychiatric, or behavioral health setting of some kind prior to their entry into the emergency housing program. A records review confirmed this to be true with all 53 having reported they had been hospitalized or seen by a mental health professional in their past.

The collected data for the 53 records included the diagnosis the clients reported having been given at some point in their lives compared to the diagnosis(es) they were given when exiting the program. The diagnoses are based on their groupings within the DSM-5. For example, antisocial, histrionic, and borderline fall under the category of “personality disorders.” A paired sample t-test was conducted to compare the number of clients reporting a diagnosis coming into the program, compared to the same diagnosis reported when discharging. As seen by the two-sided P levels being less than 0.05, the pairs that showed a level of significance were PTSD, Bipolar, Personality Disorders, and substance use disorders. Figure 7 looks more specifically at these diagnosis pairings side by side.

The orange columns represent the diagnoses reported on the intake documents completed at their entry into the program. The green columns represent the diagnoses of clients at discharge from the program. 38% of clients reported a PTSD diagnosis coming in (intake) with 80% being given a PTSD diagnosis when leaving (discharge). Only 3% of clients reported having received a substance use disorder diagnosis, but 90% of the clients were diagnosed with a substance use disorder upon discharge. The evidence supports the beginning hypothesis that PTSD and substance related, and addictive disorders are being underdiagnosed within this population.

On a related note, 28% of the 53 client charts indicated having been diagnosed with bipolar in their history, but only 8% of clients met criteria for that diagnosis when leaving the program. 23% of clients reported being diagnosed with a personality disorder, but only 8% of clients met full criteria for those diagnoses when leaving. The data reveals statistically significant over-diagnosing clients in this population with Bipolar and Personality Disorders.

Sex trafficking and sexual exploitation are complex and lead to survivors having compounded mental health needs. The research supports there is a misconception about what sex trafficking is and what it looks like among survivors. Sex trafficking, particularly when it co-occurs with an SUD, is often not recognized by law enforcement and community members as a problem in many communities (Langton et al., 2022). With this lack of awareness or understanding, there is also a lack of a trauma informed approaches and lens among other professionals in the field. Survivors of trafficking, complicated by an SUD, face stigma from law enforcement, courts, the medical community, and victim services providers.

There needs to be more time spent with survivors when they present to a professional, even if they have not been identified as a survivor. In looking at the research data, a very small percentage of the clients reported receiving a substance use disorder diagnosis in their past, yet 90% of the clients were diagnosed with a substance use disorder at discharge. The exit diagnoses were based on their reported substance use, the baseline established at intake through drug testing, evidence-based assessments related to SUD, and having met criteria for a diagnosis. According to Levine (2017), women who have experienced sex trafficking and/or exploitation are likely to be diagnosed with depression, anxiety, post-traumatic stress disorder, mood disorders, and substance use disorders. However, the research conducted for this study would suggest there is an over-diagnosing of some disorders, and an under-diagnosing of others. Many of the women served in the program have substance use disorder that had been overlooked due to an overfocus of the medical and mental health community on other presented symptoms. After spending 30 + days in the program, developing safe and trusting relationships, other explanations for their symptoms began to emerge, mostly heavy substance use in response to the trauma they had been enduring. Some providers do not explore substance use or complex trauma, and instead offer a diagnosis inconsistent with the more deeply hidden issues. This presents concerns for several reasons such as it can push survivors toward other measures of help, like medications, which may only exacerbate their current conditions, and they do not receive the specialized care they need for SUD and trauma.

Given the clients of this study were female, a discussion about gender bias is needed. A survey conducted in early 2019 by TODAY found that more than one-half of women, compared with one-third of men, believe gender discrimination in patient care is a serious problem. One in five women say they have felt that a health care provider has ignored or dismissed their symptoms, and 17% say they feel they have been treated differently because of their gender—compared with 14% and 6% of men, respectively. Studies show that women’s perceptions of gender bias are correct. Compared with male patients, women who present with the same condition may not receive the same evidence-based care.

