Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

Abstract

This article reviews an emergency department-based clinical vignette of a trafficked patient with co-occurring pregnancy-related, mental health, and substance use disorder issues. The authors, including a survivor of human trafficking, draw on their backgrounds in addiction care, human trafficking, emergency medicine, and psychiatry to review the literature on relevant general health and mental health consequences of trafficking and propose an approach to the clinical complexities this case presents. In their discussion, the authors explicate the deleterious role of implicit bias and diagnostic overshadowing in trafficked patients with cooccurring addiction and mental illness. Finally, the authors propose a trauma-informed, multidisciplinary response to potentially trafficked patients. CaseDr. Shah, an emergency department (ED) resident in New York City, entered the room of a young pregnant patient who was bleeding and visibly frightened. The patient, who only spoke Spanish, was accompanied by her brother, who translated. He explained that the patient suffered from schizophrenia and had been refusing her medications for the last couple of weeks. He added that she'd had a few episodes of aggressive behavior, directed at others and herself. While the patient's brother was talking, Dr. Shah noticed a few bruises and puncture marks with associated ecchymosis (subcutaneous bleeding similar to a bruise) on the patient's arm. The brother saw that Dr. Shah had noticed these marks and explained that the patient sells herself for drugs.Dr. Shah began to suspect that the patient's brother might not be trustworthy, so she requested a certified clinical interpreter. Through the interpreter, the patient conveyed that she was miscarrying and asserted that she does not have schizophrenia, although she admitted feeling depressed sometimes. The patient's tone became increasingly desperate and she explained, through the interpreter, that the man claiming to be her brother was holding her captive. She stated she was brought to the US as his fiancée,

Medical education and human trafficking: using simulation

“…Rather, the scenario was designed to arouse suspicion for abuse in the form of trafficking and prompt students to practice disclosing confidentiality, building trust, and developing an action plan to address the patient’s immediate needs. One principal point for this simulation was to reinforce that healthcare’s role is not immediate forceful removal of trafficked persons against their will, but rather a focus on survivor empowerment and meeting their stated needs through a trauma-informed approach [15–17]. …”

Diagnostic overshadowing: An evolutionary concept analysis on the misattribution of physical symptoms to pre‐existing psychological illnesses

“…and their effects on patient interaction and care (Blair et al 2011;Tsipursky 2020). Such reflexive reactions may lead to missed diagnoses, ineffective therapies, and disrespectful interactions; these outcomes relate to diagnostic overshadowing as well (Joy et al 2016;Stoklosa et al 2017).…”

“…How might nurses and other providers prevent diagnostic overshadowing from occurring? Whether an answer is engaging in self-critical evaluation (Wood & Tracey 2009) or receiving education on traumainformed care (Stoklosa et al 2017), collaboration between physical and mental healthcare professionals (Shefer et al 2015;van Nieuwenhuizen et al 2013), changes in charting practices (Joy et al 2016), or, likely, a mixture of these intervention approaches, one critical initial move must be made. This first step requires acknowledging that diagnostic overshadowing exists and that its occurrence is both widespread and serious (Giddings 2013;Happell et al 2016).…”

Fierce Autonomy: How Girls and Young Women Impacted by Commercial Sexual Exploitation Perceive Health and Exercise Agency in Health Care Decision-Making

“…In addition, unstable homes, lack of familial support, and gaps in supervision are catalysts to both systems involvement (i.e., in the juvenile or child welfare system) and exploitation, exacerbating a myriad of health issues. Adverse health effects are not mutually exclusive-and comorbidity, defined as the presence of two or more diagnoses, may further exacerbate vulnerabilities and health needs among youth affected by CSE (Kelly et al, 2017;Lalor & McElvaney, 2010; National Institute on Drug Abuse, 2012; Rafferty, 2008;Stoklosa et al, 2017). Mechanisms for these negative health effects are multifaceted and can begin prior to and sustained throughout the exploitation.…”