Sex trafficking is multi-layer and can involve drugs, violence, and manipulation by both strangers and people these survivors trusted. As a result, the survivor may not feel comfortable discussing their past and experiences. Many female survivors have shared they were stigmatized and blamed for being trafficked so there was a lack of trust that prevented survivors from seeking help. Many female survivors will not share their trauma or substance use histories, or do not share them in a way in which the service provider understands the complexity of their story. Survivors also expressed that there was a lack of a trauma-informed approaches from professionals, especially those involved in the criminal justice system, which prevented them from receiving the support they needed (Rajaram & Tidball, 2018).

The importance of receiving the support and treatment needed to address mental health and substance use cannot be dismissed. What are the barriers that keep survivors from receiving the help they need? The results of the study show a consistent pattern of misdiagnosis. A misdiagnosis will result in the client becoming confused and potentially distraught when the course of treatment recommended isn’t working. They may feel it’s a personal failing, and even develop feelings of guilt or shame when they don’t make progress under the diagnosis (Akers, 2019). Additionally, there are several other critical points of learning for the communities and providers that serve survivors. The points below are not exhaustive of the changes or further discussion needed. Rather, they are representative of the key highlights of the study and of changes that could have significant impact for survivors.

1. Lack of understanding about sex trafficking and how trauma impacts behavior and mental health – the story a survivor shares may be disjointed and seem “unreal” because of their trauma and/or substance use.

2. More emphasis needs to be placed on the prevalence and pervasive impact of trauma and substance use so that service providers can develop more responsive services.

3. Lack of a trauma informed lens among service providers and understanding of the behaviors that result from both trauma and substance use – in managed care systems the push to get a diagnosis for reimbursement rushes an accurate picture of the client. Lack of training and education about symptoms and manifestation in survivors.

4. Incorrect or inaccurate diagnoses exacerbates the problems for survivors as many will be misdirected to systems of care not designed to address their needs or will be denied care based on a faulty diagnosis. Many long-term treatment programs designed for trafficking survivors will not accept certain diagnoses that are overused by providers (schizophrenia, borderline personality disorder, dissociative identity disorder). Medications may be prescribed for the incorrect diagnosis, which can have detrimental effects on the survivor both physically and psychologically (why am I not getting better?).

5. Lack of education with clients about substance use disorders – more information about the effects of substance use on traumatic stress is needed.

6. Complex-PTSD as a more accurate diagnosis for survivors - potentially long and complex histories of trauma and poly-victimization.

7. Stigma and bias training for mental health professionals, law enforcement, and medical providers to reduce barriers to accessing needed treatment.

8. Female survivors may be experiencing gender bias.

An estimated 27.6 million people are trafficked around the world, and most sex trafficking victims are women and children (Polaris, 2022). Victims of sex trafficking experience high levels of stress which changes the neurochemical and structure of their brain functioning, which suggests that behaviors and reported symptoms may not be easily discernible in a short amount of time, such as one visit with a mental health professional, or a medical provider. Additionally, many victims of sex trafficking report having adverse childhood experiences, which are also connected to mental health symptoms and patterns of maladaptive behaviors. It isn’t always easy or straightforward to produce a correct diagnosis, and a misdiagnosis may prevent the actual condition from getting better. In many cases, it can lead to the root issue getting worse (Akers, 2019).

Inherit in most studies, there are some noted limitations. Given that the data used for the study was self-reported, it could be biased as well as with respect to diagnosis, the participants may not recall the information accurately. This was addressed by requesting outside providers records for confirmation of self-report and mental health records comparison; however, the limitation remains.

The relatively small sample size is also a limitation. The smaller size makes it difficult to determine if this would be a true outcome for a larger sample or population of female survivors.

Data Availability

The author confirms that all data generated or analyzed during this study are included in this published article. Furthermore, primary, and secondary sources and data supporting the findings of this study were all publicly available at the time of submission.

Conflict of Interest

Author declares she has no conflict of interest.

Ethics Committee

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Internal Review Board of Eastern Kentucky University (3/9/2023; No. 5160).

Consent to Participate and Publish

Informed consent was obtained from all participants for both participation and publication.

Acknowledgements

The author would like to acknowledge the valuable contributions of Abby Nemec, MSW, CSW of National Youth Advocate Program (NYAP), and Kellie Dingus, MSW student at Eastern Kentucky University.

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No competing interests reported.

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Diagnosis Challenges when Substance Use and Trauma are Part of the Narrative: A Review of Human Trafficking Cases Among Women and Critical Points of Learning for the Mental Health Community

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